311/885. Acute atraumatic subdural hematoma associated with moyamoya disease in an African-American. A 57-year-old black woman with an atraumatic subdural hematoma was treated for congestive heart failure and was found to have moyamoya disease. The association of these two lesions is rare and has never been described in an African-American. High cerebral venous pressures and changes in cerebral perfusion caused by congestive heart failure and the loss of cerebrovascular autoregulation in moyamoya disease may explain the spontaneous occurrence of a subdural hematoma. Recommendations for management are discussed. ( info) |
| We presented the case of a 78-year-old man with mental retardation and spastic paraparesis diagnosed early in life as cerebral palsy. Six years prior to demise he had post-traumatic subdural hematoma, which was removed surgically. The neuropathological examination revealed the sequelae of the recent trauma, superimposed on the extensive old lesions. Cavitary changes in the periventricular white matter and cortical ulegyria in the border zones of the major cerebral arteries vascularization were characteristic of perinatal hypoxic-ischemic lesions. Peculiar in the ulegyria were extensive areas with numerous corpora amylacea adjacent to the areas of fibrillar and cellular gliosis. Another sequelae of involution processes was the atrophy of brain hemispheres (secondary microcephaly). The case appears to be an example of the late degenerative involution changes developing on the background of lesions originated from the perinatal period. ( info) |
313/885. Spinal epidural hematoma following epidural anesthesia versus spontaneous spinal subdural hematoma. Two case reports. Two cases of lumbar hemorrhage with subsequent persistent neurologic sequelae are presented and their possible causes are discussed in the context of a literature review: one patient with spontaneous spinal subdural hematoma with no trauma or lumbar puncture and one with spinal epidural hematoma associated with preceding epidural catheterization for postoperative pain relief. The subdural hematoma was associated with a thrombocytopenia of about 90,000/microliters due to intraoperative blood loss. This might have been contributory to the formation or expansion of the hematoma, but it is not convincing since a platelet count of this amount should not lead to spontaneous bleeding. Both patients received low-dose heparin, but since coagulation tests were normal, prolonged bleeding does not appear to be a likely cause, although it cannot be excluded. In conclusion, the reasons for both hematoma remain unclear. With regard to the epidural hematoma and low-dose heparinization, the possible coincidence of spontaneous lumbar hematoma and lumbar regional block should be taken into consideration. ( info) |
314/885. Spontaneous spinal subdural hematoma: case report and review of the literature. We report the case of a pediatric patient with a spontaneous spinal subdural hematoma that was not associated with a coagulation abnormality. Six cases have been reported previously. The patient improved after surgical drainage. The possible causes of this rare problem are discussed. ( info) |
315/885. Iatrogenic spinal subdural haematoma. Spinal subdural haematoma is a rare condition, usually seen in association with lumbar puncture or a bleeding disorder. It carries a high morbidity and mortality, and successful treatment requires prompt surgical intervention. We present a case of mixed spinal subarachnoid and subdural haemorrhage complicating failed spinal anaesthesia combined with anti-coagulation in an elderly woman, together with a review of the literature. ( info) |
316/885. Bilateral subdural hematomas diagnosed with technetium-99m-HMPAO brain SPECT. An elderly patient with a complex history of organic dementia but a normal neurologic examination had a 99mTc-hexamethylpropylene-amine-oxime (HMPAO) brain scan for a suspected cerebrovascular accident or space-occupying lesion. The study showed no perfusion abnormality in the brain parenchyma, but bilateral flattening and inversion of the normal hemispheric convexities, with separation from the skull was identified. Bilateral subdural hematomas (SDH) were suspected and the patient had a computed tomographic scan that confirmed the diagnosis. ( info) |
