SUMMARY

A Kuwaiti woman of 47 years came to hospital after being involved in a road traffic accident fully conscious but complaining of headache. She had no obvious head injury. Clinically there was no neurological deficits, skull radiography was normal and hence was discharged home after a period of observation. Twenty four hours later she was admitted to hospital with impaired consciousness, dilated right pupil and right spastic hemiparesis. CT scan of the brain showed right fronto-parietotemporal mass with shift of the brain to the opposite side. At emergency craniotomy extensive subdural haematoma was found and evacuated and a bleeding cortical artery in the sylvian fissure coagulated. She made a rapid, uneventful recovery after craniotomy, and she remained neurologically normal during follow-up.

RESUME

Une femme Koweitienne de 47 ans a ete hospitalisee apres un accident de la voie publique. Elle n’a pas eu de perte de canescence mais se plaignait de cephalees. Elle ne presentait pas de blessure evidente a la tete. Cliniquiment, il n’y avait pas de deficit neurologique. La radio du crane etait normale, elle rentra donc chez elle apres une periode d’observation; 24 beures apres, elle etait hospitalisee avec une dimunution de la conscience, une mydriase droite et une hemiparesie droite spastique. Le scanner cerebral a montre une masse fronto-parietotemporale droite avec deplacement du cerveau du cote oppose. Une trepanation faite en urgence a permis d’evacuer un hematome sous-dural etendu et de coaguler une artere corticale sylvienne qui saignait. Le retablissement de la patiente a ete rapide apres la trepanation, et l’examen neurologique normal pendant toute la duree du suivi.

Keywords : Subdural haematoma, Arterial origin

INTRODUCTION

Although subdural haematoma is usually of venous origin, it is known that it can sometimes result from arterial rupture occurring in association with an aneurysmal or arteriovenous malformation (1,6), neoplastic lesions on the dura (8), infection, vitamin C deficiency, alcohol abuse and coagulopathy (3). Rarely, the arterial rupture may be spontaneous when it occurs in the absence of obvious head trauma and of the above predisposing and risk factors.

Whatever the aetiology, the literature review of acute subdural haematoma (ASH) of arterial origin has shown it to be attended by an unusually high mortality of about 50 per cent (12) due to delay in diagnosis and institution of appropriate surgical treatment. We present a case in this paper in which early diagnosis and prompt correct neurosurgical intervention led to a successful outcome.

CASE REPORT

S.F., a 47 year old Kuwaiti woman, the mother of seven children, was involved in a road traffic accident on January 31, 1990. The car she was driving overturned over after bursting a tyre and she was thrown against the steering wheel. She did not lose consciousness. She come to the Casualty Department of Al-Adan Hospital, Kuwait complaining of headache. On physical examination, she was correctly oriented and cooperative; there was no head wound and the neurological system was clinically normal. Skull and chest radiograms obtained were normal. She was kept under observation in the Casualty Department for four hours after which she was allowed to go home because she remained clinically stable.

On February 1, 1990, about 24 hours after discharge, an ambulance brought her back to the Medical Section of the Casualty Department of Al-Adan Hospital on the suspicion that she had suffered a stroke because she was drowsy. After leaving hospital on January 31, 1990, her headache had worsened especially on the right side, accompanied by vomiting, unsteadiness of gait and slurring of her speech. On examination by the receiving physician, She was described as drowsy with a Glasgow coma score of 10, right facial palsy of upper motor neurone type and right spastic hemiparesis. The scalp was normal, her pulse rate was 56 per minute and the blood pressure 160/110 mm Hg. She was admitted to the Medical Ward of the hospital with the diagnosis of cerebrovascular accident, with the differential diagnosis of subdural haematoma.

An electrocardiogram showed sinus bradycardia and an emergency CT scan of the brain revealed a large right fronto-parieto-temporal mass with marked shift of the brain to the left side. Neurosurgical consultation was immediately sought.

Within one hour of admission, she rapidly passed from a drowsy state into coma with the right pupil dilated but slowly reacting to light. She was intubated and put on controlled ventilation in preparation for emergency neurosurgical operation.

