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Note the small subdural fluid collection (black arrow) indicating subdural empyema.
In addition, a subdural fluid collection can be seen (long arrow).
Another subdural fluid collection was present in the anterior section of the spinal cord (at C5 D1 level) with a consequent posterior dislocation.
Clinical symptoms are usually accompanied by magnetic resonance imaging (MRI) findings related to cerebrospinal fluid (CSF) depletion including subdural fluid collections, enhancement of the pachymeninges, engorgement of venous structures, pituitary hyperemia and sagging of the brain [11].
Characteristic MRI findings are thickened pachymeninges with contrast enhancement, subdural fluid collections, engorged cerebral veins, rounded dural sinuses, brain sagging, disappearance of the CSF space of the optic nerve sheath and an inferiorly displaced midbrain [35, 36].
In contrast, MRI findings were substantially unmodified, showing only a mild reduction of brain sagging, with persistent subdural fluid collection in the same regions, epidural venous engorgement and diffuse meningeal enhancement in supratentorial and infratentorial regions (images not shown).
Moreover, imaging revealed not only the presence of pachimeningeal thickening, enhancing after contrast administration, but also, as mentioned, downward displacement of brain and engorgement of venous structures, such as dural sinuses, Galen vein and epidural venous plexi associated with bilateral subdural cerebrospinal fluid collections, signs suggestive of IH.
Included patients neither had postoperative cerebrospinal fluid leakage nor subdural empyema.
To reduce frequency of subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection, we made only a minimal opening of the arachnoid membrane, and this was followed by suturing the arachnoid membrane after STA-MCA bypass using a 10-0 nylon suture (Ethicon, Somerville, N.J). to prevent CSF leakage (Fig. 4b) in last four patients.
The inner sheet is separated from the arachnoid by the narrow subdural space, which is filled with fluid.
This possible less accurate coincidence between MRI planning and MER registration on the second operative side may be due to cerebral fluid (CSF) loss and subsequent subdural air invasion during surgery in some cases, potentially causing brain displacement [ 9].
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