I am very desperate for your response, no one else wants to help me. To make a long story short, this question is regarding my father. He had a ct scan and this was the result. The patient has had a left frontoparietal and a right frontal craniotomy. A subdural drain has now been inserted on the left side with mild improvement in the left subduarl fluid collection (subdural hygroma or chronic subdural hematom. There is also what appears to be a small epidural collection over the left frontoparietal region which is unchanged. What effect would this epidural collection over the left frontoparietal region have on my father? The right chronic subdural fluid collection is probably unchanged since the previous exam. It contains a minimal amount of acute or subacute hemorrhage which is stable. What effect would this have on my father? The midline structure are mildly shifted from right to left. What does this mean? There is encephalomaiacia in the left parietotemporal region secondary to an old infarct and there was mild enlargement of the lateral ventricles slightly greater on the left side. Again there was holo tympanic density in the mastoid bones bilaterally probably due to fluid and or debris although it would be impossible to exclude cholesteatomas. What is cholesteatomas? A minimal amount of pneumocephalus was noted on the left side. My father has had bypass surgery about 12 years ago. He had a bad stroke 5 years ago, the left side of his brain they told my sisters and I is like a walnut in a box. He still has his mind, but lost his speech when he had the stroke. The eeg is abnormal. There is moderate generalized background slowing which can be seen with a variety of duffuse processes affectig the brain. They say he is in a coma, but he can be aroused.

Dr. Joshua’s Answer:

I’ve only got a minimal history and a ct report to work with, so I’m going to have to make some educated guesses here in trying to explain the situation to you. I will not make any treatment suggestions, as he is being treated by neurosurgeons already. May I suggest that you go through your questions with the attending neurosurgeon - he/she will be able to give you better answers!

It looks like he’s had a massive left middle cerebral artery stroke 5 years ago. This would cause loss of speech and movement on the right side.

Now he’s hospitalized because of subdural hematoma, both sides. Has he been on warfarin (Coumadin) treatment since the stroke? This would predispose him to subdural hematoma (collection of blood between the brain and the skull). Sometimes subdural hematoma can occur spontaneously, especially in patients on warfarin treatment, but 99% of subdural hematomas result from hitting the head. Craniotomy is the type of operation that is performed for acute subdural hematoma. It looks like there is a consequent problem with chronic subdural hematoma (persistent collection of blood inside the skull). A drain has been inserted on the left to decrease the size of the subdural collection.

It’s important to make a difference between a hygroma (collection of fluid) and a subdural hematoma (collection of blood). Since he’s had a left side massive stroke, there is more space on the left and he will have some subdural hygroma on the left side, especially after craniotomy. This does not generally require treatment or drainage, unless it can be demonstrated that it is causing pressure, dislocating the brain and worsening his clinical condition.

On the other hand, if there is a persisting subdural hematoma, repeat burr holes or drainage is considered especially if the hematoma is causing clinical symptoms.

A mild brain shift to the left speaks against the pressure effect of the left sided collection. Also the radiology report notes that there is improvement in the left subdural collection. This means that the drain treatment is working. The drain will probably be removed soon.

Cholesteatoma is a benign (not cancer) skin cyst in the deeper structures of the ear. It does not necessarily require treatment. If a cholesteatoma is found, an ENT doctor is consulted. On the other hand, the mastoid CT finding may more likely be due to trauma (skull base fracture - also does not require treatment) or infection.

I’ll just go through the CT report to explain the terminology:

The patient has had a left frontoparietal and a right frontal craniotomy. A subdural drain has now been inserted on the left side with mild improvement in the left subduarl fluid collection (subdural hygroma or chronic subdural hematom. There is also what appears to be a small epidural collection over the left frontoparietal region which is unchanged.

A small epidural collection is probably just the result of the craniotomy operation, and would not have any effect on your father.

The right chronic subdural fluid collection is probably unchanged since the previous exam. It contains a minimal amount of acute or subacute hemorrhage which is stable.

There is no mention of the thickness of the subdural collection on the right, so it’s impossible for me to estimate the significance of this finding. The good news is that it hasn’t grown in size since the previous exam.

The midline structure are mildly shifted from right to left.

This is could be due to the right sided collection having a mass effect on the brain, and also because of the stroke there is more space on the left side to expand to.

There is encephalomaiacia in the left parietotemporal region secondary to an old infarct and there was mild enlargement of the lateral ventricles slightly greater on the left side.

This is an expected finding after a stroke.

Again there was holo tympanic density in the mastoid bones bilaterally probably due to fluid and or debris although it would be impossible to exclude cholesteatomas.

This is explained previously

A minimal amount of pneumocephalus was noted on the left side.

Pneumocephalus=air inside the skull. This is the result of operation, and nothing to worry about.

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