At operation, no scalp wound was found. A right parietal burr hole showed no extradural haematoma but a blue bulging non-pulsatile dura indicating subdural haematoma. A fronto-parieto-temporal craniotomy was performed. When the dura was opened. an extensive fronto-parieto-temporal subdural haematoma which had partially clotted was revealed; it was peeled off and removed completely to show normal looking brain. At the bottom of the wound, close to the skull base, a slowly bleeding cortical artery was found; the vessel was easily coagulated and the bleeding arrested.

The patient made a remarkable good and uneventful postoperative recovery. She come off the ventilator on February 3 and soon regained full consciousness. She moved all her limbs satisfactorily and the right pupil became normal. She was transferred from the Intensive Care Unit to the Surgical Female Ward on February 4 and discharged from hospital on February 11, 1990. She complained of dizziness and had elevated blood pressure which necessitated treatment with methyldopa. She had been known to have arterial hypertension for about a year before her accident but had been on irregular treatment.

She was last seen in Neurosurgery Clinic on June 19, 1990, doing well and neurologically normal. She was booked to attend the Clinic again by the middle of August 1990. She could not keep that appointment with the Iraqi invasion in Kuwait on August 2, 1990.

DISCUSSION

Acute subdural haematoma (ASH) of arterial origin is probably not as rare as formerly thought (3, 14) and the features appear uniform enough to make it a distinctive entity of its own. The patients are middle-aged to elderly. The bleeding artery is seen at operation close to the base of the skull in the region of the Sylvian fissure and the brain is grossly normal. CT scan shows that the brain shift is often considerable such that it produces ipsilateral hemiparesis, the Kernohan’s phenomenon (5).

All these features were present in our patient. The Kernohan’s phenomenon was common in the cases reported by Tokoro et al (14). Indeed, Talalla and McKissock (13) had suggested that the phenomenon is a sign of ASH of arterial origin; unrelieved the shift caused by the rapid increase in the size of the haematoma can precipitate quick deterioration in the level of consciousness and even death.

ASH of arterial origin can easily be confused with cerebrovascular accident, as was our case and those reported in the literature (12, 13) Tokoro et al (14) labelled it an unusual form of cerebrovascular accident. This seems appropriate since the bleeding in the cases reported came from the cortical branches of the middle cerebral artery. This is an anatomical territory of arterial junction where strains and stresses, which can be precipitated by mild or unobserved head trauma can cause arterial rupture and bleeding.

Two factors which predispose to arterial bleeding into the subdural space in our case are head injury and arterial hypertension. Although she had no obvious head wound and skull radiography was normal, head trauma cannot be totally excluded in our case. Drake (2) had postulated that in the so called spontaneous variety of ASH of arterial origin, head trauma is involved but it may be minor and mild and pass unnoticed. Shenkin (11) found arterial bleeding in over 60 percent of his 39 patients with traumatic subdural haematoma.

Arterial hypertension was present in about 45 per cent of cases of ASH of arterial origin described in the literature (7,14). Subdural haematoma has been observed to be commoner in hypertensives than in normotensive individuals (9).

Delay in instituting neurosurgical treatment can be fatal as shown by case 3 of Stephenson and Gibson (12) and accounts for the high mortality associated with this disease. On the other hand, prompt neurosurgical evacuation of the haematoma is very rewarding with the survivor gaining a life with little or no neurological deficits (3).

Simple burr hole is not enough to remove the subdural clotted blood and control the arterial bleeding. Jamieson and Yelland (4) advised that once the subdural haematoma had been detected through a burr hole, the latter should be converted to a craniotomy, as we did in our case. A craniotomy is essential not only to completely evacuate the large thick and extensive haematoma but also to facilitate the arrest of the arterial bleeding. The procedure makes for adequate intracranial decompression and a good early post operative recovery.

SUMMARY

Out of a total of 1041 verified neoplastic lesions of the central nervous system (CNS) operated by the Author over a period of 40 years of neuro-surgical practice in Italy and in Kenya (this series does not include vascular malformations or haematomas, parasitic or infectious lesions and/to cystic arachnoiditis), 215 patients have been operated for benign meningiomas of CNS. Meningiomas with signs of hystologic anaplasia were excluded. Of the 215 meningiomas, 174 were intracranial and 41 intraspinal. A critical review of the surgical treatment of these cases is carried out.

