Chronic epidural hematoma presenting with diplopia

Background: Epidural hematomas are common intracranial pathologies secondary to traumatic brain injuries and are associated with overlying skull fractures up to 85% of the time. Although many require immediate surgical evacuation, some are observed for stability and followed up conservatively with serial imaging or enlarge slowly overtime, similar to chronic subdural hematomas. Those in the latter category may present with vague symptoms such as diplopia or headache and are often found on routine outpatient evaluation. When concerning findings such as significant mass effect are present, surgical evacuation is necessary. Case Description: Here, we present the case of a 32-year-old man who presented with diplopia 6 weeks after experiencing head trauma and was found to have a chronic epidural hematoma. On resection, thick, inflammatory tissue was observed and carefully resected, revealing normal dura underneath. Six weeks after evacuation of the hematoma, the patient had near-complete resolution of his diplopia and complete resolution of his epidural hematoma. Conclusion: Given the consistency and nature of the fibrous material observed intraoperatively in this case, near-complete resection of the tissue was likely necessary to help facilitate adequate reexpansion of brain parenchyma and improve clinical outcomes.

Bilateral subdural hygromas after endovascular coiling for ruptured aneurysmal subarachnoid hemorrhage: an unusual and rare complication

ABSTRACT Subarachnoid hemorrhage (SAH) with subdural hygroma (SH) was rarely reported after endovascular coiling. A 60-year-old male presented with impaired consciousness and convulsions due to SAH from a ruptured aneurysm. It was managed by endovascular coiling 20 h after the onset of symptoms. Serial brain imaging for 2 weeks revealed progressive bilateral SHs, more on contralateral side of leaking aneurysm. Management of SH was discussed in a multidisciplinary setting to be conservative as there was neither significant mass effect nor hydrocephalus. The patient recovered neurologically except for mild dysarthria. The SH persisted for 2 months and then cleared gradually. We concluded that SH may arise and become symptomatic as an unusual sequela of post-coiling of a ruptured intracranial aneurysm, in which the SH can complicate the clinical course of SAH. However, the symptomatic SH may resolve spontaneously and completely without any intervention, but needs meticulous neurological assessment and follow-up.

Giant simple hepatic cyst mimicking as hydatid cyst: diagnostic dilemma

Giant liver cysts are uncommon. Hepatic cysts are usually asymptomatic and are found incidentally but they can become symptomatic and cause bleeding, infection, mass effect to adjacent structures or rupture. We described two cases of symptomatic liver cysts described suspected clinically and radiologically reported as hydatid cyst but were revealed to be simple liver cysts following surgery. Two elderly men presented with an enlarging abdominal mass and abdominal pain for 1 week. Both patients on radiology had large cysts in the liver causing significant mass effect on adjacent structures and characteristics were suggestive of hydatid cyst. Diagnostic laparoscopy with drainage was done for both patients and revealed as simple hepatic cyst. Hence simple liver cyst can mimic as hydatid cyst attaining giant dimensions and should be considered as an important differential diagnosis.

Malignant middle cerebral artery infarction following subacute subdural hematoma: A case report and literature review

Background: Subacute subdural hematomas (ASDH) are only treated surgically when they cause mass effect significant enough to give symptoms. Rarely, sub-ASDH may cause enough pressure to result in a malignant middle cerebral artery (MCA) territory infarction. Decompressive craniectomy (DC) is the last resort to reduce intracranial pressure following malignant MCA infarction. Herein, we review the literature and describe a case of MCA/posterior cerebral artery (PCA) territories infarction following drainage of a sub-ASDH that was treated with DC with good outcome. Case Description: We report a case of malignant right-sided MCA/PCA infarction in a 62-year-old man who presented with progressive headache following a cycling incident leading to a head injury. Initial CT head demonstrated a small right ASDH. He had no neurological deficit, headache settled on analgesia, and there was no expansion of the SDH on the repeat CT; therefore, he was managed conservatively. He was admitted 6-days later with worsening headaches and hyponatremia. Repeat CT revealed an increase in size of the hematoma and mass effect leading to a mini-craniotomy and evacuation of hematoma. He developed left-sided hemiplegia, slurred speech and hyponatremia, and CT head demonstrated a right-sided MCA/PCA infarction with significant mass effect. He underwent emergent DC and subsequent cranioplasty and ultimately recovered to mRS of 2. Conclusion: SDH are frequent neurosurgical entities. Malignant MCA/PCA strokes following mini-craniotomies are rare but need to be considered especially during the consent process.

