Treatment of patients with traumatic subdural effusion and concomitant hydrocephalus

Clinical article

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Object

Traumatic subdural effusion (TSE) is a common sequela of traumatic brain injury. Surgical intervention is suggested only when TSE exerts mass effect. The authors have found that many patients with TSE exerting mass effect have concomitant hydrocephalus. Patient experiencing this occurrence were studied, and the pathogenesis of this phenomenon was discussed in the context of recent advances in the understanding of CSF circulation.

Methods

During a 2-year period, the authors' institution treated 14 patients with TSE who developed hydrocephalus, after 1 of the patients suffered subdural drainage and other 13 received subdural peritoneal shunt (SPSs). Thirteen of those who had SPSs received programmable ventriculoperitoneal shunts (VPSs) for the hydrocephalus. The clinical characteristics as well as the imaging and operative findings of these patients were reviewed.

Results

All patients with symptomatic TSE exerting mass effect received SPSs. All of these patients had a modified Frontal Horn Index of more than 0.33 at presentation, and high opening pressure on durotomy. Following a brief period (4–7 days) of clinical improvement, the condition of all patients deteriorated due to hydrocephalus. Programmable VPSs were inserted with the initial pressure set at approximately 8–10 cm H2O according to opening pressure at ventriculostomy. Shunt valve pressure was gradually decreased to 5–7 cm H2O, according to clinical and radiological follow-up.

Conclusions

Elevated modified Frontal Horn Index in patients with TSE is suggestive of concomitant hydrocephalus. The authors propose that tearing of the dura-arachnoid plane following trauma contributes to TSE and may also impede CSF circulation, causing hydrocephalus. Shunt pressure was adjusted to relative low pressure, indicating the old age of the patients and poor reexpansion of brain parenchyma after the mass effect. Subdural peritoneal shunts and VPSs are indicated in those patients with TSE exerting mass effect with concomitant hydrocephalus.

Abbreviations used in this paper: GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; mFHI = modified Frontal Horn Index; SDH = subdural hematoma; SPS = subdural peritoneal shunt; TSE = traumatic subdural effusion; VPS = ventriculoperitoneal shunt.

Article Information

Address correspondence to: Kuo-Chuan Wang, M.D., Division of Neurosurgery, Department of Surgery, National Taiwan University, No. 7, Chung-San South Road, 100 Taipei, Taiwan. email: wang081466@yahoo.com.tw.

Please include this information when citing this paper: published online December 16, 2011; DOI: 10.3171/2011.10.JNS11711.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial CT scans showing the 2 different types of measurement of the FHI. A: Conventional FHI is the largest width of the frontal horns divided by the internal diameter from inner table to inner table at this level. Hydrocephalus is suggested when the FHI is larger than 0.5. B: Modified FHI is the largest width of the frontal horns divided by the diameter from cortex to cortex at this level. Hydrocephalus is suggested when the mFHI is larger than 0.33.

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    Graph of serial change of mFHI at admission, before SPS insertion, before VPS insertion, and at 3 months follow-up. The result showed a significant difference in the mFHI between the good outcome and poor outcome groups (p = 0.02).

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    Case 1. Axial CT scans from an 84-year-old man who was admitted due to a ground-level fall. A: Image obtained immediately after the fall (mFHI = 0.321). B: Image obtained on the 7th day after the fall showing TSE on both sides, with more on the left side (mFHI = 0.334). C: Image obtained 37 days after injury showing persistent subdural effusion after repeated subdural drainage. D: Image obtained 65 days after injury showing bilateral dilated ventricles (mFHI = 0.500).

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    Case 2. Axial CT scans obtained in a 77-year-old man who was admitted to the neurosurgical service due to disorientation 3 days after a head concussion. A: Image obtained at admission (Day 3). B: Image obtained on Day 11 right after SPS insertion. C: Image obtained on Day 33, showing gradual deterioration. A programmable VPS was inserted after this CT study, and pressure was set at 8 cm H2O. D: Image obtained on Day 60. The patient's condition had slightly improved, and the image shows persistent hydrocephalus. The pressure of the programmable VPS was adjusted to 5 cm H2O. E: Image obtained approximately 6 months after injury. The patient had an excellent recovery and lives independently.

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