RESUME

En 40 ans l’Auteur a opere en Italic et au Kenya 1041 tumeurs du S.N.C., sans tenir compte des realformations vasculaire, des hematomes, des processus expansifs d’origine infectieuse ou parasitaire ni des arachnoidites. Parmi ces tumeurs, 215 etaient meningiomes benins a localization intracraniens 174 lois et intraspinale 41 lois. Une revue critique du traitement chirurgical de ces cas est exposee.

Keywords : Meningiomas, Surgical treatment

INTRODUCTION

The incidence of neoplastic lesions of the CNS constitutes normally around 10 percent of the surgical material in a neurosurgical practice (ZULCH). In our experience of nearly 6000 major neurosurgical operations carried out in 40 years, the number of 1041 verified neoplastic lesions of the CNS is the 17.5 per cent of the whole neurosurgical material. This high incidence may be due to the high incidence of neoplastic lesions admitted and operated in the Neurosurgical Clinic of the University of Padua Italy, where I have worked for fifteen years, and to the high incidence of the same lesions referred from all over Eastern Africa to Nairobi, were I have been working for the last 25 years.

In this series, the relative incidence of meningiomas compared with other tumours of the CNS, was as follows:

TABLE 1

The meningiomas constitute about 20 per cent of all neoplastic lesions of the CNS in this series, more than a third of the number of the gliomas.

The relative incidence of histopathological type of various neoplasms of this series compared in percentage with other large series, was as follows:

TABLE 2

There are not very significant difference, except for a slightly higher incidence in the meningiomas, a higher incidence in the sarcomas, osteomas and embryonic tumours and a lower incidence of neurinomas and pituitary adenomas in the Author’s series compared with those of CUSHING’S, OLIVECRONA AND ZULCH.

MENINGIOMAS OF THE CENTRAL NERVOUS SYSTEM

Age incidence
The incidence of age per decade was as follows:

TABLE 3

As seen in table 3, meningiomas may occur at any age but reach their peak of incidence in the middle age. The oldest patient of this series was 74, the youngest was 2. The average age was 36 years. The sex incidence shows, as in other series, that the meningiomas are commoner in female (123 cases or 57 percent) than in males (92 cases or 43 percent).

ANATOMICAL LOCATION

Although meningiomas may arise anywhere, they show a strong predilection for some anatomical sites. The anatomical location and the biological behaviour of the tumours lead to the recognition of typical clinical syndromes, characteristic for each group; these clinical features are not considered in this paper.

From the histopathological point of view, only benign meningiomas were included in this series, excluding the meningosarcomas and fibrosarcomas.

a) Intracranial Meningiomas

Out of the 174 intracranial meningiomas, 165, were supratentorial and only 9 in the posterior fossa. 43 of them were located on the right side, 58 on the left and 73 in the midline.

The incidence of the anatomical location of these meningiomas as well as its percentage are compared with the same location in cushing’s series and are as follows:

TABLE 4

There are some differences between the percentage in the two series: there is a higher incidence of parasagital, falx, convexity, suprasellar, ventricular and tentorium meningiomas in our series and a lower incidence of sphenoidal ridge and posterior fossa meningiomas in our series compared CUSHING’S.
Incidentally in our series the proportion of parasagital (38 cases) to falx (14 cases) meningiomas was 3 to one as in McKISSOCK’S series (GAUTIER and SMITH, 1970) and not 10 to one as in CUSHING’S series. Of the sphenoidal wing meningiomas, 15 were of the outer third, 7 of the middle third and 4 of the inner third.

Of the meningiomas of the posterior possa, 4 were located in the ponto-cerebellar angle, 2 in the clivus and 3 were in the convexity.

Out of three lateral ventrical meningiomas, all were on the left side as in the other series.

The tentorium meningiomas were all supratentorial, on being located on the free edge of the tentorium.

