PMC9562247_01
(A) Axial MRI images of the brain displaying the course of regression of a bilateral subdural hematoma in the fronto-parietal region, leading to a compression of both cerebral hemispheres without a midline shift. (Left) Six days preoperative. (Middle) Three weeks postoperative, a slight subsidence of fluid accumulation was observed with a normalization of the ventricular system and reappearance of fronto-parietal cerebral sulci. (Right) Five months postoperative with complete regression of the large subdural hematomas. (B) Sagittal MRI images of the brain showing regression of venous compartment enlargement due to a liquor-leak syndrome. (Left) Four days preoperative. (Middle) Three weeks postoperative. (Right) Five months postoperative.
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Surprisingly, a brain MRI revealed a bilateral subdural hematoma in the fronto-parietal region with sizes ranging from 18 mm width on the left side and 13 mm width on the right side, leading to a compression of both cerebral hemispheres and a reactive supra- and infratentorial dural thickening without a midline shift (Fig. 1). Five days later, the MRI of the skull showed a reduction of the SDH by 4 mm on the left side and 2-3 mm on the right side with a normalization of the ventricular system and reappearance of frontoparietal cerebral sulci (Fig. 1). Four weeks after surgery, the CSF extravasation subsided slightly, and there was no recurrence detected on brain MRI (Fig. 1).
(A) CT myelography of the cervicothoracic spine four days preoperative, with a coronal and axial view of a DM out of the intervertebral disc at the T1-2 level, which was assumed to be responsible for the dural leak. (B) MRI of the cervicothoracic spine. (Left) Four days preoperative. (Middle) Three weeks postoperative with fluid extravasation at the T1-2 level. (Right) Five months postoperative with complete regression of the epidural leakage.
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To search for the cause of the SIH, the patient underwent an MRI of the entire spinal column, which exposed a circular CSF extravasation around the dural sac from the C3- to the T10 level (Fig. 2). Additionally, to the T1-2 level, where a calcified microspur was discovered, the intervertebral disc at the T2-3 level showed localized calcifications (Fig. 2).
Intraoperative endoscopic view of the tear accessed through an interarcuate fenestration at the T1-2 level (left) and its coating with TachoSil( ), a fibrinogen-thrombin sealant patch (right).
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Therefore, it was decided to perform an endoscopically assisted microsurgical closure of the ventral dural dehiscence by duraplasty accessed through an interarcuate fenestration at the T1-2 level (Fig. 3).