Spectrum of Imaging Findings in Oriental Cerebral Schistosomiasis and Their Categorization by MRI

Introduction: To describe the spectrum of imaging findings in oriental cerebral schistosomiasis and characterizing different stages by MRI.Methods: A retrospective review of the clinical and MRI images of twenty nine pathologically proven cases of neuroschistomiasis was performed. Patients with either absence of complete MR examination, previously treated patients were excluded from the study. MRI images were analyzed and lesions were evaluated for the following parameters - distribution, size, clusterity, perilesional edema, mass effect, intralesional hemorrhage, necrosis, cystic degeneration, any abnormal enhancements, any atypical features as abscess,vasculitis, infarctions, or focal atrophy and encephalomalacia.Results: Lesions were only supratentorial in 25 cases, only infratentorial in 3 cases while were both supratentorial and infratentorial in 1 case. Lesions were unilateral in 26 cases. Significant mass effect was noted in 8 cases. All nodular and mass lesions were hyperintense or isointense in T1WI while all but two lesions were hyperintense in T2WI. Lesions were predominantly as clustered nodules (12 cases). All nodules enhanced homogeneously except three that demonstrated ring like enhancement. Masses were demonstrated either homogeneous (2 cases) or heterogeneous in enhancement (2 cases). Central linear enhancement was noted in 12 cases, leptomeningeal enhancement in 10 cases while gyral enhancement was noted in 1 case.Conclusions: Radiological presentation of neuroschistosomiasis varies at different stages of infection as well as among the asymptomatic groups. Recognition of spectrum of presentation has an implied role in the overall management and outcome in cases

Superior Hypophyseal Artery Ruptured Aneurysm in a 5-Month-Old Child Presenting as an Acute Subdural Hematoma: A Case Report

<b><i>Introduction:</i></b> We present a very rare case of ruptured superior hypophyseal artery (SHA) aneurysm that presented as an acute subdural hematoma (SDH) discussing its initial presentation, diagnosis, and treatment modalities. To our knowledge it is one of very few if any cases of a ruptured aneurysm in infants regarding that specific vascular location. <b><i>Case Report:</i></b> A 5-month-old boy was referred to our department due to acute SDH over the right cerebral hemisphere without significant mass effect nor hydrocephalus. Further evaluation revealed a right internal carotid artery (ICA) aneurysm arising from the SHA segment. Microsurgical clip ligation using a fenestrated, angled clip was performed with simultaneous subdural clot removal and proximal control of the ICA dissected in the neck. Our patient made an excellent recovery without any complicating features. <b><i>Conclusion:</i></b> Surgical management seems to be a better option in this subgroup of patients given the long life expectancy and durability of microsurgical clip ligation. We believe that our brief case report would add some insight into the management of this rare subgroup of patients, leading to better decision-making and outcome.

Massive Temporalis Muscle Swelling after Decompressive Craniectomy: Case Report

Background: Decompressive Craniectomy is a surgical procedure in neurosurgery to handle brain swelling subsequent to trauma, vascular insult, or tumor. There are different techniques and measurements of decompressive craniectomy performed worldwide. We follow the regular trauma flap involving fronto-temporo-parietal craniectomy. There have been many complications seen in these procedures, like brain herniation, malignant swelling, hydrocephalus, infection, etc. But we have encountered quite rare complications of decompressive craniectomy which had massive swelling of the temporalis muscle leading to significant mass effect and midline shift.

