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Introduction: External hydrocephalus (eHC) is commonly defined as a subtype of infant "hydrocephalus" consisting of macrocepahly associated with enlarged subarachnoid space and no or mild ventriculomegaly. This status is thought to be related to impaired CSF absorption because of arachnoid villi immaturity. However, other factors like the venous system might be involved in the development of the clinical picture., Methods: All patients diagnosed with eHC received prospectively contrast-enhanced 3D MR phlebography. Venous sis abnormalities were graded depending on the number of affected sinus segments and type. External CSF space volume was quantified planimetrically., Results: Seventeen patients with the typical clinical feature of eHC were included. In 15, venous sinus abnormalities were found. There was a significant correlation between the volume of the widened cortical subarachnoid space (CSAS) and the number of venous sinus segments affected. Conversely, ventricular volume was not correlated., Conclusion: These results support the hypothesis that impaired venous outflow plays a major role in external hydrocephalus development. Raised venous pressure increases intracranial pressure accelerating head growth, resulting in an enlargement of the cortical subarachnoid space. Increased venous pressure increases the capillary bed pressure and brain turgor preventing ventricular space to enlarge forcing displacement of ventricular CSF to the subarachnoid space. As a result, ventriculomegaly is rarely found. The descriptive term "external hydrocephalus" implying a primary etiology within the CSF system is misleading and this work supports the notion that venous hypertension is the leading cause of the clinical picture.

Acute subdural hematoma (ASDH) is a frequent complication of severe head injury, whose secondary ischemic lesions are often responsible for the severity of the disease. We focused on the differences of secondary ischemic lesions caused by the components, 0.4ml venous- or arterial-blood, or saline, infused in the subdural space, evaluating the differences in vivo model, using rats. The saline infused rats are made for elderly atrophic brain with subdural effusion (SDE) model. Our data showed that subdural blood, both venous- and arterial-blood, aggravate brain edema and lesion development more than SDE. This study is the first study, in which different fluids in rats' subdural space, ASDH or SDE are compared with the extension of early and delayed brain damage by measuring brain edema and histological lesion volume. Blood constituents started to affect the degree of ischemia underneath the subdural hemorrhage, leading to more pronounced breakdown of the blood-brain barrier and brain damage. This indicates that further strategies to treat blood-dependent effects more efficiently are in view for patients with ASDH., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Purpose of Review: The aim of this article is to review recent findings on the pathophysiology of idiopathic changes in intracranial pressure. The review will focus on idiopathic intracranial hypertension (IIH) and spontaneous intracranial hypotension (SIH)., Recent Findings: Substantial evidence indicates that IIH is associated with delayed absorption of cerebrospinal fluid (CSF). Stenoses of the transverse sinus are common in IIH, but their clinical significance has not been entirely clarified. Despite the observed efficacy of endovascular treatment in some IIH patients, a correlation between the extent of observed stenoses and the clinical course of the disease could not be demonstrated. The underlying cause of SIH is a spontaneous CSF leakage into the epidural space. Conservative treatment and the epidural blood patch remain the treatment of choice for this rare syndrome., Summary: Recent clinical evidence indicates that IIH is probably a result of CSF outflow abnormality rather than of CSF production. Further research is needed to elucidate the causes of elevated intracranial pressure and the mechanism leading to visual loss. Prospective randomized clinical trials are needed to clarify a possible therapeutic potential of endovascular treatment. Research efforts on SIH should focus further on associated connective tissue disorders predisposing to CSF leaks.

Spontaneous Intracranial Hypotension is a syndrome involving reduced intracranial pressure secondary to a dural tear which occurs mostly due to connective tissue disorders such as Marfans Syndrome, and Ehler Danlos Syndrome. Patients with dural ectasias leading to CSF leakage into the subdural or epidural space classically present with orthostatic headaches and cranial nerve deficits mostly seen in cranial nerves V-VIII. Diagnosis of SIH is confirmed with the aid of neuroimaging modalities of which Cranial MR imaging is most widely used. SIH can be treated conservatively or with epidural blood patches which are now widely being used to repair dural tears, and their effectiveness is being recognized. Recently epidural injection of fibrin glue has also been used which has been found to be effective in certain patients.

