case_images: PMC4754592_01
case_images: Initial brain computed tomography obtained at admission showing a chronic subdural hemorrhage (arrowheads) over both cerebral hemispheres, which compressed the adjacent brain.
case_images: jkns-59-69-g001.jpg
case_images: PMC4754592_01_jkns-59-69-g001.jpg
case_images: F1
case_images: Initial brain computed tomography (CT) showed lower subdural attenuating crescentic form fluid collection along the bilateral frontotemporoparietal area, which is typical of a SDH (Fig. 1).
case_images: Postoperative CT scans demonstrating extensive pneumocephalus in the subdural space in both the frontal areas, the subarachnoid space of both sylvian and the basal cistern. Note that a drainage catheter was placed over both the cerebral hemispheres (arrows) (A and B).
case_images: jkns-59-69-g002.jpg
case_images: PMC4754592_01_jkns-59-69-g002.jpg
case_images: F2
case_images: However, postoperative CT taken in 1 hour after surgery revealed an unusually extensive pneumocephalus that occupied both the frontal area, the subarachnoid space of both sylvian, and the basal cistern (Fig. 2).
case_images: Brain magnetic resonance imaging obtained 3 days after surgical drainage of the subdural hemorrhage. T2-wighted (A) axial image revealing re-accumulation of fluid content mixed with acute and chronic hemorrhage. T1-weighted sagittal image (B) showing sagging of the brain stem (asterisk).
case_images: jkns-59-69-g003.jpg
case_images: PMC4754592_01_jkns-59-69-g003.jpg
case_images: F3
case_images: Brain magnetic resonance imaging (MRI) was performed 3 days later, and showed bilateral re-accumulation of subdural fluid collection and downward displacement of the midline structures with the brainstem, called "sagging" (Fig. 3).
case_images: Radionuclide cisternography showing CSF leakage at the right distal sacral area (arrowhead) on the 3 hours image (A-D).
case_images: jkns-59-69-g004.jpg
case_images: PMC4754592_01_jkns-59-69-g004.jpg
case_images: F4
case_images: The 3-hour image revealed CSF leakages at the right distal sacral area (Fig. 4).
case_images: Brain CT scans obtained 7 days after epidural blood patch demonstrating effacement of brain stem contour implying transtentorial herniation (A) and increased subdural hemorrhage (B).
case_images: jkns-59-69-g005.jpg
case_images: PMC4754592_01_jkns-59-69-g005.jpg
case_images: F5
case_images: He became increasingly lethargic a week after the epidural blood patch and a follow-up brain CT scan revealed SDH enlargement with transtentorial herniation of the right-side parahippocampal gyrus (Fig. 5).
case_images: T2-weighted sagittal (A) and axial (B) magnetic resonance images of the lumbar spine revealing a large lobulating cystic lesion in the sacral canal and right sacral foramen at the S2-upper S3 level with a fistula (arrow), which is supposed to be CSF leaking site.
case_images: jkns-59-69-g006.jpg
case_images: PMC4754592_01_jkns-59-69-g006.jpg
case_images: F6
case_images: Afterwards, lumbar MRI was performed for exact anatomical evaluation of the leaking location, and revealed a large lobulating cystic lesion with a fistula in the sacral canal and right sacral foramen at the S2-upper S3 level, which were compatible with a large meningeal cyst (Fig. 6).
case_images: Follow-up Brain CT scans 10 days after spine surgery showing restoration of brain stem contour (A) and reduced subdural hemorrhage (B).
case_images: jkns-59-69-g007.jpg
case_images: PMC4754592_01_jkns-59-69-g007.jpg
case_images: F7
case_images: Follow-up brain CT obtained 10 days after spinal surgery indicated that the subdural hematoma had resolved (Fig. 7) and the patient was doing well at the 6-month follow-up examination.