BACKGROUND: En-plaque meningioma (EPM) presents preoperative diagnostic challenges due to its atypical radiologic features. This case report describes the preoperative diagnostic challenges in identifying EPM that affected its operative management.
METHODS: A 58-year-old female patient presented to the emergency department with decreased consciousness and a history of a fall on the head two months earlier. For the past year, the patient also complained of worsening headaches. One week before, the patient also complained of nausea, vomiting, and fluctuating fever. Although a CT scan of the head showed a mass in the left temporoparietal region, the patient was initially diagnosed with subacute subdural hematoma (saSDH) and planned for SDH evacuation surgery using the burr hole technique. However, intraoperative findings revealed an extradural intracranial tumor, so the procedure was switched to tumor excision craniotomy, and based on histopathological examination, it was confirmed to be an anaplastic malignant meningioma, WHO grade III.
CONCLUSIONS: EPM is one of the rare subtypes of meningioma with an atypical and radiologically variable appearance that often presents challenges in preoperative diagnosis. In this case, the patient\'s history of falling on the head and the CT scan of the head that resembles saSDH may obscure the preoperative diagnosis and affect the patient\'s management.
CONCLUSIONS: EPM can manifest like other intracranial disorders. In this case, the patient\'s fall history may obscure the clinicians\' diagnosis of the meningioma, leading to preoperative misdiagnosis with saSDH. Therefore, meticulous preoperative diagnosis is essential to determining the patient\'s medical treatment and outcome.

UNASSIGNED: Spontaneous intracranial hypotension (SIH) is frequently complicated by subacute subdural hematoma (SDH) and more rarely by bilateral thalamic ischemia. Here, we report a case of SIH-related SDH treated with three epidural patches (EPs), with follow-up of the intracranial pressure and lumbar intrathecal pressure.
UNASSIGNED: A 46-year-old man presented bilateral thalamic ischemia, then a growing SDH. After failure of urgent surgical evacuation, he underwent three saline EPs, two dynamic myelography examinations and one digital subtraction angiography-phlebography examination. However, because of no dural tear and no obstacle to the venous drainage of the vein of Galen, no therapeutic procedure was available, and the patient died.
UNASSIGNED: The case exhibited a progressive increase in the transmission of lumbar intrathecal pressure to intracranial pressure during the three EPs. The EPs may have successfully treated the SIH, but the patient did not recover consciousness because of irreversible damage to both thalami.
UNASSIGNED: Clinicians should be aware of the bilateral thalamic ischemia picture that may be the presenting sign of SIH. Moreover, the key problem in the pathophysiology of SIH seems to be intraspinal and intracranial volumes rather than pressures. Therefore, intracranial hypotension syndrome might actually be an intraspinal hypovolume syndrome.

This study aimed to investigate whether a simple endoscopic method was effective for the evacuation of traumatic subacute subdural hematomas.
A total of 51 patients with subacute subdural hematomas requiring surgery were enrolled in this study. An endoscopic hematoma evacuation was performed through a small bone window for 22 patients. Hematoma evacuation by open surgery was performed for 29 patients. The postoperative Glasgow Coma Scale scores improvement, surgery times, displacement of midline measurements, and intraoperative blood loss were recorded and analyzed for each patient.
The average time from the initial incision to suture completion was 38.41 ± 6.97 minutes for the endoscopic surgery group and 74.66 ± 9.54 minutes for the open-surgery group (P < 0.01). The average total blood loss was 41.36 ± 10.82 ml for the endoscopic group and 250.00 ± 58.25 ml for the open-surgery group (P < 0.01). No postoperative bleeding occurred in either group. The midline displacement measurement showed significant improvement on the day after surgery, with 5.21 ± 1.98 mm in the study group versus 6.75 ± 1.37 mm in the control group (P < 0.01). At the 1-month follow-up appointment, the midline measurement was normal in both groups. Computed tomography scans revealed almost no residual hematomas, representing an average evacuation rate of 100% in both groups. The average Glasgow Coma Scale scores improvement on the day after surgery were 1.77 ± 1.93 in the endoscopic surgery group and 1.66 ± 0.77 in the open-surgery group (P = 0.766).
Endoscopic subacute subdural hematoma removal through a small bone window achieved satisfactory hematoma removal using a minimally invasive method when compared with an open-surgery method.