B) Intraspinal meningiomas

Out of 41 cases of intraspinal meningioma, 17 were located in the cervical spinal whilst 24 in the thoracic spine. Of the 17 cervical meningiomas, 11 were located in the upper cervical and 6 in the middle cervical spine. In the thoracic spine 7 meningiomas were located in the upper thoracic spine, 12 in the middle and 5 in the lower thoracic spine. No meningiomas have been found in this series in the lumbar spine.

SURGICAL TREATMENT

The results of the surgery ofmeningiomas depends on many factors: the size and location of the tumor, the degree of involvement of vascular and nervous surrounding structures, the experience of the surgeon, and his attitude to the alternatives of total or partial extirpation. The removal of some meningiomas is often a matter of great difficulty, mainly in the deeply placed ones. It is in such deeply placed tumors that the modern aids such as intravenous mannitol, lumbar CSF drainage, controlled respiration, induced hypotension, improved light and magnification helps in reducing and better controlling the haemorrhage as well as improving the approach and excision of the tumours.

Since the successful total removal of a large olfactory groove meningioma, my first meningioma of this series operated on the 4th of November, 1960, my policy has always been to try to achieve a total removal of these tumours, and this for the following reasons:

1 ) Operations on recurrent meningiomas are much more traumatizing and often complicated by thick adhesions, with consequent high mortality and morbidity

2) At least 90 per cent of all meningiomas can be totally removed in one stage (rarely in two stages close to each other) with a reasonable surgical risk, low morbidity and relative low mortality.

By total removal it is intended that not only the tumour, but its dural or vascular implant and any bone possibly involved has to be largely removed. If this is not the case, and only a doubt is left that some tumoral cells are left behind, one has to talk of a subtotal removal because most certainly a recurrence may occur, even at a long distance.

In my personal experience two are the golden rules for the removal of these tumours: one is the large access to the lesion and the second, the most important, is to interrupt as soon as possible its blood supply.

There is no doubt that convexity, falx, lateral ventricle and intraspinal meningiomas can be removed totally. The greatest problem arises in the parasagital, the sphenoidal ridge, mainly the ones of the inner third, the suprasellar and the ones of the posterior fossa and clivus.

For those in the last group, there are rare cases where the risk of total removal may suggest a subtotal one. The results of surgery in this series are as follows:

TABLE 5

A few comments on the results, although the statistics are often complicated and of doubtful value, mainly when there are not on very large series.

Nevertheless, out of 203 maningiomas totally removed, the mortality rate was of 8 cases, around 4 per cent, and it has to be mentioned that one of the eight cases, a meningioma of the falx died of a cardiac arrest, without any connection with the surgery. Out of 12 subtotal removal, the mortality was of 4 cases, meaning 33 per cent: it is obvious that the subtotal removal was performed in the poor risk patients and in the poor risk tumours. I remember that the one of these cases was a very bad recurrence of a meningioma of the tentorium operated elsewhere.

A relatively high mortality rate is found in the meningiomas of the tentorium (20%), less in the suprasellar meningiomas (8%), posterior fossa (11%) and sphenoidal ridge meningiomas (8%).

Out of 205 survivors, 149 (73%) made a good recovery with full working capacity, 43 patients (21%) made a fair recovery, able to support themselves but with neurological deficits (several of them had visual problems) 13 patients (6%) are completely disabled.

The best prognosis for the meningiomas of the CNS is for the meningiomas of the convexity and for the intrapinal meningiomas. For the rest, the prognosis, as said before, depends on many factors. It may be possible that the next generation of neurosurgeons may achieve always a total removal without mortality and very low mobility as has been emphasized some years ago by GOSTA NORLEN.

And eventually the problem of the recurrence should be mentioned. In this series a final assessment on the recurrence is difficult to do, mainly due to the short time the patient in Italy has been followed up: in seven years of time there have been no recurrence. Many of the cases operated in Kenya have gone lost in the follow up. Again, in all cases followed up for a long period of time (twenty years) there have been only one recurrence of a suprasellar meningioma 13 years after surgery.

In conclusion, in the surgery of the meningiomas an aggressive attitude towards a total removal is probably the treatment of choice.