The recent increase of publications of SSEH(cons) has to be explained by the introduction of MRI in daily medical practice. As a result, more patients with a mild or benign clinical course are being diagnosed. In earlier times those patients would have escaped medical attention. The mean length of the hematoma in SSEH(cons) appears to be significantly higher compared to SSEH(oper). This suggests that spontaneous regression of neurological symptoms may result from decompression of the neural structures by spreading of the (liquid) hematoma along the spinal epidural space in the early stages after haemorrhage. Based on the present review, there appear to be no factors which promote conservative treatment in SSEH. In the majority of cases with SSEH, the mainstay of treatment will remain surgical decompression of the neural structures and removal of the hematoma. The decision for conservative treatment has to be based on the severity of the neurological deficit and on the clinical course. Retrospectively, the length of the hematoma seems to give a clue to the spontaneous recovery which occurs in some cases of SSEH. Nevertheless, hematoma-length can not be used as a guide to treatment.

The critical factors for recovery after spontaneous spinal epidural hematoma are the level of preoperative neurological deficit and the operative interval. The vertebral level of the hematoma did not correlate with postoperative results, which suggests that local compression, rather than vascular obstruction, is the main factor in producing neurological deficit.

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Object In this paper the authors systematically evaluate the results of different surgical procedures for chronic subdural hematoma (CSDH). Methods The MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and other databases were scrutinized according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) statement, after which only randomized controlled trials (RCTs) and quasi-RCTs were included. At least 2 different neurosurgical procedures in the management of chronic subdural hematoma (CSDH) had to be evaluated. Included studies were assessed for the risk of bias. Recurrence rates, complications, and outcome including mortality were taken as outcome measures. Statistical heterogeneity in each meta-analysis was assessed using the T2 (tau-squared), I2, and chi-square tests. The DerSimonian-Laird method was used to calculate the summary estimates using the fixed-effect model in meta-analysis. Results Of the 297 studies identified, 19 RCTs were included. Of them, 7 studies evaluated the use of postoperative drainage, of which the meta-analysis showed a pooled OR of 0.36 (95% CI 0.21–0.60; p < 0.001) in favor of drainage. Four studies compared twist drill and bur hole procedures. No significant differences between the 2 methods were present, but heterogeneity was considered to be significant. Three studies directly compared the use of irrigation before drainage. A fixed-effects meta-analysis showed a pooled OR of 0.49 (95% CI 0.21–1.14; p = 0.10) in favor of irrigation. Two studies evaluated postoperative posture. The available data did not reveal a significant advantage in favor of the postoperative supine posture. Regarding positioning of the catheter used for drainage, it was shown that a frontal catheter led to a better outcome. One study compared duration of drainage, showing that 48 hours of drainage was as effective as 96 hours of drainage. Conclusions Postoperative drainage has the advantage of reducing recurrence without increasing complications. The use of a bur hole or twist drill does not seem to make any significant difference in recurrence rates or other outcome measures. It seems that irrigation may lead to a better outcome. These results may lead to more standardized procedures.

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Objective-The aim of this study was to investigate prospectively in an unselected series of patients with an aneurysmal subarachnoid haemorrhage what at present the complications are, what the outcome is, how many of these patients have "modern treatment"-that is, early obliteration of the aneurysm and treatment with calcium antagonists-what factors cause a delay in surgical or endovascular treatment, and what the estimated eVect on outcome will be of improved treatment. Methods-A prospective, observational cohort study of all patients with aneurysmal subarachnoid haemorrhage in the hospitals of a specified region in The Netherlands. The condition on admission, diagnostic procedures, and treatments were recorded. If a patient had a clinical deterioration, the change in Glasgow coma score (GCS), the presence of focal neurological signs, the results of additional investigations, and the final diagnosed cause of the deterioration were recorded. Clinical outcome was assessed with the Glasgow outcome scale (GOS) at 3 month follow up. In patients with poor outcome at follow up, the cause was diagnosed. Results-Of the 110 patients, 47 (43%) had a poor outcome. Cerebral ischaemia, 31 patients (28%), was the most often occurring complication. Major causes of poor outcome were the eVects of the initial haemorrhage and rebleeding in 34% and 30% of the patients with poor outcome respectively. Of all patients 102 (93%) were treated with calcium antagonists and 45 (41%) patients had early treatment to obliterate the aneurysm. The major causes of delay of treatment were a poor condition on admission or deterioration shortly after admission, in 31% and 23% respectively. Conclusions-In two thirds of the patients with poor outcome the causes of poor outcome are the eVects of the initial bleeding and rebleeding. Improved treatment of delayed or postoperative ischaemia will have only minor eVects on the outcome of patients with subarachnoid haemorrhage.(J Neurol Neurosurg Psychiatry 2000;68:337-341)

Multidetector CT angiography can be used as a primary examination tool in the diagnostic work-up of patients with SAH.

Reviewing the literature on the vascular anatomy of the spinal epidural space, it appeared that the knowledge of the internal vertebral venous plexus is limited. Injection studies of the entire internal vertebral venous plexus after application of modern techniques, to the best of our knowledge, have never been performed. Based on the clinical importance of these structures, it was decided to study the human vertebral venous system after Araldite CY 221 injection, in order to update the morphological characteristics of the internal vertebral venous system.The vertebral venous systems of ten fresh human cadavers, between 64 and 93 years of age, were injected with Araldite CY 221 mixture. All cadavers were dissected and the posterior and anterior internal vertebral venous plexuses were studied in detail.The anterior part of the internal vertebral venous plexus is fairly constant. On the contrary, the posterior internal vertebral venous plexus showed a striking segmental and interindividual variability. In the tho- The plexus venosus vertebralis is an extensive vascular network that has largely escaped attention of anatomists, physiologists and clinicians. It is considered to be valveless and extends along the entire length of the vertebral column, finding a cranial terminus in the dural sinuses. It parallels, joins and at the same time bypasses the longitudinal veins of the thoracoabdominal cavity. Like the azygos veins, it unites the superior and inferior vena cava, but on the other hand it is protected from direct thoracoabdominal pressure waves because of its course in the rigid spinal canal (Batson,