BACKGROUND: Determining a subdural hematoma (SDH) to be chronic by definition takes 3 wk, whereas organized chronic SDH (OCSDH) is an unusual condition that is believed to form over a much longer period of time, which generally demands large craniotomy. Therefore, it is a lengthy process from the initial head trauma, if any, to the formation of an OCSDH. Acute SDH (ASDH) with organization-like, membranaceous appearances has never been reported.
METHODS: A 56-year-old woman presented to our hospital with a seizure, and computed tomography (CT) on admission was negative for signs of intracranial hemorrhage. She had clear consciousness and unimpaired motor functions on arrival and remained stable for the following week, during which she underwent necessary examinations. On the morning of day 10 of hospitalization, she accidentally hit her head hard against the wall in the bathroom and promptly lapsed into complete coma within 2 h. Therefore, we performed emergency CT and identified a left supratentorial SDH that was an absolute indication for surgery. However, the intraoperative findings were surprising, with no liquefaction observed. Instead, a solid hematoma covered with a thick membrane was noted that strongly resembled an organized hematoma. Evacuation was successful, but the family stopped treatment the next day due to financial problems, and the patient soon died.
CONCLUSIONS: Neurosurgeons should address SDHs, especially ASDHs, with discretion and individualization due to their highly diversified features.

Subacute subdural hematoma (SASDH) is a neurotraumatic entity. There are few reports of chronological changes of cerebral blood flow (CBF) on arterial spin labeling (ASL) and subcortical low intensity (SCLI) on fluid-attenuated inversion recovery (FLAIR) images of magnetic resonance imaging (MRI) observations from the injury onset, deterioration, to post-surgery. We reported a SASDH patient presenting postoperative cerebral hyperperfusion (CHP) syndrome with chronological changes of those findings. An 85-year-old woman fell and presented right ASDH. She was treated conservatively due to no neurological deficits. On day 3, ASL image revealed increased CBF against brain compression. On day 7, the CBF was normalized on ASL image, but SCLI was confirmed. On day 14, SCLI was strengthened. Then she developed left hemiparesis due to brain compression by SASDH. Considering age and comorbidities, we performed endoscopic hematoma removal under local anesthesia, and her neurological deficits improved after the surgery. On postoperative day 1, she newly presented left upper limb paresis. MRI revealed increased CBF and enhanced SCLI. We diagnosed CHP syndrome, and antihypertensive treatment improved the symptoms gradually. However, SCLI had been consistently observed, and CBF easily changed depending on the blood pressure, suggesting dysfunction of the CBF autoregulation. We showed the endoscopically treated SASDH patient with CBF\'s chronological changes on ASL images and SCLI on FLAIR images. Long-time brain compression would lead to dysfunction of the CBF autoregulation, and we should be careful about CHP syndrome after the endoscopic surgery for SASDH.

BACKGROUND: A complication after surgical intervention for chronic and subacute subdural hematoma drainage is the recurrence of hematoma, often requiring repeat surgical management. Recurrence rates varied widely across the published series, which may partially be due to different technical strategies used by the surgeons involved in the study. We decided to review our patients with chronic and subacute subdural hematomas that were surgically managed with a burr hole procedure by a single surgeon to compare recurrence rates with the evidence available.
METHODS: A retrospective review of the medical records was performed on the patients who underwent burr hole surgical intervention to drain a chronic or subacute subdural hematoma between April 1995 and March 2020. All patients were under the care of a single surgeon at an academic institution. Variables analyzed included age, sex, laterality of the hematoma, and recurrence.
RESULTS: During the selected timeframe, 610 cases were identified. There were 35 cases of recurrence of the hematoma. The recurrence rate after burr hole drainage was 5.73%.
CONCLUSIONS: Surgical drainage of chronic and subacute subdural hematoma via burr hole using consistent stepwise management is associated with a relatively low recurrence rate in our single surgeon patient cohort.

