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A : CT shows an isodense subdural hematoma in the left frontal and parietal region with compressed ipsilateral ventricle and midline shift. B : Postoperative CT illustrates a subtotal evacuation of the subdural hematoma and restoration of the midline structures with the residual hematoma cavity replaced by low density fluid and air.
Source publication
Chronic subdural hematoma (CSDH), which rarely happens in the young, is thought to be a disease of the elderly. Whereas unspecific symptoms and insidious onset in juveniles and young adults, as a result of its relative low morbidity, CSDH is usually neglected even undertreated in the young. Through the three cases and review of the current literatu...
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Intracranial hypotension (IH) can occur following lumbar drainage for clipping of an intracranial aneurysm. We observed 3 cases of IH, which were all successfully treated by epidural blood patch (EBP). Herein, the authors report our cases.
Citations
... From the literature, it may be postulated that nontraumatic CSDHs in young patients could be associated with spontaneous AC-related hemorrhage. [1,2,7,8,10,11,14,15] e etiologies of hemorrhage in subdural and/or intracystic spaces include: (1) rupture of bridging veins by tearing of the outer wall of the AC; [7,14] (2) rupture of unsupported blood vessels around the cyst wall; [7,8] and (3) rupture of leptomeningeal vessels at the base of the cyst. [7,8] To the best of our knowledge, there are no reported cases of nontraumatic SDH followed by AC hemorrhage. ...
... From the literature, it may be postulated that nontraumatic CSDHs in young patients could be associated with spontaneous AC-related hemorrhage. [1,2,7,8,10,11,14,15] e etiologies of hemorrhage in subdural and/or intracystic spaces include: (1) rupture of bridging veins by tearing of the outer wall of the AC; [7,14] (2) rupture of unsupported blood vessels around the cyst wall; [7,8] and (3) rupture of leptomeningeal vessels at the base of the cyst. [7,8] To the best of our knowledge, there are no reported cases of nontraumatic SDH followed by AC hemorrhage. ...
... [1,2,7,8,10,11,14,15] e etiologies of hemorrhage in subdural and/or intracystic spaces include: (1) rupture of bridging veins by tearing of the outer wall of the AC; [7,14] (2) rupture of unsupported blood vessels around the cyst wall; [7,8] and (3) rupture of leptomeningeal vessels at the base of the cyst. [7,8] To the best of our knowledge, there are no reported cases of nontraumatic SDH followed by AC hemorrhage. ...
Background
Diagnosing the cause of headaches can be challenging. Even if intracranial lesions are found in a patient, careful assessment is essential for diagnosis, and treatment strategies will differ for each etiology.
Case Description
A 16-year-old boy presented with sudden-onset headache which had lasted for 2 days. His headache was aggravated in the orthostatic position. The patient denied recent head trauma. He had been diagnosed with an arachnoid cyst (AC) in his right middle cranial fossa. Computed tomography (CT) revealed bilateral subdural effusions and slit-like lateral ventricles with no significant changes to the AC. After intravenous hydration followed by 2 days bed rest, his symptoms abated. He was diagnosed as having suffered spontaneous cerebrospinal fluid (CSF) hypovolemia. One month later, the patient experienced recurrent gradual onset headache and vomiting. CT revealed chronic right side subdural hematoma (SDH) with intracystic hemorrhage, which resulted in the elevation of intracranial pressure. An urgent hematoma evacuation was performed. He became symptom-free immediately after surgery. Postoperative follow-up CT showed no change in the AC and no recurrence of SDH. The lateral ventricles and subdural space were normal in size.
Conclusion
We report a case presenting multiple types of secondary headaches, which were caused by intracranial hypotension or hypertension, with different etiologies. These were spontaneous CSF hypovolemia, nontraumatic intracystic hemorrhage form of AC, and nontraumatic chronic SDH. Although lesions seen at the time of initial diagnosis did not need surgical treatment, careful observation and repetitive imaging assessments might be useful for discovering unsuspected additional etiologies requiring surgical intervention.
... In the pediatric population, chronic SDH is associated with AC [12]. Particularly, cyst location in the MCF is recognized for being associated with increased susceptibility to the development of SDH [13,14]. In pediatric patients with chronic SDH and AC, symptoms include headache and vomiting, whereas hemiparesis was prevalent in patients without AC. ...
Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic.
A 14- year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school.
ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.
... 4 While head injury, falls, use of anticoagulants and antiplatelets on a background of senile atrophy of the brain are the most widely recognized risk factors in the elderly population, the younger patients share some risk factors with some peculiarities. 3,[5][6][7] Playing of wind instruments such as the flute, trumpet and saxophones has Playing wind instruments as a risk factor for chronic subdural haematoma: A report of 2 cases been reported in few publications as a risk factor for CSDH. 8,9 Much attention, however, has not been given to this Valsalva effect cause that can affect the profession or hobby of many individuals worldwide. ...
... Among the risk factors are aging with associated cerebral atrophy, trauma (many times mild or unnoticed) to the head, anticoagulant and antiplatelet use, alcoholism, ventriculoperitoneal shunting and seizure disorders. 7 The diagnosis of CSDH in the elderly can be obvious. In the young, however, it can easily be missed on clinical ground. ...
... Chronic subdural hematoma (cSDH) is a diagnosis with increasing prevalence among the older. Nevertheless, cSDH is also seen in younger patients (previously defined as <50 years in literature), although less commonly (1)(2)(3)(4)(5). And while cSDH in the young is often associated with predisposing condition i.e., arachnoid cysts, coagulation disorders, or ventriculoperitoneal shunts, even cSDH without predisposing condition has been reported, often in connection with head trauma (6,7). ...
