Mozart's chronic subdural hematoma

No commemoration of the bicentennial of Mozart's death would be complete without some consideration of that premature yet predictable demise. Mozart's premonitions of death are well known and apparently played a role in the composition of the K.626 Requiem and perhaps other works. His death has traditionally been ascribed to infectious causes, chiefly rheumatic fever or post-streptococcal glomerulonephritis, exacerbated by intemperance and chronic penury. Pathology has been difficult because of his supposed burial in a pauper's grave, the location and contents of which were later supposedly lost. Mozart's burial place in St. Mark's Cemetery in Vienna was known and, in the parlance of the day, "reorganized" a decade later, as the occupants of plots were disinterred to make room for the more recently decreased. A skull believed to the Mozart's was saved by the successor of the gravedigger who had supervised Mozart's burial, and then passed into the collections of the anatomist Josef Hyrtl, the municipality of Salzburg, and the Mozarteum museum (Salzburg). Forensic reconstruction of soft tissues related to this skull reveals substantial concordance with Mozart's portraits. The skull suggests premature closure of the metopic suture, which has been suggested on the basis of his physiognomy. A left temporal fracture and concomitant erosions raise the question of chronic subdural hematoma, which would be consistent with several falls in 1789 and 1790 and could have caused the weakness, headaches, and fainting he experienced in 1790 and 1791. Aggressive bloodletting to treat suspected rheumatic fever could have decompensated such a lesion to produce his death on December 5, 1791.     

Interhemispheric subdural hematoma

The interhemispheric subdural hematoma (ISH) is a special subdural hematoma with regard to both location and symptomatology. The most widely described clinical signs and symptoms associated with an ISH are a lucid interval and the falx syndrome. The latter is featured by a contralateral hemiparesis that is accentuated in the lower extremity but spares the face. Minor head trauma or a preexisting coagulation disorder are also often found. Nonsurgical treatment should be chosen in patients with little neurologic dysfunction and a stable clinical course. Patients with progressive neurologic deterioration and focal neurologic deficits should be operated on without delay. This article provides a review of 99 published cases of ISH and adds 3 cases to the existing literature.     

Spontaneous intracranial hypotension associated with subdural hematoma: diagnostic usefulness of percutaneous subdural tapping and magnetic resonance imaging

A 55-year-old woman presented with headache which was characterized by aggravation in the upright position and relief in recumbency. Although intracranial hypotension syndrome was considered to be the most-likely possible entity, computed tomography (CT) scans demonstrated subdural fluid collections associated with findings reminiscent of transtentorial herniation. Because of these CT features, cerebrospinal fluid pressure measurement by a lumbar puncture was not performed. In stead, as an alternative method, she underwent percutaneous subdural tapping, which failed to obtain spontaneous drainage of liquid haematoma, indicating intracranial hypotension. In addition, gadolinium-enhanced magnetic resonance imaging study performed later supported the diagnosis of spontaneous intracranial hypotension. Thus, the usefulness and safety of percutaneous subdural tapping for the diagnosis of spontaneous intracranial hypotension is stressed.     

Supratentorial arachnoid cyst and associated subdural hematoma: neuroradiologic studies

CT and MR images of 8 patients with supratentorial arachnoid cyst complicated by subdural hematoma were studied and compared with those of 8 patients who developed nontraumatic subdural hematoma without arachnoid cyst. Of the 8 patients with supratentorial arachnoid cyst, CT and MR disclosed temporal bulging and/or thinning of the temporal squama in all 6 patients with middle fossa arachnoid cysts, and the thinning of the calvaria was evident in another patient with a convexity cyst. Calvarial thinning at the site corresponding to interhemispheric arachnoid cyst was clearly depicted on coronal MR images. In contrast, none of the 8 young patients with nontraumatic subdural hematoma without arachnoid cyst had abnormal calvaria. Temporal bulging and thinning of the overlying calvaria were identified as diagnostic CT and MR features of arachnoid cyst with complicating intracystic and subdural hemorrhage. Radiologists should be aware of this association and should evaluate the bony structure carefully.     

Failure of computerized axial tomography to demonstrate a chronic subdural hematoma

A chronic subdural hematoma may present in a computerized axial tomography (CAT) scan with the same density as normal brain tissue. The presence of a lesion may be suggested only by its mass effect. The lack of contrast enhancement or edema may help to differentiate a chronic subdural hematoma for a neoplasm or a cerebrovascular accident.     

