Endoscopic evacuation of septated chronic subdural hemorrhage – Technical considerations, results, and outcome

Background: Chronic subdural hematoma (cSDH) is a common entity in the elderly. Homogeneous or well-liquefied CSDH has a standard line of treatment through burr hole and irrigation. However, the management of septated chronic subdural hematoma (sCSDH) with multiple membranes does not have a well-defined surgical approach. The neomembranes forming septations prevent evacuation of clots through burr holes, and the small remaining loculi with clots will enlarge overtime to cause recurrence. Methods: Patients with sCSDH were operated through a minicraniotomy (2.5 cm × 2.5 cm) using rigid endoscopes for visualization of the subdural space. Using endoscope, the entire subdural space can be visualized. The neomembranes are removed with standard neurosurgical microinstruments. The entire cavity is irrigated under vision to remove all clots and ensures hemostasis. Results: Eighty-three endoscope-assisted evacuations were done in 68 patients from January 2016 to April 2020. Fifty (73.5%) patients had unilateral and 18 (26.5%) had bilateral subdural. Only 1 patient (1.47%) had a clinically significant recollection of subdural bleeding 1 month after the procedure. Over a mean follow-up period of 25.3 months (range 1–53 months), rest of patients did not show any recollection. Conclusion: Endoscopic evacuation of sCSDH is a safe and effective method and can be used to improve clot evacuation, and remove neomembranes under direct vision to reduce the rates of recollection. This method also obviates the need for larger craniotomies to remove membranes.

Head Injury without Head Blow? A Rare Case of Subdural Hematoma Associated with Minute Arachnoid Cyst in a Teenage Skater

Background Skateboarding has been reported to cause diverse kinds of injuries, including head trauma. However, the risk of brain injury without direct blow to the head seems to be underestimated. In particular, the impact of the inertial forces related to the vigorous character of skateboarding tricks is not sufficiently recognized. Case Description In our report, we demonstrate a case of chronic subdural hematoma developing without previous blow to the head in a 17-year-old skater bearing small frontal convexity arachnoid cyst. Conclusion Based on the described case, the possibility of acceleration and angular forces related to skate park leisure activities resulting in subdural hematoma needs to be discussed. This risk should be critically appraised in patients carrying arachnoid cyst as a malformation predisposing to develop subdural bleeding.

A CASE REPORT OF ACUTE NONTRAUMATIC SPONTANEOUS SUBDURAL HAEMATOMA DUE TO PSEUDOANEURYSM OF MIDDLE MENINGEAL ARTERY

Acute subdural bleeding is blood collection in subdural space, usually caused by laceration of the bridging vein that runs from cortex to meningeal layer. On the other hand, the acute epidural hematoma is a collection of blood above the dura mater, usually caused by tearing of the middle meningeal artery. Subdural hematoma acute more likely happen in elderly than young adult. This case report discusses acute spontaneous subdural hematoma that was caused by a pseudoaneurysm of the middle meningeal artery. Seventeen years old boy came with symptoms of high intracranial pressure because of massive subdural bleeding. He was undergone craniotomy. After the clot removal operation, Digital Subtraction Angiography revealed vascular blush and pseudoaneurysm of the middle meningeal artery. Onyx embolization was delivered to proximal to a distal branch of the middle meningeal artery. The patient recovered in good condition, and no rebleeding in two years. Conclusion. Acute spontaneous subdural bleeding even though it is quite rare, but the chance of fatal rebleeding is high. As a result, one still has to look for the source of bleeding and manage comprehensively with embolization.

Safety and efficacy of rivaroxaban in pediatric cerebral venous thrombosis (EINSTEIN-Jr CVT)

Anticoagulant treatment of pediatric cerebral venous thrombosis has not been evaluated in randomized trials. We evaluated the safety and efficacy of rivaroxaban and standard anticoagulants in the predefined subgroup of children with cerebral venous thrombosis (CVT) who participated in the EINSTEIN-Jr trial. Children with CVT were randomized (2:1), after initial heparinization, to treatment with rivaroxaban or standard anticoagulants (continued on heparin or switched to vitamin K antagonist). The main treatment period was 3 months. The primary efficacy outcome, symptomatic recurrent venous thromboembolism (VTE), and principal safety outcome, major or clinically relevant nonmajor bleeding,were centrally evaluated by blinded investigators. Sinus recanalization on repeat brain imaging was a secondary outcome. Statistical analyses were exploratory. In total, 114 children with confirmed CVT were randomized. All children completed the follow-up. None of the 73 rivaroxaban recipients and 1 (2.4%; CVT) of the 41 standard anticoagulant recipients had symptomatic, recurrent VTE after 3 months (absolute difference, 2.4%; 95% confidence interval [CI], −2.6% to 13.5%). Clinically relevant bleeding occurred in 5 (6.8%; all nonmajor and noncerebral) rivaroxaban recipients and in 1 (2.5%; major [subdural] bleeding) standard anticoagulant recipient (absolute difference, 4.4%; 95% CI, −6.7% to 13.4%). Complete or partial sinus recanalization occurred in 18 (25%) and 39 (53%) rivaroxaban recipients and in 6 (15%) and 24 (59%) standard anticoagulant recipients, respectively. In summary, in this substudy of a randomized trial with a limited sample size, children with CVT treated with rivaroxaban or standard anticoagulation had a low risk of recurrent VTE and clinically relevant bleeding. This trial was registered at clinicaltrials.gov as #NCT02234843.

