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Upper line: Very thin chronic subdural hematoma (CSDH) is bilaterally identified, but sulci are obvious in both hemispheres, and a midline shift is not recognized on computed tomography (CT). The thickness of the right CSDH is 7 mm, and the left is 5 mm. Middle line: One month after the shunt valve pressure was changed to 200 mmH 2 O, CT revealed a definite enlargement of the right CSDH. And the sulci are unclear in the right hemisphere due to hematoma compression, and a mild midline shift to the left is also recognized. CSDH of the left side is absorbed. Lower line: Bilateral CSDHs completely disappear on CT performed three months after surgery.
Source publication
Key Clinical Message
Traumatic CSDH enlarged in two cases with VP or LP shunt system although the shunt valve pressure was increased to 200 mmH2O. In surgery, the hematoma cavity pressure was found to be 130 and 140 mmH2O, suggesting that to raise the shunt valve pressure is not effective for decreasing CSDH volume.
Contexts in source publication
Context 1
... 83-year-old Asian male visited our clinic because of progressively worsening disorientation as he sustained mild head trauma 1 month ago, and head computed tomography (CT) showed bilateral thin CSDH (7 mm in thickness) (Fig. 1 upper). The patient underwent ventri- culo-peritoneal (VP) shunt for idiopathic normal pres- sure hydrocephalus (iNPH) 3 years ago. The shunt valve pressure had been controlled at 130 mmH 2 O using a Codman Hakim programmable valve system (Johnson & Johnson, New Brunswick, NJ, USA), and the shunt pres- sure was raised to 200 mmH 2 O. One ...
Context 2
... month later, the patient visited our clinic because of a difficulty in walk- ing due to mild left hemiparesis. Head CT showed enlarged right CSDH with mild midline shift to the left, although the left CSDH had disappeared spontaneously ( Fig. 1 middle). Burr-hole opening and irrigation of the hematoma was performed under local anesthesia. ...
Context 3
... to walk steadily by himself and discharged. After 1 month, due to recurrence of iNPH, his walking became unsteadily and orientation sta- tus deteriorated. The shunt valve pressure was changed to 130 mmH 2 O. In 1 month, the patient visited our clinic walking steadily with better orientation, and CT showed complete disappearance of the hematoma (Fig. 1 ...
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Introduction
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Objective
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Citations
... complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts in humans [9,10] and animals [3,11]. The development of subarachnoid haemorrhages and hematomas secondary to hemispheric ventricular collapse leads to acute progression of neurological signs and decompressive surgery is the first choice of treatment in human patients [12,13] and animals [14]. ...
... The incidence of subdural hematomas and subarachnoid haemorrhages is a well described complication after shunt placement in human [12,13,28] and veterinary medicine [11,29,30] and are thought to be a result of stretching and eventual disruption of the dura-arachnoid desmosomal attachments and bridging veins while the intracranial pressure changes secondary to the placed shunt and excessing opening pressure in the valve [30,31]. Sporadically, hematomas resolve spontaneously without surgical intervention. ...
Background:
Overdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts. Here we describe a case of a spontaneous hemispheric ventricular collapse in an untreated dog with congenital hydrocephalus internus.
Case presentation:
A twelve-week-old, male, intact Golden Retriever was presented with a history of peracute obtundation, impaired vision, and progressive gait abnormalities of all limbs for three days. Neurological examination revealed a dome shaped skull, a broad-based stance and a moderate cerebellar ataxia. The postural responses were markedly delayed in all limbs. Moderate ventro-lateral strabismus, vertical nystagmus and absent menace response were observed bilaterally. Clinical signs indicated multifocal localisation (forebrain, cerebellum). Magnetic resonance imaging (MRI) showed dilation of all cerebral ventricles, irregular thinning of the periventricular white and grey matter, consistent with internal hydrocephalus. In addition, the hemispheres were collapsed at the right temporal and left frontal lobe with haemorrhage filling the adjacent subarachnoid space. The dog underwent left frontal and right temporal craniotomy for removal of the haemorrhage. The dog improved on all neurological signs and was discharged after seven days. A repeat MRI three months postsurgical intervention showed reexpansion of the cerebral hemispheres. Subarachnoid haemorrhages were markedly reduced.
Conclusions:
Collapse of the hemispheres can occur spontaneously in dogs with hydrocephalus internus. Removal of the haemorrhage can improve clinical signs.