Value of Adding Cisternostomy to Decompressive Hemicraniectomy in the Management of Traumatic Acute Subdural Hematoma Patients

BACKGROUND: Surgical evacuation of acute subdural hematoma has remained the mainstay of the treatment for acute subdural hematoma (ASDH) in patients with progressive neurological deficits, increasing intracranial pressure (ICP), or significant mass effect. Cisternostomy entails opening the basal cisterns aiming to their opening to atmospheric pressure and therefore reducing the intraparenchymal pressure. AIM: We aimed to evaluate value of adding cisternostomy to decompressive craniotomy on outcome of traumatic ASDH patients. METHODS: Prospective study included 40 patients who presented to Cairo University hospital emergency department with traumatic acute subdural hematoma in the period between January 2018 and June 2019 and matching our inclusion criteria: Age from 12 to 65 years, traumatic acute subdural hematoma with thickness ≥ 10 mm or midline shift ≥ 5 mm, and Glasgow Coma Scale (GCS) on admission < 10, with no associated intraparenchymal hematoma ≥ 1 cm or severe comorbidities. Patients were randomized into one of two groups according to their order of coming. The first group patients were operated on by decompressive craniotomy (DHC) plus cisternostomy and the second group was operated on by decompressive craniotomy only. Glasgow Outcome Score (GOS) was used for outcome assessment. RESULTS: Outcome was better 2nd but not statistically significant – in the first group (DHC+ cisternostomy) in terms of mortality: 7/20 patients (35%) (p = 0.337) and median GOS: 3 (p = 0.337), compared to the second group (DHC only) in which mortality occurred in 10/20 (50%) and median GOS was 1. Adding cisternostomy to decompressive craniotomy increased surgery time with 35.5 minutes in average. In our study, older age and lower GCS on admission had significantly worse outcome. CONCLUSION: Adding cisternostomy to decompressive craniotomy in traumatic patients had better 2nd but not statistically significant outcome. Whether it should replace the routine decompressive craniotomy in these cases or not needs further larger clinical trials.

Extensive Upper Airway Hematoma Secondary to Supratherapeutic Warfarin Anticoagulation

Case Presentation: A 63-year-old female presented to the emergency department complaining of cough, neck swelling, dysphagia, and dysphonia for two days, with a past medical history of atrial fibrillation managed with warfarin. Investigations revealed a supratherapeutic international normalised ratio (greater than 10). Imaging and endoscopic examination showed an extensive retropharyngeal hematoma with significant mass effect on the airway. Discussion: A rare but potentially fatal complication of warfarin anticoagulation is upper airway hematoma, with violent coughing described as an inciting cause. Signs of airway compromise necessitate specialist consultation and definitive airway management, while mild cases without airway concerns can be managed conservatively with medical anticoagulation reversal.

Rare case of giant pediatric cavernous angioma of the temporal lobe: A case report and review of the literature

Background: Giant cavernous malformations of the central nervous system are quite rare. They are more common in children and may be misdiagnosed as other intracranial neoplasms. Here, we presented a very rare giant cavernous angioma mimicking a neoplastic temporal lobe lesion in an 18-month-old male. Case Description: An 18-month-old male presented with two initial seizures. Although the clinical examination was normal, the computed tomography (CT) scan showed a large left temporal mass (66 mm diameter) exerting significant mass effect and midline shift. The brain magnetic resonance (MR) imaging demonstrated a large left temporal heterogeneously enhancing lesion with significant perilesional edema and mass effect. The patient underwent gross total removal of the lesion that proved to be an intracranial cavernous angioma. Postoperatively, he did well, exhibiting no residual neurological deficit, and has remained lesion and seizure-free. Conclusion: This and 12 other cases in the literature focus on intracranial cavernous angiomas that could have been readily misdiagnosed as tumors. It confirms why obtaining appropriate preoperative MR and CT studies, followed by surgical intervention, is essential to confirm the correct underlying pathology and appropriately and optimally treat the patient.