Study Design: Case report and review of the literature., Objective: To describe a case of multiple supra- and infratentorial hemorrhages after spinal surgery presenting with seizure., Summary of Background Data: Cerebrospinal fluid overdrainage is a well-documented factor associated with remote cerebellar hemorrhage, but supratentorial hemorrhages after spinal surgery have been reported rarely., Methods: A 64-year-old woman underwent a sacral laminectomy for recurrent chordoma. A negative pressure wound drain was left in after surgery and drained 1300 mL in the first 48 hours. On the fourth postoperative day, the patient presented with tonic-clonic seizures., Results: Diagnostic imaging showed multiple supra- and infratentorial intraparenchymal hemorrhages and a massive sacral cerebrospinal fluid leak. The patient underwent emergent surgery for a primary repair of the presumed dural defect., Conclusion: Patients who present with severe positional headache, altered mental status, or tonic-clonic seizures after undergoing intradural spinal procedures involving massive cerebrospinal fluid loss may be suffering from multiple supra- and infratentorial intracranial hemorrhages.

Background: This study presents a patient with a stroke who had total paralysis of his left-side limbs after intracranial haemorrhaging, who later experienced partial weakness of the right-side limbs after a subdural hygroma. Both conditions occurred without major trauma. He received two separate operations, a craniotomy and placement of a ventriculoperitoneal shunt, before the appearance of the subdural hygroma., Case Study: According to the literature, heterotopic ossification is often reported with major trauma-associated diseases, but is less frequently found in patients with non-traumatic conditions, from which this patient suffered. Although the patient had experienced no major trauma, he had multiple heterotopic ossifications on the side of the subdural hygroma-affected limbs, which exhibited better motor control and were less spastic than those of the opposite side. These heterotopic ossifications were around joints of the hip, knee and shoulder on his right side, as proven by plain radiography and a triple-phase bone scan and resulted in marked limitations of joint motions. This patient thus had major disabilities of his limbs bilaterally., Conclusions: The occurrence of heterotopic ossifications in the less-paretic limbs might have worsened this patient's functional outcome.

Objective: External hydrocephalus, introduced by Dandy and Blackfan in 1914 [Am J Dis Child 1914;8:406-482], is used to describe the clinical condition of cerebrospinal fluid (CSF) accumulation in the subarachnoid space with its space expansion and increased intracranial pressure in pediatric patients. Benign subdural effusion, subdural hygroma and pseudohydrocephalus are some terms used to describe some conditions, not clearly defined at the moment as separate pathological entities. We report 3 pediatric cases which had CSF collections after craniotomy. Neuroimaging investigations revealed CSF collection after surgery. All 3 cases had a poor clinical course with resolution after shunting. This report analyzes the mechanisms and pathophysiology of postoperative extra-axial CSF collections (PECC), indicating that CSF accumulations in the extra-axial spaces (inside or outside the arachnoid) after surgery have a common pathophysiology. Therefore, the treatment protocol can be specific., Patients: Three pediatric cases, aged from 11 months to 6 years, had large tumors located from their suprasellar region to the hypothalamus and third ventricle. The tumors were excised surgically through either an anterior interhemispheric translamina-terminalis or a transsylvian translamina-terminalis approach or both. The surgery conducted created a wide opening of the anterior interhemispheric or the sylvian fissures, dissecting the lamina terminalis and Liliequist's membrane resulting in a new artificial CSF tract from the basal cisterns to the subdural space. Clinical symptoms such as deterioration of consciousness level developed within a few weeks after surgery, and a follow-up computed tomography image confirmed subdural CSF collection. Symptoms improved after ventriculoperitoneal (V-P) shunting., Discussion: External hydrocephalus, subdural effusion and the other entities mentioned above are frequently observed in children, and little is known about their pathophysiology. To differentiate from the whole entity of CSF accumulation within the subdural and subarachnoid space, we use the term PECC to specify the main pathophysiological condition resulting from a wide dissection and opening of the arachnoid membrane and communication with the basal cisterns., Conclusion: We present the occurrence of CSF collections in the extra-axial space after surgery as the specific condition of PECC. Broadly dissecting the arachnoid membrane, with a communication remaining with the ventricles, is the main factor contributing to PECC, and patients have shown that V-P shunting is an effective procedure preventing progression and effectively treating PECC., (Copyright © 2011 S. Karger AG, Basel.)