Masked subdural hematoma in alcoholics

Nineteen cases of subdural hematomata in alcoholics are discussed to show the special diagnostic problems that the psychiatrist is faced with when dealing with such a disease picture. Although it is relatively easy to show that subdural hematomata in alcoholics are usually of traumatic origin, yet there is the difficulty of the psychiatrist being confronted with the task of giving medical attention to patients where, anamnestically, the trauma is of secondary importance only, and where psychopathological phenomena are a prime consideration. This syndrome, which is characterized by a fluctuation in consciousness and impulsion, psychomotor retardation, and baseless exaltation, may be regarded as suggesting the presence of a subdural hematoma in a person addicted to the use of alcoholic beverages in excess, even if the medical history of the patient is free from any traumata.     

Ultrastructure of collagen fibers in the outer membrane of recurrent chronic subdural hematoma

The three-dimensional structure of the collagen fibers in the outer membrane of recurrent chronic subdural hematoma was studied by scanning electron microscopy (SEM). Specimens obtained at surgery were treated with NaOH at room temperature to digest away all cellular components and expose the collagen fibers. SEM observation of the dural side of the outer membrane showed the collagen fibers were woven into a compact feltwork with a dense arrangement. The fiber bundles had a honeycomb structure framed by the collagen fibers. Observation of the hematoma side found the collagen bundles had a sparse wavy appearance. The arrangement of the collagen fibers on the dural side is different from that on the hematoma side. The thick outer membrane may be formed by granulation resulting from inflammatory reaction. Collagen fibrillar networks are not fragile, and may reinforce the outer membrane of the recurrent hematoma.     

Isodense subdural hematoma presenting with paraparesis: case report

Computerized tomography (CT) has replaced cerebral angiography in many institutions as the diagnostic test of choice in cranial trauma. However, isodense subdural hematomas can be a source of false-negative results on CT scans, resulting in omissions in therapy. The authors report a patient with bilateral isodense subdural hematomas who presented with paraparesis but was otherwise alert and fully oriented. The CT findings caused an initial diagnostic dilemma before being resolved.     

Intracranial subdural hematoma after lumbar myelography

Two cases of intracranial subdural hematoma after lumbar myelography are reported. This complication should be considered in patients who complain of prolonged headache or who develop neurological signs after lumbar puncture.     

Physiopathogenesis of subdural hematomas. Part 1: Histological and biochemical comparisons of subcutaneous hematoma in rats with subdural hematoma in man

The dorsal subcutaneous injection in rats of 12 ml or more of autologous hemolyzed whole blood clotted in situ induced the formation of sterile, hemispheric lesions, 47% of which showed an initial decrease in volume followed by a progressive enlargement. The behavior, histology, and biochemical characteristics of the liquid contents of these lesions were found to be remarkably similar to those of subdural hematomas in man. To evaluate the role of the various blood components that may have influenced the formation and growth of these lesions, more than 150 clots composed of human platelet-free plasma, autologous hemolyzed blood, or autologous whole blood were implanted subcutaneously in rats by either surgical or injection techniques. The in vitro behavior of the different clots used was also assessed. This systematic approach led to the following conclusions: 1) the composition and volumes of the clots are critical variables; 2) plasma-fibrin provides the matrix shape of the lesions; 3) the breakdown products derived from erythrocytes, hemoglobin, leukocytes, and other solid blood elements induce neomembrane formation and contribute to the lesion's subsequent growth; and 4) inflammation mechanisms appear to be essential, while cerebrospinal fluid plays no discernable role in this process.     

Acute spinal subdural hematoma following lumbar puncture

A case of acute spinal subdural hematoma following lumbar puncture in a patient with a normal coagulation profile is reported. Lumbar myelography may be unsuccessful. Other methods of myelography (via cisternal or lateral cervical puncture) to corroborate a block may be made or a laminectomy at the proper clinical level without further studies may be indicated.     

Chronic subdural hematoma associated with middle meningeal arteriovenous fistula treated by a combination of embolization and burr hole drainage

A rare case of chronic subdural hematoma associated with a middle meningeal arteriovenous fistula was treated by a combination of embolization and burr hole drainage. This clinical situation might be missed in this era of computed tomography, when cerebral angiography is seldom indicated for the diagnosis of neuro-traumatic diseases. We should bear in mind the possibility of this clinical situation of a chronic subdural hematoma associated with a linear skull fracture crossing the middle meningeal groove in order to avoid possible hemorrhagic complications during surgery for chronic subdural hematoma.     