... [10] The assumption is that in cases of communicating hydrocephalus as in NPH patients, decreasing ventricular shunt drainage would force CSF to spread into alternative routes, such as the basal cisterns, thus ameliorating the buildup of intraventricular pressure. [17] A recent large prospective study among shunted NPH patients showed that the majority of cases with chronic hygromas or SDH in patients with adjustable valves were managed conservatively by readjusting the opening pressures. In comparison, most patients with fixed valves had to undergo surgical interventions, including BH and shunt ligation. ...
Background:
Ventriculoperitoneal shunting (VPS) is considered a risk factor for developing subdural hematomas (SDH). Treating cases of acute SDH (aSDH) in shunted normal-pressure hydrocephalus (NPH) patients can be challenging, and data in this field are scarce. We report our experience treating shunted NPH patients presenting with aSDH.
Methods:
Eight patients, aged 73 ± 6 years, with a history of VPS for NPH, hospitalized because of aSDH were included in this study. We retrospectively analyzed data regarding patients' clinical and radiological presentation, hospitalization course, the use of antithrombotics, and response to different treatment regimens.
Results:
Four patients had pure aSDH, three had acute on chronic SDH, and one had subacute SDH. Patients presented with GCS 13-15 and various neurological signs, mainly confusion and unsteady gate. Two cases improved following resetting of their programmable shunt valve to its maximal pressure setting. Six cases improved after evacuation of the hematomas, five of them were operated a few days after initially resetting of the valve pressure. Three patients were discharged home, whereas five were referred to rehabilitation. Extended Glasgow Outcome Scale scores at discharge and during long-term follow-up were 5 and 7, respectively.
Conclusions:
Treatment of patients with VPS for NPH, presenting with aSDH, may differ according to the neurological status, imaging, and clinical course. Treatment options include restricting shunt function, hematoma evacuation, or both.
... [10] The assumption is that in cases of communicating hydrocephalus as in NPH patients, decreasing ventricular shunt drainage would force CSF to spread into alternative routes, such as the basal cisterns, thus ameliorating the buildup of intraventricular pressure. [17] A recent large prospective study among shunted NPH patients showed that the majority of cases with chronic hygromas or SDH in patients with adjustable valves were managed conservatively by readjusting the opening pressures. In comparison, most patients with fixed valves had to undergo surgical interventions, including BH and shunt ligation. ...
FROM THE RECORDS of approximately 1500 shunt operations performed between 1987 and 1992, we identified 37 adults between ages 38 and 86 years (mean, 70 yr) with the normal-pressure hydrocephalus (NPH) syndrome who underwent surgery by a single surgeon. Since 1990, we have routinely used a flow-regulated shunt system (Orbis-Sigma valve [OSV]; Cordis Corporation, Miami, FL) in these patients. In this study, we compared the OSV system with conventional differential-pressure (DP) shunt systems uniformly used before 1990. This series (n = 37) consisted of 62% men (n = 23) and 38% women (n = 14). We excluded all patients with hydrocephalus associated with central nervous system neoplasms, intracerebral hemorrhage, or trauma as well those with radiographically documented late-onset aqueductal stenosis. All patients presented with the NPH clinical syndrome, chiefly with magnetic gait. In addition, 75% of patients experienced cognitive loss and 59% experienced urinary incontinence. The mean duration of preoperative symptoms was 35 months (range, 7–120 mo). Eight patients (22%) had undergone previous shunting procedures before referral to our service. A total of 89 shunt operations were performed in the 37 patients. Using actuarial methods and controlling for a history of prior shunt surgery, we found no significant difference in the time to initial malfunction (shunt survival) between the OSV and the DP shunts. There were three subdural hematomas and one infection in the OSV group compared with no complications in the DP valve group (P = 0.11). Thirty-six patients were available for follow-up, at a mean of 14 months after surgery. Nearly 90% of all patients experienced improvement in gait after shunting, regardless of the valve system that was used. There was one unrelated death. Realizing the limitations of a retrospective analysis and on the basis of the limited number of patients in this study, we conclude that using actuarial methods, we found no significant difference in shunt survival when comparing the OSV with the standard DP valve shunt systems with antisiphon devices in patients with NPH. Contrary to previous reports, the OSV is not free of overdrainage complications. Most patients (89%) with the NPH syndrome who primarily presented with gait disorder experienced significant improvement in gait after either OSV or DP shunting procedures when selected for surgery on the basis of the clinical syndrome and confirmatory radiographic data.