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46-year-old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head-shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.

Background: Low cerebrospinal fluid volume is typically diagnosed in patients presenting with positional headaches. However, severe intracranial hypotension and brain sagging may cause orthostatic coma. We present a case that illustrates this uncommon presentation., Method: Case report., Results: A 50-year-old man presented with orthostatic headaches and then developed bilateral subdural hematomas. Following unilateral subdural hematoma evacuation, the patient became gradually drowsier and more confused. Upon transfer to our hospital, he would become comatose each time he was placed in the upright position. Successful epidural patch at the level of a spontaneous cerebrospinal fluid leak documented by myelography resulted in complete resolution of his orthostatic symptoms despite reaccumulation of the subdural fluid collection., Conclusions: Evacuation of subdural fluid collections may be detrimental in patients with low CSF volume by exacerbating the intracranial hypotension. Extreme brain sagging may lead to anatomical distortion of the diencephalon and brainstem resulting in coma.

Background: Adequate repair of cerebrospinal fluid leak remains a significant challenge in endoscopic skull base surgery. Laser tissue welding (LTW) is a method of creating an instant watertight wound closure using a chromophore doped biological solder, which may be used for cranial base reconstruction. The objective of this study is to assess the safety and technical feasibility of endoscopic LTW in human sinonasal mucosa., Methods: A prospective, Institutional Review Board-approved study was performed of 10 patients undergoing endoscopic LTW using an albumin and hyaluronic acid-based solder for repair of mucosal injuries. Data were collected on patient demographics, total lasing time, and volume of solder used. Wounds were prospectively followed by endoscopic exam and scored on a scale of zero to two by three blinded observers (B.S.B., J.N.P., and A.G.C.) for inflammation, thermal injury, and edema. Results were compared with control wounds using the Mann-Whitney U test., Results: Ten patients (seven men and three women; average age 50 years; range, 33-71 years) underwent endoscopic LTW. Total lasing time was 11 +/- 11 minutes requiring 0.96 +/- 0.83 mL of solder per patient. Patients were followed for an average of 72 days (range, 12-138 days) and no complications were noted. Solder persisted for up to 26 days and there was no significant difference between the lased and control wounds with regard to inflammation (0.87 +/- 0.72 versus 1.31 +/- 0.87), thermal injury (0.06 +/- 0.25 versus 0.12 +/- 0.34), or edema scores (1.13 +/- 0.81 versus 1.44 +/- 0.73)., Conclusion: Endoscopic LTW is a technically feasible and rapid method of wound closure in sinonasal mucosa that does not result in any significant thermal or inflammatory sequelae.

Arachnoid cysts represent a common, innocent, finding in routine neuroimaging of headache patients. We present the first report of symptomatic migraine with aura caused by the spontaneous rupture of a middle fossa arachnoid cyst into the subdural space. Brain imaging enabled an accurate diagnosis and, subsequently, adequate surgical management.

Spontaneous intracranial hypotension (SIH) is a syndrome caused by low cerebrospinal fluid (CSF) pressure due to leakage of CSF. Clinically, orthostatic headache, neck pain, nausea, emesis, interscapular pain, diplopia, dizziness, changes in hearing, visual blurring and radicular upper extremity symptoms are most frequently observed. We describe a 57-year-old man with SIH who presented with postural tremor. CSF leakage was revealed by cranial MRI. Lumbar puncture identified low CSF pressure and intrathecal gadolinium enhanced MR cisternography showed diffuse CSF leakage in the thoracolumbar region. The patient underwent epidural blood patching, which resulted in complete resolution of postural tremor within 2 months., (Copyright 2009 Elsevier Ltd. All rights reserved.)