Modifications of the pupil in acute subdural hematoma

This study is based on the observation of 81 operated acute subdural haematoma. The various coordinates concerning the clinical aspects and the evolution are analysed in function of the presence or absence of pre-operatory anisoria. The discussion abords the gravity of this sign and its value in localizing the lesion, as well as the clinical distinction between ipsi-lateral and contra-lateral mydriasis. Possible subdivisions in cases of contra-lateral relative mydriasis, as well as their probable pathophysiological mechanisms and respective clinical and prognostic implications are also examined.     

Spontaneous resolution of subdural hematoma. MRI findings

In the present study, to clarify the role of the N-methyl-D-aspartate (NMDA) receptor in the appearance of diazepam withdrawal signs, the changes in [3H]dizocilpine binding in several brain regions from diazepam-withdrawn rats were investigated. Brain membranes were prepared 42-45 h after termination of diazepam treatment when maximal withdrawal signs were shown. The Bmax value for [3H]dizocilpine binding was significantly increased in cerebrocortical, but not hippocampal and cerebellar, tissues from diazepam-withdrawn rats, while the Kd value did not change in any group. Together with our previous finding that NMDA receptor antagonists potently suppress diazepam withdrawal signs, these results suggest that the upregulation of the NMDA receptor in the cerebral cortex may play an important role in the appearance of spontaneous withdrawal signs caused by discontinuation of chronic diazepam treatment.     

Meningioma associated with acute subdural hematoma--case report

1. The aim of the present study was to determine the brain sites mediating aspects of respiratory and cardiovascular control in adult humans using non-invasive functional magnetic resonance (fMRI) procedures, thereby avoiding the spatial and temporal sampling limitations associated with classic neural assessment techniques. 2. We examined activity changes across the entire brain following application of respiratory loads and upon induction of blood pressure and heart rate alterations. Magnetic resonance signals were visualized with a 1.5 Tesla scanner in healthy volunteers (22-52 years of age) using procedures that optimally assess changes in brain tissue microcirculation. Images were collected during a Valsalva manoeuvre, inspiratory loading, hypercapnia, cold pressor challenges to the hand and forehead and during intervening baseline states. 3. Image values from experimental conditions were compared with corresponding baseline values on a pixel-by-pixel basis to identify brain regions in which the experimental conditions produced physiological activation. 4. Ventilatory and pressor challenges elicited significant changes in regional image signal intensity in areas within the orbital cortex, amygdala, hypothalamus and hippocampus. Cerebellar, medullary and pontine areas were also recruited. However, while particular brain regions were only activated during specific stimuli, other regional signal changes occurred with multiple experimental manipulations. 5. The findings indicate that respiratory and cardiac challenges elicit discrete activity changes over multiple brain sites. Activated regions include structures not often related to respiratory or cardiovascular regulation, such as the cerebellum; a prominent role for limbic forebrain structures in mediating the response is also suggested. The fMRI visualization procedures may greatly assist in the determination of neural structures that mediate respiratory and cardiovascular control in humans.     

Cerebral venous sinus thrombosis associated with systemic multiple hemangiomas manifesting as chronic subdural hematoma--case report

A 35-year-old male was admitted with headache, nausea, and vomiting persisting for 2 days. Computed tomography (CT) revealed a left chronic subdural hematoma. Cerebral angiography demonstrated cerebral venous sinus thrombosis (CVST). He had presented with a subcutaneous mass involving the neck at age 2 years, which was shown to be a cavernous angioma, and thereafter shown signs of consumptive coagulopathy with systemic multiple hemangiomas. Burr hole aspiration of the hematoma was performed. Seventy-two-hours later, he developed clouding of consciousness and right hemiparesis. CT revealed a fresh hematoma in the operated subdural cavity and hemorrhagic diathesis manifested. A frontotemporoparietal large craniotomy was performed to remove the hematoma. Extensive electrocauterization was required. He had a satisfactory postoperative course. Collateral venous pathways, resulting from the CVST due to systemic multiple hemangiomas, may have caused hemodynamic stress in the bridging veins which subsequently induced chronic subdural hematoma.     

Subdural hematoma associated with arachnoid cyst

We describe 3 young patients with history of mild cranial trauma who presented the rare association of subdural hematoma and arachnoid cyst. Clinical and radiological signs are reviewed.