Operative indications and choices on traumatic subdual fluid collection: Evaluation of CT cisternography and epidural pressure monitoring

Abstract

Purpose: To verify the importance of CT cisternography (C-CT) and epidural pressure monitoring (EDPM) as determining factors for surgical indications and the selection of surgical procedures in the treatment of traumatic subdural fluid collection (SDFC). Subjects and Methods: A total of 75 patients, admitted at our hospital during the 5-year perid, January 1993 to December 1997, and diagnosed as having SDFC with CT, were subjected to the present study. These patients were all had a 1 month follow-up after the onset of SDFC. After that, C-CT and EDPM were subsequently performed on 31 patients (male: female=22: 9; age range of 31 to 82 with a mean age of 62.4; bilateral cases: unilateral caes=20: 11), 21 with unchanged or aggravated SDFC, and 10 with altered absorption values on repeated CT. These cases were investigated with regard to (1) examination results, (2) surgical indications and the selection of surgical procedures, and (3) surgical results and prognosis. Results: (1) On C-CT, no filling (N), delayed filing (D), and early filling (E) were observed in 11, 18, and 2 cases respectively, the majority (29 cases; 93.5%) categorized as N and D. EDPM revealed continuous high pressure (CH), intermittent high pressure (IH) and continuous low pressure (CL) in 9, 17, and 5 cases respectively, the majority (26 cases; 83.9%) categorized as CH and IH. (2) Surgery was performed on 29 cases, including those with altered absorption values on repeated CT, N and D cases on the C-CT, CH and IH cases on the EDPM, and symptomatic E cases on the C-CT with symptomatic CL on EDPM. As surgical treatment, irrigation+drainage were performed on 10 cases of the absorption value changed group; irrigation+indwelling of Ommaya resrvoir were performed on 6 cases of the SDFC unchanged or aggravated group with N cases on C-CT and CH cases on EDPM, and subdural-peritoneal (S-P) shunt operation was performed on the other 13 cases of SDFC unchanged or aggravated group. S-P shunting was performed on 4 recurrence cases. (3) During the postoperative follow-up which lasted from 2 months to 4 years and 4 months, SDFC eventually disappeared from all cases. Two cases without no surgery showed aggravation of SDFC on CT or symptoms during the follow-up period of between 6 months and 2 years and 4 months. Conclusion: C-CT and EDPM were confirmed to be useful determining factors for surgical indications and the selection of surgical procedures, allowing us to produce a flowchart for therapeutic guidance.