A 15-year-old boy presented with a case of middle cranial fossa arachnoid cyst associated with subdural effusion and manifesting as headache and vomiting after minor head injury. Computed tomography disclosed a cystic lesion in the left middle cranial fossa and ipsilateral subdural effusion. Fundoscopic examination revealed papilledema. A small tear of the cyst wall was confirmed endoscopically. Fenestration of the cyst was performed under the operating microscope. Postoperative course was uneventful. The tear in the outer wall of an arachnoid cyst may suggest the mechanism of occurrence of subdural effusion associated with middle cranial fossa arachnoid cyst.

We present a case of expansive CSF collection in the cerebellar convexity. The patient was a 74 years old lady who one month before had suffered a cerebellar infarct complicated with acute hydrocephalus. She had good evolution after decompressive craniectomy without shunting. Fifteen days after surgery, the patient started with new positional vertigo, nausea and vomiting and a wound CSF fistula that needed ventriculoperitoneal shunt (medium pressure) because conservative treatment failed. After shunting, the fistula closed, but the patient symptoms worsened. The MRI showed normal ventricular size with a cerebellar hygroma, extending to the posterior interhemispheric fissure. The collection had no blood signal and expanded during observation. A catheter was implanted in the collection and connected to the shunt. The patient became asymptomatic after surgery, and the hygromas had disappeared in control CT at one month. This case shows an infrequent problem of CSF circulation at posterior fossa that resulted in vertigo of central origin. A higroma-ventricle-peritoneal shunt solved the symptoms of the patient.

Background: Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables., Methods: Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction., Results: Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair., Conclusion: The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.

Osteogenesis imperfecta (OI) is a rare inherited disorder characterized by disruption of normal collagen formation, brittle bones, and low bone density, predisposing to multiple bone fractures and wide-spectrum symptomatology. Extradural and subdural hematomas and spinal cord injuries have been reported but mainly in children with OI. We cared for a 60-year old woman with OI and bilateral nontraumatic subdural hematomas possibly caused by spontaneous intracranial hypotension.

Spontaneous intracranial hypotension and trigeminal neuralgia are examples of pain syndromes arising from shifting anatomical relationships in the posterior fossa. We report both conditions occurring in the same patient and resolving following surgical closure of a cervical nerve root sleeve dural defect. This case further elucidates the pathophysiologic basis of both forms of head pain.

Cerebrospinal fluid leakage is a rare but critical condition with a substantial risk of intracranial infection, therefore its diagnosis and treatment is of major importance. CSF leakage diagnostic can be a challenging problem. Nephelometric measurement of beta-trace protein in the liquorrhoea is a non-invasive and fast method that can be used for CSF leakage diagnosis. It should kept in mind, however, that the cut-off of 1.1 mg/L is not suitable for patients with bacterial meningitis and those with a reduced glomerular filtration rate. Complementary use of beta-trace protein assay and beta2-transferrin detection is therefore recommended.

Background: Decompressive craniectomy is an important method for managing refractory intracranial hypertension in patients with head injury. We reviewed a large series of patients who underwent this surgical procedure to establish the incidence and type of postoperative complications., Methods: From 1998 to 2005, decompressive craniectomy was performed in 108 patients who suffered from a closed head injury. The incidence rates of complications secondary to decompressive craniectomy and risk factors for developing these complications were analysed. In addition, the relationship between outcome and clinical factors was analysed., Findings: Twenty-five of the 108 patients died within the first month after surgical decompression. A lower GCS at admission seemed to be associated with a poorer outcome. Complications related to surgical decompression occurred in 54 of the 108 (50%) patients; of these, 28 (25.9%) patients developed more than one type of complication. Herniation through the cranial defect was the most frequent complication within 1 week and 1 month, and subdural effusion was another frequent complication during this period. After 1 month, the "syndrome of the trephined" and hydrocephalus were the most frequent complications. Older patients and/or those with more severe head trauma had a higher occurrence rate of complications., Conclusions: The potential benefits of decompressive craniectomy can be adversely affected by the occurrence of complications. Each complication secondary to surgical decompression had its own typical time window for occurrence. In addition, the severity of head injury was related to the development of a complication.

