Transcranial cerebral herniation after chronic subdural hematoma treatment with no dura closure

Abstract

Abstract-The authors report a patient with unilateral painful hand and moving finger in whom tactile stimulation interrupted both the movement and the pain. This effect suggests a gating mechanism at a segmental level. The difference between afferent and efferent pathway levels and the delay of several months between trauma and occurrence of symptoms support a central mechanism, most probably involving sensorimotor reorganization at a segmental level. NEUROLOGY 2006;67:491-493 C. Wider, MD; T. Kuntzer, MD; P. Olivier, MD; D. Debatisse, MSc; R. Nançoz, MD; P. Maeder, MD; J. Bogousslavsky, MD; and F. Vingerhoets, MD Painful hand and moving fingers (PHMF) was first described in 1985 in a patient suffering from radiation-induced brachial plexopathy, with pain and movements of all fingers. 1 Since then, few cases have been reported, generally in patients with peripheral nerve, plexus, or root disease.2-4 Deep aching or pulling pain often precedes movements by several months. Involuntary movements are composed of complex sequences of flexion/extension and abduction/adduction, which cannot be imitated. Treatment is unsatisfactory. Similar symptoms occur in the inferior limb in the much more common syndrome of painful legs and moving toes (PLMT). 5,6 We report a patient with unilateral PHMF after median nerve lesion in whom tactile stimulation in the same territory simultaneously interrupted both the movement and the pain.Case report. A 55-year-old woman was referred to our center for pain and movement in the left hand. Two years before, she had suffered traumatic fracture of the left distal part of the radius bone. After conservative treatment, she developed continuous pain, hyperalgesia, and sudomotor changes and was diagnosed with complex regional pain syndrome (CRPS), treated by pamidronate and calcitonin for 2 years. She reported no abnormal movement. Nine months before our evaluation, she had median nerve surgical decompression of the carpal tunnel. Two months later, she developed involuntary movement of the third left finger, followed after another 2 months by sharp pain in the hand with third finger predominance. Upon notice that it would help both the pain and the movement, she started wearing a glove.Physical examination showed continuous involuntary pseudorhythmic and rapid movements of the third left finger, at a frequency of 3 to 5 Hz, with predominance of flexion/extension but with some abduction/adduction component that sometimes gave it a rotating aspect (see video, segment 1 on the Neurology Web site at www.neurology.org). The patient could not willingly stop the movement, nor would contralateral action either reduce or increase it. Tactile stimulation of the palmar aspect of the first to third fingers immediately, simultaneously, and completely stopped both the movement and the pain (video, segment 2), as would pinprick and fork application. In contrast, stimulation outside the median territory on the internal aspect of the hand or on the dorsal aspect of the fingers did not affect either the moveme...

Spontaneous Delayed Brain Herniation through a Subdural Membrane after Tumor Surgery

“…3,6 In the adult case reports, local cerebral edema after the surgical evacuation of the hematoma has been proposed as the trigger for the local brain herniation. 5,6 In our patient, we could not identify a clear trigger for the development of the acute herniation. Of course, since the deterioration occurred suddenly, an epileptic seizure (with Todd's paresis) was an important differential diagnosis, especially since the patient was known to have epilepsy.…”

“…Of these, four cases occurred in the pediatric population, [1][2][3][4] and the other two in adult patients. 5,6 In the case reports of adult patients (57 and 77 years), the brain herniation happened shortly after the neurosurgical procedure, namely, a partial membranectomy for an organized chronic subdural hematoma 6 and an evacuation of a chronic subdural hematoma with a small craniotomy without dural closure. 5 In the pediatric cases (mean age 12 months), the time interval between surgery and herniation was at least 7 months.…”

“…5,6 In the case reports of adult patients (57 and 77 years), the brain herniation happened shortly after the neurosurgical procedure, namely, a partial membranectomy for an organized chronic subdural hematoma 6 and an evacuation of a chronic subdural hematoma with a small craniotomy without dural closure. 5 In the pediatric cases (mean age 12 months), the time interval between surgery and herniation was at least 7 months. It has been hypothesized that rapid brain growth and flexibility due to a lack of myelination lead to a greater risk of herniation compared with adults.…”

Organized chronic subdural hematomas treated by large craniotomy with extended membranectomy as the initial treatment

“…[ 6 ] Burr hole with drainage is mandatory for nonseptated and mostly liquified CSH. [ 9 13 14 15 16 ] Although CSH is well known as a curable disease in the elderly and can be adequately managed with burr holes with drainage, the initial treatment of CSH can be ineffective. The reason behind the failure of this procedure should be viewed in the light of a number of factors: excessive formation of solid neomembrane,[ 5 ] multilayered intrahematomal architecture nonliquefied hematoma with different hemorrhagic foci with layering effects.…”