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Oren N. Gottfried, Wayne M. Gluf and Meic H. Schmidt

Cavernous hemangioma of the calvaria is a very rare disease, and patients usually present with headaches or a visible skull deformity. Few reports of patients presenting with intradiploic or epidural hemorrhages are found in the literature. No case of an intradural hemorrhage from a cavernous hemangioma of the skull has been reported to date. The authors present the case of a 50-year-old man in whom a symptomatic subdural hematoma (SDH) resulting from a cavernous hemangioma of the calvaria had hemorrhaged and eroded through the inner table of the skull and dura mater. The patient underwent surgery for evacuation of the SDH and resection of the calvarial lesion. Postoperatively, the patient experienced immediate relief of his symptoms and had no clinical or radiological recurrence. Calvarial cavernous hemangiomas should be considered in the differential diagnosis of nontraumatic SDHs. Additionally, skull lesions that present with intracranial hemorrhages must be identified and resected at the time of hematoma evacuation to prevent recurrences.

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Levin Häni, Sonja Vulcu, Mattia Branca, Christian Fung, Werner Josef Z’Graggen, Michael Murek, Andreas Raabe, Jürgen Beck and Philippe Schucht

OBJECTIVE

The use of subdural drains after surgical evacuation of chronic subdural hematoma (CSH) decreases the risk of recurrence and has become the standard of care. Halfway through the controlled, randomized TOSCAN (Randomized Trial of Follow-up CT after Evacuation of Chronic Subdural Hematoma) trial, the authors’ institutional guidelines changed to recommend subgaleal instead of subdural drainage. The authors report a post hoc analysis on the influence of drain location in patients participating in the TOSCAN trial.

METHODS

The study involved 361 patients enrolled in the TOSCAN trial. The patients were stratified according to whether they received surgery before (cohort A) or after (cohort B) the change in institutional protocol. An intention-to-treat analysis was performed with surgery for recurrence as the primary endpoint. Secondary endpoints were outcome-based on modified Rankin Scale scores, seizures, infections, parenchymal brain injuries, and hematoma diameter.

RESULTS

Of the 361 patients included in the analysis, 214 were stratified into cohort A (subdural drainage recommended), while 147 were stratified into cohort B (subgaleal drainage recommended). There was a 31.78% rate of crossover from the subdural to the subgaleal drainage insertion site due to technical or anatomical difficulties. No differences in the rates of reoperation (21.5% [cohort A] vs 25.17% [cohort B], OR 0.81, 95% CI 0.50–1.34, p = 0.415), infections (0.47% [cohort A] vs 2.04% [cohort B], OR 0.23, 95% CI 0.02–2.19, p = 0.199), seizures (3.27% [cohort A] vs 2.72% [cohort B], OR 1.21, 95% CI 0.35–4.21, p = 0.765), or favorable outcomes (modified Rankin Scale score 0–3) at 1 and 6 months (91.26% [cohort A] vs 96.43% [cohort B], OR 0.39, 95% CI 0.14–1.07, p = 0.067; 89.90% [cohort A] vs 91.55% [cohort B], OR 0.82, 95% CI 0.39–1.73, p = 0.605) were noted between the two cohorts. Postoperatively, patients in cohort A had more frequent parenchymal brain tissue injuries (2.8% vs 0%, p = 0.041). Postoperative absolute and relative hematoma reduction was similar irrespective of the location of the drain.

CONCLUSIONS

Subgaleal rather than subdural placement of the drain did not increase the risk for reoperation for recurrence of CSHs, nor did it have a negative impact on clinical or radiological outcome. The intention to place a subdural drain was associated with a higher rate of parenchymal injuries.

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Scoliosis and hydrocephalus in myelocele patients

The effects of ventricular shunting

Peter Hall, Richard Lindseth, Robert Campbell, John E. Kalsbeck and Alonso Desousa

scoliosis to shunting; one patient (Case 1), whose scoliosis worsened, showed considerable improvement of strength in the upper extremities. In the unselected group of 29 shunted patients, ventricular shunts were complicated by symptomatic subdural hematomas in two patients; one of these also had a shunt infection. Both were treated successfully following shunt removal. One of the 11 selected patients in this series died 8 months after the shunt procedure of an unrelated cause. Discussion Ventricular shunting produced a short-term improvement in seven of 11

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Asokumar Buvanendran, Richard W. Byrne, Maruti Kari and Jeffrey S. Kroin

idiopathic CSF leak was suspected. An MR image of the spine did not reveal evidence of CSF leak ( Figs. 1B and C ). Due to our suspicion of a CSF leak, a lumbar EBP procedure was performed with 20 ml of autologous blood (with bed rest for 24 hours after the procedure), resulting in relief of headache and associated symptoms for a week. Nevertheless, the patient's symptomatic subdural hematomas recurred and he presented again to the emergency service ( Fig. 2A ), requiring surgical drainage of the hematomas. After the second subdural drainage surgery a spinal column CT

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Joshua J. Chern, Samir Sarda, Brian M. Howard, Andrew Jea, R. Shane Tubbs, Barunashish Brahma, David M. Wrubel, Andrew Reisner and William Boydston

evacuation of delayed, symptomatic subdural hematoma following rupture of an arachnoid cyst. The patient was observed in the hospital and discharged with follow-up 2 weeks later. On postdischarge Day 10 the patient became symptomatic and came to the ED. The clinical change was acute, and routine imaging in the asymptomatic postdischarge period would likely not have revealed new pathology. Acquisition of postdischarge imaging following minor head trauma remains a common practice. However, these data demonstrate that, in a large series of consecutive pediatric patients

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Patrick W. Hanlo, Giuseppe Cinalli, W. Peter Vandertop, Joop A. J. Faber, Lars Bøgeskov, Svend E. Børgesen, Jürgen Boschert, Paul Chumas, Hans Eder, Ian K. Pople, Willy Serlo and Eckehard Vitzthum

results very comparable to what were published 20 years ago. 2 The causes of shunt malfunction can be defined as those related to the patient, those related to the surgery, and those related to the shunt. Among shunt-related problems, chronic overdrainage has been demonstrated to cause both acute (symptomatic subdural hematoma) and more delayed (proximal obstructions or slit-ventricle syndromes) shunt failure. 9, 10, 18 Overdrainage is a general term that encompasses all phenomena that induce shunt flows well in excess of CSF production rates. Postural overdrainage