Spontaneous intracranial hypotension is an uncommon but not rare cause of new onset daily persistent headaches. A delay in diagnosis is the norm. Women are affected more commonly than men and most are in the fifth or sixth decade of life. The underlying cause is a spontaneous spinal cerebrospinal fluid (CSF) leak. Typically the headache is orthostatic in nature but other headache patterns occur as well. Associated symptoms are common and include neck pain, a change in hearing, diplopia, facial numbness, cognitive abnormalities and even coma. Typical imaging findings consist of subdural fluid collections, pachymeningeal enhancement, pituitary hyperaemia and brain sagging, but magnetic resonance imaging may be normal. Myelography is the study of choice to identify the CSF leak but is not always necessary to make the diagnosis. Treatment consists of bedrest, abdominal binder, epidural blood patching, percutaneous fibrin glue injection or surgical CSF leak repair. Outcomes have been poorly studied.

Background: Traumatic subdural hygroma (TSHy) is an accumulation of cerebrospinal fluid (CSF) in the subdural space after head injury. It appears to be relatively common, but its onset time and natural history are not well defined. Considered a benign epiphenomenon of trauma, the pathogenesis of TSHy is still unclear and many questions remain unanswered. This study adds to the information on TSHy, and proposes a classification based on pathogenesis., Methods: Thirty-four consecutive adult patients with TSHy were analyzed for clinical evolution and serial CT scan, during a period of several months. TSHy diagnosis was based on published CT scan criteria of hypodense subdural collection after trauma, without enhancement and neomembrane, with a minimum distance of 3 mm between the skull and brain. Ventricle size was analyzed by calculating the bicaudate index (BCI). For comparison, the BCI was measured from CT scan at three moments: admission, at time of TSHy diagnosis, and from last CT scan., Results: There were 34 patients, aged between 16 and 85 years (mean 40), half of them were below 40 years. Road traffic crashes were the main cause of head injury. The mean time for hygroma diagnosis was 9 days. Twenty-one patients (61.8%) underwent conservative treatment for TSHy and 13 (38.2%), surgical treatment. TSHy are early lesions and can be detected in the first 24 hours after trauma, usually as small subdural effusion (SSEff). Based on clinical and CT scan findings, we divided the 34 patients into 3 groups, (Ia and Ib) without evident mass effect and (II) with evident mass effect. Group Ia includes patients without ventricle dilation; Ib, patients with associated ventricle dilations., Conclusions: SSEff detected in the first 24 hours posttrauma in our series evolved into TSHy suggesting that this is an early lesion; all THSy were divided in three groups according to the pathophysiologic mechanism. These three groups probably represent a continuum of CSF absorption impairment. Group Ia represents what most authors consider a simple hygroma, with no impairment on CSF absorption. Group Ib represent the external hydrocephalus form with various degrees of CSF imbalance, and group II were the cases presenting marked mass effect.

A watertight closure of the dura is important in preventing post-operative complications. Various techniques are described to close small dura defects. We present a simple technique that uses on site homologues dura tissue to bridge small dura defects by separating the periosteum from the inner meningeal layer. This provides a low-cost, tension-free repair without the use of synthetic materials or need to harvest autologous materials.

We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH). Thirty-six (61%) patients were women; the mean age was 47 years (range 20-68). Cerebral MRI with contrast confirmed SIH in all patients. Headache characteristics were obtained by direct semistructured interview; in a minority of cases information was completed retrospectively through a phone call. All SIH patients suffered from headache. Early recognition of SIH may avoid dangerous worsening due to delayed diagnosis. Orthostatic headache, the main symptom, suggests the diagnosis.