317/885. Masked Cushing's disease in an aged man associated with intraventricular hemorrhage and tuberculous peritonitis. A 77-year-old man complained of headache, dizziness and tactile hallucination. Based on those clinical signs and the findings of computed tomography scanning and magnetic resonance imaging, he was diagnosed as having pituitary adenoma. Clinical signs and symptoms of Cushing's disease had not been apparent because of the occurrence of the disease at an old age. An increase in serum cortisol and adrenocorticotropic hormone indicated the presence of Cushing's disease. Physical findings obtained thereafter were also compatible with the disease. While the patient was being prepared for surgery, pituitary apoplexy and intraventricular hemorrhage occurred. Massive ascites appeared as a result of tuberculous peritonitis. In spite of treatment for these complications, his general condition progressively deteriorated and he died 39 days after the intraventricular hemorrhage. This case presents the difficulty in the treatment of masked Cushing's disease in the elderly population. ( info) |
318/885. Meningiomas with haemorrhagic onset. Classically meningiomas present and evolve with a progressive course. Meningiomas manifest themselves mainly in middle and old age when the incidence of strokes is higher. The authors report three instances of meningioma with acute haemorrhagic onset. The clinical picture of our cases consisted of subarachnoid bleeding, subdural hematoma and intracerebral haemorrhage respectively. The diagnostic difficulties encountered when assessing these patients are discussed. The current literature regarding meningioma associated with haemorrhage is reviewed. One of our cases seems to be the first reported case of subarachnoid haemorrhage originating from a meningioma of the petrous bone. ( info) |
319/885. Can infant death from child abuse be prevented? OBJECTIVE: To assess the effectiveness of a child abuse surveillance and intervention program in protecting infants at risk. DESIGN AND SETTING: A retrospective review of all children discussed by the Suspected child abuse and Neglect Team of the Mater Misericordiae Children's Hospital, South Brisbane, over the five year period January 1986 to December 1990. patients: A total of 2126 children were discussed by the team; 375 were infants (less than 12 months of age) at the time of the initial discussion. Nine infants died suddenly and these nine deaths were examined in detail. RESULTS: All deaths were considered initially to be due to sudden infant death syndrome (SIDS), but autopsy findings in six suggested death was not accidental and in the other three significant doubt was raised by the history. Identifying risk factors for non-accidental injury were clearly present in all cases; however, there were major problems with notification to the appropriate authorities. Even in cases where appropriate identification and notification occurred planned interventions by multiple agencies failed to prevent death of these infants. CONCLUSIONS: There is a growing awareness of child abuse as a significant cause of morbidity and mortality in developed countries, but intervention is fraught with multiple difficulties and prevention programs are few. Recommendations are offered for improvement in recognition and notification of incipient child abuse as well as appropriate interventions to prevent infant deaths. Inappropriate death recording procedures may result in some sudden deaths being recorded as SIDS when in fact they are caused by child abuse. ( info) |
320/885. Electrocardiographic changes and intracranial pathology. A young woman who sustained severe head trauma presented to the operating room for emergent surgical intervention. Her electrocardiogram (ECG) exhibited signs of myocardial ischemia, which resolved several days postoperatively. ECG changes suggestive of cardiac pathology can be associated with intracranial pathology, most notably subarachnoid hemorrhage. Delay of operative therapy may have catastrophic results. Experimental data indicates massive sympathetic outflow results from stimulation of the lateral and posterior hypothalamic regions. Large amounts of norepinephrine are released into the systemic circulation, resulting in hypertension, tachycardia, dysrhythmias and ECG changes. myocardial ischemia and injury can occur from the effects of this excessive sympathetic stimulation. In certain case reports, neurologic patients who experienced ECG changes had normal hearts on postmortem examination. This implies that myocardial recovery can occur despite the appearance of an abnormal ECG in the neurologic patient. Anesthetic management of these patients involves prevention of further increases in intracranial pressure and avoidance of hyperventilation in the presence of hypotension or vasospasm. Continuous ECG monitoring is essential. Ventricular dysrhythmias may prove resistant to conventional pharmaceutical management. Beta blockade may be indicated to prevent excessive cardiac stimulation by endogenous catecholamines, and, in addition, may prevent the formation of the microscopic cardiac lesions typical of this hyperstimulation. ( info) |