PMC4754592_01
Initial brain computed tomography obtained at admission showing a chronic subdural hemorrhage (arrowheads) over both cerebral hemispheres, which compressed the adjacent brain.
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F1
Initial brain computed tomography (CT) showed lower subdural attenuating crescentic form fluid collection along the bilateral frontotemporoparietal area, which is typical of a SDH (Fig. 1).
Postoperative CT scans demonstrating extensive pneumocephalus in the subdural space in both the frontal areas, the subarachnoid space of both sylvian and the basal cistern. Note that a drainage catheter was placed over both the cerebral hemispheres (arrows) (A and B).
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F2
However, postoperative CT taken in 1 hour after surgery revealed an unusually extensive pneumocephalus that occupied both the frontal area, the subarachnoid space of both sylvian, and the basal cistern (Fig. 2).
Brain magnetic resonance imaging obtained 3 days after surgical drainage of the subdural hemorrhage. T2-wighted (A) axial image revealing re-accumulation of fluid content mixed with acute and chronic hemorrhage. T1-weighted sagittal image (B) showing sagging of the brain stem (asterisk).
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F3
Brain magnetic resonance imaging (MRI) was performed 3 days later, and showed bilateral re-accumulation of subdural fluid collection and downward displacement of the midline structures with the brainstem, called "sagging" (Fig. 3).
Radionuclide cisternography showing CSF leakage at the right distal sacral area (arrowhead) on the 3 hours image (A-D).
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F4
The 3-hour image revealed CSF leakages at the right distal sacral area (Fig. 4).
Brain CT scans obtained 7 days after epidural blood patch demonstrating effacement of brain stem contour implying transtentorial herniation (A) and increased subdural hemorrhage (B).
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F5
He became increasingly lethargic a week after the epidural blood patch and a follow-up brain CT scan revealed SDH enlargement with transtentorial herniation of the right-side parahippocampal gyrus (Fig. 5).
T2-weighted sagittal (A) and axial (B) magnetic resonance images of the lumbar spine revealing a large lobulating cystic lesion in the sacral canal and right sacral foramen at the S2-upper S3 level with a fistula (arrow), which is supposed to be CSF leaking site.
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F6
Afterwards, lumbar MRI was performed for exact anatomical evaluation of the leaking location, and revealed a large lobulating cystic lesion with a fistula in the sacral canal and right sacral foramen at the S2-upper S3 level, which were compatible with a large meningeal cyst (Fig. 6).
Follow-up Brain CT scans 10 days after spine surgery showing restoration of brain stem contour (A) and reduced subdural hemorrhage (B).
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F7
Follow-up brain CT obtained 10 days after spinal surgery indicated that the subdural hematoma had resolved (Fig. 7) and the patient was doing well at the 6-month follow-up examination.