Aim: Serous sheets are currently used in Neurosurgery as dural substitute. The aim of this study is to demonstrate that the horse pericardium, which has the essential charasteristics of reabsorbable membranes and moreover is BSE-free, is an excellent dural substitute., Methods: 200 patients, 53 suffering from cranial traumatic conditions and 97 from cranial and craniospinal neoplastic pathologies, underwent a surgical procedure with the application of horse pericardium as a dural prosthesis., Results: The follow-up controls of the patients included a neurosurgical visit and advanced diagnostic imaging (CT or MR). In the first 3 cases, an accumulation of CSF occurred under the surgical edge. Lumbar 7-days drainage was required in just one case. The use of Zero 5 suture seems to have obviated this problem, as it was never observed again in subsequent cases. The diagnostic imaging showed no alterated images and no clinical-neurological sequelae regarding the prosthesis in question were recorded., Conclusions: The Audiomesh Neuro prosthesis has all the characteristics of reabsorbable membranes: they are free from antigenic effects and do not produce any toxic catabolites. The membrane proved to be resistant to surgical suture, impermeable to CSF and is transparent. Yet the suture must be carried out carefully through a small non-traumatic needle. Audiomesh Neuro does not adhere to the underlying cerebral cortex and does not cause any clinical evidence or radiological artifacts.

Background: Idiopathic hypereosinophilic syndrome is characterized by persistent hypereosinophilia with end organ damage and no definite underlying cause. It has been recognized that eosinophils can induce varying degrees of neural damage. There are only a few reports in the literature regarding CSF by eosinophils, and the relationship between hypereosinophilic syndrome and eosinophilic leukemia remains unclear., Case Description: We report a case of IHS with CSF infiltration by immature eosinophils and significant subdural effusion with underlying brain parenchyma compression. He was treated by inserting a subdural-peritoneal shunt with improvement. Respiratory distress and pulmonary infiltration with eosinophils developed. Imatinib mesylate (Gleevec) was added with improvement, and subsequent CSF study showed normalization of CSF cytology analysis. However, re-collection of subdural fluid developed later and resulted in consciousness disturbance, and the patient died thereafter., Conclusion: Idiopathic hypereosinophilic syndrome remains a serious condition with a poor prognosis for most patients. Cerebrospinal fluid infiltration by immature eosinophils is a rare condition in IHS and may lead to poor prognosis, as observed in this patient, despite improved medical management (steroid and imatinib mesylate) and adequate surgical shunting for the subdural effusion.

Accidental puncture of the dura mater with resultant leakage of cerebral spinal fluid (CSF) and development of postdural puncture headache (PDPH) is a known potential complication of percutaneous placement of spinal cord stimulator (SCS) leads. However, the implications and management strategies for this complication have not been thoroughly reported. We report two cases of SCS lead placement complicated by CSF leak and PDPH.

Contralateral acute complications such as acute epi/subdural hematomas can be encountered after evacuation of a chronic subdural hematoma, though they are rare. We found only one case of chronic subdural hematoma following the surgery for contralateral chronic subdural hematoma, have been published in English language literature. A 73-year-old male admitted to our hospital with a right-sided subdural hematoma. The subdural hematoma was evacuated through a burr-hole. A left-sided subdural higroma appeared after operation and turned into classical subdural hematoma in the course of time. After evacuation of contralateral chronic subdural hematoma, the patient recovered completely. All stages of the development of contralateral chronic subdural hematomas were shown by serial computed tomograms. It was suggested that traumatic chronic subdural hematomas develop from mostly subdural higromas. If contralateral subdural higroma is seen after surgical evacuation of a chronic subdural hematoma, the possibility of development of contralateral chronic subdural hematoma must be kept on mind.

Object: The various terms used to describe subdural fluid collection--"external hydrocephalus", "subdural hygroma", "subdural effusion", "benign subdural collection", and "extraventricular obstructive hydrocephalus"-reflect the confusion surrounding the diagnoses of these diseases. Differentiating external hydrocephalus from simple subdural hygroma may be difficult, but the former appears to be a distinct clinical entity separate from the latter. In this report, the authors present a diagnostic method for differentiating external hydrocephalus from simple subdural hygroma, based on their clinical experience in treating subdural fluid collection after mild head trauma., Methods: Twenty patients with subdural fluid collection after mild head trauma were included in this study. Ventricle size was measured using a modified frontal horn index (mFHI); that is, the largest width of the frontal horns divided by the bicortical distance in the same plane, instead of the inner table distance. Bur hole trephination was performed on the appearance of a subdural fluid collection thicker than 15 mm on computed tomography (CT), persistent (longer than 4 weeks) or increasing in size, and accompanied by neurological symptoms (confusion or memory impairment). During the procedure, subdural pressure was measured using a manometer before opening the dura mater. Subdural pressure varied among the patients, ranging from 3 to 27.5 cm H2O. Four patients with a subdural pressure greater than 15 cm H2O had hydrocephalus after surgery (p < 0.05). Hydrocephalus developed in a pediatric patient (2 years old) with a subdural pressure of 12 cm H2O. All of the patients in whom hydrocephalus developed after bur hole trephination had had enlarged ventricles (mFHI > 33%) on preoperative CT scans., Conclusions: Monitoring subdural pressure may be a valuable tool for differentiating subdural hygroma from external hydrocephalus in patients with mild head trauma. Additionally, the mFHI reflects the nature of the subdural collection more accurately than the standard frontal horn index.