Pertimbangan Etika Klinik dan Medikolegal untuk Pengelolaan Anestesi pada Kasus Cedera Otak Traumatik

Cedera Otak Traumatik (COT) merupakan penyebab utama kematian dan kesakitan pada anak-anak dan dewasa muda di seluruh dunia. Dilaporkan sebuah kasus COT pada seorang pasien anak laki-laki berusia 5 tahun yang jatuh dari lantai 2. Pasien didiagnosis dengan cedera kepala berat dengan perdarahan epidural dan subdural dengan level ASA 3–4. Dilema etis yang dihadapi ahli anestesi adalah tindakan anestesi berisiko tinggi tetapi kemungkinan penyelamatan nyawa tidak berhasil, sehingga apakah masih tetap dilakukan operasi atau hanya diberikan terapi suportif?. Laporan ini membahas tentang pemecahan dilema etik dan medikolegal berdasarkan teori etika klinik. Hasil pertimbangan etika dan medikolegal pada kasus ini dilakukan secara komprehensif dengan menghasilkan keputusan bersama antara tim dokter dengan keluarga pasien. Dengan pemberian informasi yang adekuat mengenai indikasi medik dengan tetap memperhatikan sudut pandang permintaan (keinginan) pasien, kualitas hidup maupun fitur kontekstual maka meskipun pada akhirnya pasien ini tidak berhasil diselamatkan, paling tidak keluarga pasien puas atas pelayanan yang telah diberikan. Clinical Ethics and Medicolegal Considerations for Anesthesia Management in Cases of Traumatic Brain InjuryAbstractTraumatic Brain Injury (COT) is a leading cause of death and illness in children and young adults throughout the world. A case of COT was reported in a 5-year-old boy who fell from the 2nd floor. The patient was diagnosed with a severe head injury with epidural and subdural bleeding with ASA levels 3-4. The ethical dilemma faced by the anesthesiologist is the high-risk anesthetic procedure but the possibility of life saving is unsuccessful, so whether the surgery is still being performed or only given supportive therapy?. This report discusses solving ethics and medicolegal dilemmas based on clinical ethics theory. The results of ethical and medicolegal considerations in this case were carried out comprehensively by producing a joint decision between the team of doctors and the patient's family. By providing adequate information regarding medical indications while still giving attention to the patients' preferences, quality of life and contextual features, even though these patients were ultimately unsuccessful, at least the patient's family was satisfied with the services provided.

Rare case of dural arteriovenous fistula presenting by spontaneous acute subdural hematoma: A case report and review of literature

Introduction. Dural arteriovenous fistulas represent pathological acquired bonds between the meningeal blood vessels (arteries) and drainage veins associated to them. These fistulas can vary in clinical presentations, from being asymptomatic to causing serious neurological deficits, depending mostly on the localization and size. Only one fourth of dural fistulas present themselves with intracranial bleeding. This hemorrhage is most frequently localized in subarachnoid space, occasionally intracerebrally, and seldom beneath the dura mater, ie subdurally. Case report. We presented a rare case of a patient with spontaneous acute subdural hematoma. After the initial treatment and consequent imaging methods, a diagnosis of a dural arteriovenous fistula was established. After the craniotomy for hematoma evacuation, the patient underwent an uneventful endovascular treatment. Despite the rarity of non-traumatic acute subdural hematoma caused by dural arteriovenous fistula, one should not overlook the possible pathogenesis and etiology in patients with spontaneous acute subdural hematoma. Even with the absence of the symptoms and signs of subdural bleeding, dural arteriovenous fistula, as a cause of it, should not be immediately ruled out. Conclusion. Despite the rarity of non-traumatic acute subdural hematoma being caused by dural arteriovenous fistulas, one should not immediately overlook the possible pathogenesis and etiology. Cautious approach is needed when treating such diseases even in the absence of typical symptoms.

Characteristics and prognostic factors of intracranial hemorrhage in children

Objective Finding the characteristics and risk factors associatedwith prognosis in children suffering from intracranial hemorrhage.Methods This was a retrospective medical record review of chil-dren (older than 1 month old) admitted with intracranial hemor-rhage to the Department of Child Health the Sanglah Hospital,Denpasar, during the period of January 1998 to December 2000.Prognostic factors were identified by chi-square and multivariateanalysis with significance of p<0.05Results There were 56 patients eligible for the study. Among themwere 35 (63%) males and 21 (27%) females. Forty-three (77%)were less than one year of age, 40 (71%) without history of traumaand the major clinical manifestation was paleness (89%). The mostcommon location was subdural bleeding, 21 patients (38%). Fac-tors associated with prognosis was the bleeding location (p<0.05)Conclusions Intracranial hemorrhage was more common in malesand in infants. The most common clinical manifestation was pale-ness. Bleeding location was associated with prognosis

Managing Subdural Bleeding Associated With Rivaroxaban

Objective: To report 3 cases of subdural bleeding associated with rivaroxaban managed by 3-factor prothrombin complex concentrate (PCC3). Case Summaries: Case 1 presented with a 1-cm thick subdural hematoma (SDH) 12 hours after her last dose of rivaroxaban. Case 2 presented with a right 1-cm acute right SDH with 2 to 3 mm of midline shift 24 hours after his last dose of rivaroxaban. Case 3 presented with a 1.8-cm thick right cerebral convexity hematoma 12 hours after her last dose of rivaroxaban. All patients received 23 to 35 units/kg PCC3 with 1 to 3 units of fresh frozen plasm (FFP) and demonstrated no progression in lesions measured by repeat computed tomography (CT). Two patients were discharged to rehabilitation facilities and 1 patient ultimately died due to the location of the lesion. Discussion: Rivaroxaban has no specific antidote. Current bleeding management strategies are based on expert opinion. The risks and benefits for differing strategies are unclear, and no clinical experience has been reported to date. These cases begin to illuminate differences among choices for managing bleeding associated with Xa inhibitors. Conclusion: In this case series, 25 to 35 units/kilogram PCC3 and FFP 1 to 3 units ceased rivaroxaban-associated bleeding without thrombogenic complications.