... Correct interpretation of clinical presentation is important for timely diagnosis. Nevertheless, the reports from literature on the clinical presentation of younger patients with cSDH are varied and often conflicting (1)(2)(3)(4)(5). Also, even though surgical evacuation is the main treatment modality in cSDH patients, little is known as to the recurrence rates, morbidity and mortality of young patients with surgically treated cSDH. ...
Objective: Chronic Subdural Hematoma (cSDH) is primarily a disease of elderly, and is rare in patients <50 years, and this may in part be related to the increased brain atrophy from 50 years of age. This fact may also influence clinical presentation and outcome. The aim of this study was to study the clinical course with emphasis on clinical presentation of cSDH patients in the young (<50 years).
Methods: A retrospective review of a population-based cohort of 1,252 patients operated for cSDH from three Scandinavian neurosurgical centers was conducted. The primary end-point was difference in clinical presentation between the patients <50 y/o and the remaining patients (≥50 y/o group). The secondary end-points were differences in perioperative morbidity, recurrence and mortality between the two groups. In addition, a meta-analysis was performed comparing clinical patterns of cSDH in the two age groups.
Results: Fifty-two patients (4.2%) were younger than 50 years. Younger patients were more likely to present with headache (86.5% vs. 37.9%, p < 0.001) and vomiting (25% vs. 5.2%, p < 0.001) than the patients ≥50 y/o, while the ≥50 y/o group more often presented with limb weakness (17.3% vs. 44.8%, p < 0.001), speech impairment (5.8% vs. 26.2%, p = 0.001) and gait disturbance or falls (23.1% vs. 50.7%, p < 0.001). There was no difference between the two groups in recurrence, overall complication rate and mortality within 90 days. Our meta-analysis confirmed that younger patients are more likely to present with headache (p = 0.015) while the hemispheric symptoms are more likely in patients ≥50 y/o (p < 0.001).
Conclusion: Younger patients with cSDH present more often with signs of increased intracranial pressure, while those ≥50 y/o more often present with hemispheric symptoms. No difference exists between the two groups in terms of recurrence, morbidity, and short-term mortality. Knowledge of variations in clinical presentation is important for correct and timely diagnosis in younger cSDH patients.
... Particularly in children and young adult patients, in the absence of a head trauma, spontaneous tearing of the AC wall during games and forced physical exercises leads to the leaking of CSF and blood into the subdural space (15,23). The amount of subdural accumulation increases over time, changing the osmotic gradient owing to the effect of subdural degradation products and fenestrated immature vessels in the subdural outer membrane (9). ...
Arachnoid cysts (ACs) are congenital malformations that may develop anywhere in the subarachnoid space along the cerebrospinal axis but are mostly observed in the temporal fossa and Sylvian fissure, predominantly in the left side. ACs account for 1% of all intracranial space-occupying lesions. ACs are a potential risk factor for subdural haematoma in all age groups following a traumatic head injury. Although an intracystic haemorrhage of AC without evidence of a head trauma is very rare, it may particularly develop in children and young adults who spend much more time engaged in games and forced physical exercise. Here we present a rare case of spontaneous intracystic haemorrhage of AC with a subacute subdural haematoma and provide a review of the literature.
... In some cases, the AC was not realized until after the initial decompression, and a second operation was needed for definitive treatment. 26,30,47 Though clearly evident in some cases, the cyst may be filled with acute or chronic blood products, making it difficult to see. Skull thinning was noted in 60% of cases, and can be a subtle, yet important finding when a SDH is seen after a sports injury or low energy trauma. ...
OBJECTIVE
Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis.
METHODS
Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non–sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed.
RESULTS
After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4–75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45–0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03–0.88]).
CONCLUSIONS
This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.
... Other interesting articles [1,2] about CSDHs in young people describes different situations, joined by the same "pathological theme": refractory headache and no hematological disorders, all treated with surgery. ...
Subdural hematoma (SDH) of spine and cranium has been widely reported in the literature, and its recurrence, surgical technique, and treatment methods have been investigated. Although the pathophysiology of intracranial SDH is still the subject of research, risk factors and the main mechanisms for its acute and chronic forms of intracranial have been researched extensively. In this section, contrary to the expected factors for SDH such as advanced age, trauma history, hypertension, and alcoholism, other entities in which the disease can be detected incidentally have been compiled and the cases of intracranial SDH in unexpected diseases have been examined.
Subdural hematomas have been observed in several sports, from ball games like basketball to noncontact sports like race walking. Soccer-related brain injury is uncommon. Only few studies have shown the existence of a relationship between the practice of sport activities and a higher risk to develop chronic subdural hematoma (CSDH), especially in a young population. The best indirect example of this association is Argentina soccer legend Diego Maradona who was operated for CSDH a month before his death. In the presence of an arachnoid cysts, the practice of sport activities may expose young patients to minor head trauma and to an increased risk of developing CSDH. We performed a literature review of all the reported cases of patients with CSDH related to sport practice, from the year 1950 through March 1, 2020, and we finalized a total of 66 cases found across 52 studies. For each case, we analyzed age, sex, sport activity practiced, delay between sport and diagnosis, symptoms, brain imaging, treatment performed, the outcome, and evolution. There is no clear consensus regarding the return of athletes to the sport after CSDH. This study will be of interest to all neurosurgeons and other physicians who treat patients with sports-related CSDH.
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.