Background: In elderly patients with aneurysmal subarachnoid hemorrhage (SAH), complications including vasosopasm, subdural effusion, and late hydrocephalus, are liable to occur even after aneurysmal surgery. We examined prospectively the efficacy of arachnoid plasty using fibrin glue membrane during surgery of ruptured aneurysms in the elderly patients for preventing complications. The effects on the modified Rankin scale (mRS) and the Glasgow outcome scale (GOS) 3 months after SAH were noted., Methods: Total of 31 patients aged more than 70 years selected from a consecutive series of patients with aneurysmal SAH, were divided into two groups alternately, a group with arachnoid plasty (n = 16) and a control group without arachnoid plasty (n = 15). Statistical analyses were performed to assess relationships among various clinical and neuroradiological variables, especially between arachnoid plasty and occurrence of symptomatic vasospasm, subdural effusion, late hydrocephalus, or outcome such as mRS and GOS 3 months after onset., Findings: Statistical analyses revealed that arachnoid plasty were associated with late hydrocephalus and subdural effusion negatively, but with better mRS at 3 months after SAH. A tendency to be associated with less frequent symptomatic vasospasm was also noted., Conclusion: Arachnoid plasty using fibrin glue is suggested to be effective in preventing complications associated with SAH and aneurysmal surgery. A better outcome in the elderly patients can be achieved.

Context: Spontaneous intracranial hypotension is caused by spontaneous spinal cerebrospinal fluid (CSF) leaks and is known for causing orthostatic headaches. It is an important cause of new headaches in young and middle-aged individuals, but initial misdiagnosis is common., Objective: To summarize existing evidence regarding the epidemiology, pathophysiology, diagnosis, and management of spontaneous spinal CSF leaks and intracranial hypotension., Evidence Acquisition: MEDLINE (1966-2005) and OLDMEDLINE (1950-1965) were searched using the terms intracranial hypotension, CSF leak, low pressure headache, and CSF hypovolemia. Reference lists of these articles and ongoing investigations in this area were used as well., Evidence Synthesis: Spontaneous intracranial hypotension is caused by single or multiple spinal CSF leaks. The incidence has been estimated at 5 per 100,000 per year, with a peak around age 40 years. Women are affected more commonly than men. Mechanical factors combine with an underlying connective tissue disorder to cause the CSF leaks. An orthostatic headache is the prototypical manifestation but other headache patterns occur as well, and associated symptoms are common. Typical magnetic resonance imaging findings include subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia, and sagging of the brain (mnemonic: SEEPS). Myelography is the study of choice to identify the spinal CSF leak. Treatments include bed rest, epidural blood patching, percutaneous placement of fibrin sealant, and surgical CSF leak repair, but outcomes have been poorly studied and no management strategies have been studied in properly controlled randomized trials., Conclusions: Spontaneous intracranial hypotension is not rare but it remains underdiagnosed. The spectrum of clinical and radiographic manifestations is varied, with diagnosis largely based on clinical suspicion, cranial magnetic resonance imaging, and myelography. Numerous treatment options are available, but much remains to be learned about this disorder.

