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Physiopathology and a new treatment of chronic subdural hematoma in children
Insights
A novel surgical technique improved venous drainage in children with chronic subdural fluid collections by addressing cortical vein narrowing. This intervention led to significant fluid reduction and improved venous flow, offering a promising treatment for this condition.
Area of Science:
- Neurology
- Pediatric Neurosurgery
- Vascular Surgery
Background:
- Chronic subdural fluid collections in children, often linked to trauma or meningitis, have unclear causes.
- A proposed mechanism involves progressive stretching and narrowing of cortical veins, leading to thrombosis and elevated venous pressure.
- This venous compromise may promote the formation of xanthochromic (yellowish) fluid in subdural spaces.
Purpose of the Study:
- To investigate a new surgical technique aimed at improving venous drainage in pediatric chronic subdural fluid collections.
- To evaluate the efficacy of lowering and advancing the superior sagittal sinus and performing a duraplasty in resolving these collections.
Main Methods:
- Sixteen children with persistent subdural fluid collections, previously treated unsuccessfully, underwent the novel surgical procedure.
- The technique involved repositioning the superior sagittal sinus and sagittal suture, combined with duraplasty, to enhance venous outflow.
- Angiography was used for follow-up to assess venous drainage and fluid collection status.
Main Results:
- Post-surgery, 14 out of 16 patients showed resolution or significant reduction of subdural fluid collections.
- Angiographic follow-up revealed normalized venous drainage through superficial cortical veins, with no evidence of 'hanging veins'.
- Intellectual development assessments showed 50% of children were normal or above normal, 31.2% were retarded, and 18.7% were borderline.
Conclusions:
- Lowering and advancing the superior sagittal sinus is an effective surgical approach for pediatric chronic subdural fluid collections.
- The technique successfully improves venous drainage, resolving fluid collections and potentially mitigating long-term neurological deficits.
- Further research is warranted to fully understand the long-term neurodevelopmental outcomes and optimize surgical strategies.
Abstract:
Chronic collections of fluid in the subdural spaces may result from trauma or may complicate meningitis. The etiological factor, or factors, which contribute to chronicity of subdural fluid in children remains obscure. We postulate that one possible mechanism is the progressive stretching and narrowing of the cortical veins, bridging the subarachnoid and subdural spaces to enter the superior sagittal sinus. This process ultimately leads to thrombosis of these 'hanging veins'. Narrowing and angulation of these veins could result in elevated back pressure favoring the formation of a transudate. 16 children who had progressive and persistent collections of xanthochromic fluid in the subdural spaces secondary to trauma or infection who were treated previously either with subdural tap, burr holes, subdural peritoneal shunt, craniotomy, stripping of membranes and/or a combination of these, were treated by lowering and advancing the superior sagittal sinus with its overlying sagittal suture and performing a duraplasty. This new surgical technique is directed to improve venous drainage from the superior anastomotic vein into the superior sagittal sinus. Angiographic follow-up showed that only 2 patients still have evidence of fluid collection: the rest of the patients showed normal arterial phases, the medullary system was minimally filled and all of these showed remarkable improvement of the venous drainage throughout the superficial cortical veins with no evidence of hanging veins. Intellectual development of these children following lowering of the superior sagittal sinus showed that 8 patients (50%) were normal or above normal; 5 patients (31.2%) were retarded and 3 patients (18.7%) were borderline.