We present a rare case of traumatic acute subdural hematoma (SDH) in which intracranial hypotension (IC) secondary to cerebrospinal fluid (CSF) leakage at the lumbar spine caused delayed neurological deterioration. A 70-year-old male sustained a head injury after ground-level fall and was brought to our institution. A brain computed tomography (CT) showed a thin acute SDH with mild brain shift, and conservative management was initiated. He exhibited neurological deterioration on the 9th hospital day, however, and a brain CT showed a change in CT density and marked an increase in hematoma volume and brain shift. It was thought that conversion from acute to subacute SDH was associated with the deterioration, and emergency hematoma evacuation was performed. Despite the surgery, neither clinical nor radiographical improvement occurred. The lack of improvement pointed to the presence of underlying IC, and a CT myelography revealed the dural sleeve of the right L2 nerve root as the source of the CSF leakage. An epidural blood patch therapy was performed on the 12th hospital day to seal the CSF leakage. The postprocedural course was uneventful, and the patient was discharged free of symptoms on the 20th hospital day. Spinal CSF leakage should be considered as a cause of delayed neurological deterioration in patients with traumatic acute SDH which exhibits conversion to subacute SDH.

UNASSIGNED: To evaluate the effectiveness and safety of neuroendoscopic surgery for chronic or subacute subdural hematoma.
UNASSIGNED: Between September 2016 and September 2018, neuroendoscopic surgery was performed on 25 patients with chronic and subacute subdural hematoma. Hematoma evacuation was performed with a 0°, 4 mm diameter rigid neuroendoscope via a transcranial neuroendoscopic approach.
UNASSIGNED: All patients successfully underwent neuroendoscopic surgery, and no surgical complications or rebleeding was observed. Postoperative computed tomography scans showed that the hematoma was successfully evacuated. All patients had recovered well at discharge, the observed 30-day mortality rate was 0%, and no patients suffered recurrence for 2-26 months after surgery.
UNASSIGNED: Neuroendoscopic surgery was a safe and effective approach for the treatment of chronic and subacute subdural hematoma. This approach has the advantages of decent visualization and minimal invasiveness and could reduce recurrence and the mortality rate.

OBJECTIVE: To discuss the pathologic mechanism of subacute subdural hematoma (sASDH).
METHODS: Three typical cases of sASDH were reported, and related literature in Chinese published in the past 15 years was reviewed.
RESULTS: Intervals from onset of acute subdural hematoma to surgery or symptom deterioration resulting in sASDH were 12.5-15.5 days (mean 14.1 days). Delayed liquefaction of hematoma clots occurred in all 3 reported cases. One patient achieved good curative effect after administration of dexamethasone, and another patient relapsed owing to poor drainage after evacuation of hematoma.
CONCLUSIONS: The conversion of acute subdural hematoma to sASDH is an inflammatory reaction process with very regular in time, and it is speculated that the pathologic mechanism may be a delayed hypersensitivity reaction. Antigen released during the liquefaction process of blood clot, with subdural neomembrane cells as antigen-presenting cells, is presented to the T lymphocytes released from the capillaries in the neomembrane and forms sensitized T lymphocytes. When the subsequent antigen is released from the blood clots with a delayed liquefaction and is exposed to sensitized T lymphocytes, the delayed hypersensitivity process occurs.

BACKGROUND: Subacute subdural hematoma (SASDH) is an entity which is yet to capture the popular imagination among the neurosurgeons. Its management is often equated clinically to that of the chronic subdural hematoma (CSDH). However, their neurological deterioration is usually rapid, which seems to align them with acute subdural hematoma (ASDH). We proceed for their epidemiological evaluation. The advantages of a novel \"double barrel technique (DbT)\" over the conventional burrhole drainage are also presented.
METHODS: This retrospective study was conducted on all the patients having clinical and radiological evidence of SASDH, admitted to a tertiary care referral institute, during the period August 2013 to December 2015. Postoperatively, patients were followed-up for 3-24 months.
RESULTS: 46.87% of the patients belonged to the 35-54 year age group with a male predominance (3.6:1); 68.7% had a history of alcohol abuse, whereas aspirin users were 25%. 87.5% cases were unilateral, 18.75% were hemispheric, and 46.87% were present on the left side. Altered consciousness (100%) followed by headache (37.5%) were the most common presenting clinical features.
CONCLUSIONS: SASDH is an uncommon neurosurgical entity (0.89% of traumatic brain injury cases in our study) and mimics both CSDH as well as ASDH. The true incidence of SASDH may have been underestimated due to its clinical imitation with CSDH. This study in a South Asian nation also provides the epidemiological data of this rare neurosurgical entity. Outcome of surgery is good; our retrospective study confirms that \"DbT\" is an adequate and safe treatment. However, a better designed, randomized control trial will be needed to reinforce our findings.