Background: Misdiagnosis of spontaneous intracranial hypotension remains a problem, despite increasing recognition., Methods: Three patients with spontaneous intracranial hypotension presented with typical findings on lumbar puncture, magnetic resonance (MR) imaging, and radioisotope cisternography. All patients showed subdural effusions in the posterior fossa on axial T2-weighted MR imaging. Axial MR images of 112 patients with other conditions were also screened for this finding., Results: One of three patients had typical orthostatic headache, and the other two had continuous headache. The finding of subdural effusions in the posterior fossa on axial T2-weighted MR imaging disappeared after treatment. Similar findings were found in 14 of 112 patients with other conditions. Most of the patients were over 60 years old or had dementia or previous radiation therapy., Conclusions: Subdural effusions in the posterior fossa can be identified by T2-weighted axial MR imaging, and are useful for the diagnosis of spontaneous intracranial hypotension and for verifying the effectiveness of treatment.

Background: Cerebrospinal fluid (CSF) leak is a complication of spinal surgery. Intraoperative or postoperative identification of a CSF leak often results in wound healing complications, lumbar drain placement, and/or reoperation. These complications usually extend a patient's hospital stay, can be painful, and have their own associated risks. The authors describe a technique that may improve on traditional interventions by managing postoperative CSF leaks after lumbar instrumentation without an additional procedure or extended hospitalization., Methods: A retrospective review of lumbar instrumentation cases performed by 5 attending surgeons from the Division of Neurosurgery, University of California at San Diego, was performed. In all, 184 charts were reviewed, spanning a 3-year period. There were 16 cases in which a dural tear and repair were carried out and subsequently treated with subfascial Jackson-Pratt (JP) drainage. Of those 16 cases, 8 patients were managed with prolonged JP drainage using the intraoperatively placed subfascial drain. Patients were discharged home on oral antibiotics according to the customary criteria with the JP drain in place and were instructed regarding proper drain maintenance. Jackson-Pratt drains were removed in clinic in a delayed fashion, approximately 10 to 17 days postoperatively. Patients were subsequently reevaluated at regular intervals for any persistent CSF leak., Results: In the 8 cases reviewed, all patients were discharged in a time frame comparable to that of patients undergoing similar instrumentation in which no CSF leak was identified, or in whom a CSF leak was identified and repaired intraoperatively. No patients suffered complications arising from prolonged drain presence. No patients suffered from persistent CSF leak after drains were removed., Conclusion: Our study suggests that routine intraoperative subfascial JP drain placement aids in the early diagnosis of postoperative lumbar CSF leak. Primary closure of dural tear remains the standard of care. Furthermore, in select cases, prolonged JP drainage in the setting of postoperative CSF leak may be a useful technique for the treatment of these leaks.

Increased attenuation in the basilar cisterns or along the tentorium cerebelli resembling subarachnoid hemorrhage (SAH) may be found on CT in the absence of blood (pseudo-SAH). The authors found pseudo-SAH on CT in four of 40 patients with spontaneous intracranial hypotension. All four patients had brain sagging with obliteration of the cisterns and pachymeningeal enhancement along the tentorium cerebelli. Spontaneous intracranial hypotension should be included in the differential diagnosis of pseudo-SAH.

Pseudotumor cerebri is uncommon in the pediatric age group and presents with clinical characteristics different from the adult form. We report a 5-year-old boy who presented with--seemingly spontaneous--alternating subdural CSF collections before progressing to develop pseudotumor cerebri. To our knowledge, this is the first report of such a presentation. In the prepubertal pediatric age group, pseudotumor cerebri may be associated with multiple etiologic factors (more than in the adult population). The exact common mechanism behind such a disorder is not known. Pseudotumor cerebri may be a disorder of CSF hydrodynamics. It may also be linked to other disorders of CSF hydrodynamics, as in our case. The exact link and mechanistic differences between these apparently related disorders deserve further analysis and investigation, possibly through dynamic MRI techniques.

The outcome of spontaneous intracranial hypotension has been unpredictable. The results of initial MRI were correlated to outcome of treatment in 33 patients with spontaneous intracranial hypotension. A good outcome was obtained in 25 (97%) of 26 patients with an abnormal MRI vs only 1 (14%) of 7 patients with a normal MRI (p = 0.00004). These findings show that normal initial MRI is predictive of poor outcome in spontaneous intracranial hypotension.