br Discussion SDH occurs most

Discussion SDH occurs most commonly as a result of bleeding from surface cerebral vessels following trauma. Significant injury is often required to rupture the bridging veins which transverse the narrow space between the arachnoid membrane and dura mater. In atrophic brains due to aging processes or alcoholism, these veins are dangled in the subdural space and are more subject to bleeding after minor injury. The same condition may occur in shunted hydrocephalic patients with CSF overdrainage. In cases of IH, occult spontaneous CSF leak could induce SDH similar to the effect of an overdraining CSF shunt, and produce the symptoms of orthostatic headache. The origin of spontaneous CSF leak could be cranial or spinal, and the exact mechanism remains obscure. Patients with connective tissue disorders (e.g., Marfan syndrome) have an increased risk of CSF leak. It is thought that structural weakness in the thecal sac serves as a predisposing factor of meningeal tear following trivial trauma or straining movements in these patients. Our case had no feature of connective tissue disorder. However, he underwent chiropractic neck treatment prior to onset of headache. Because a CSF leak could also result from spinal manipulation, it is probable that our patient suffered a meningeal tear by mechanical stress during such a maneuver. IH is an uncommon cause of headache and therefore diagnosis is often delayed. This problem is confirmed when the CSF pressure reads <60 mmH2O during lumbar puncture. However, the possibility of src kinase inhibitor herniation in patients with IH and SDH would contraindicate such a procedure. In current practice, a contrast-enhanced brain MRI examination is the analysis of choice owing to its noninvasive nature. Typical findings include pachymeningeal enhancement, brain sagging, small ventricles, SDH, and obliteration of cisterns. To locate the exact site of spinal CSF leak requires the use of CT or MRI cisternography/myelography. The treatment of CSF leak begins with conservative measures. Some patients, such as our present case, recover after bed rest and intravenous fluid supplement. An epidural blood patch or open surgical repair is required if noninvasive approaches fail. Successful treatment of CSF leak will result in resolution of SDH. It is rare that the SDH requires urgent surgical removal if symptomatic brain compression occurs. Failure to recognize and treat the underlying cause would lead to recurrent SDH and further futile procedures in such patients.
Introduction
Case report An 86-year-old woman presented with a 20-month history of occasional dull abdominal pain with spontaneous relief. She had essential hypertension with regular medical control, and had no past history of abdominal surgery. She had visited an out-patient department and an abdominal sonogram revealed no significant abnormal finding but then, with sudden onset, diffuse sharp abdominal pain developed, this time without spontaneous relief, and lasted for one day. There was no defecation or flatulence passage but mild nausea without real vomiting. There was no dramatic change in diet habit in the week before the onset of symptoms. She visited our emergency department. On physical examination there was no significant muscle guarding or tender point on the abdomen. Hypoactive bowel sounds and a moderately distended abdomen were noted. Abnormal blood tests included an elevated white cell count (11700/mm3) with 90% neutrophils and anemia (hemoglobin 8.6 g/dL). Abdominal computed tomography (CT) revealed a significant whirlpool sign with twisted mesentery, superior mesenteric artery and superior mesenteric vein (Fig. 1). There were also small bowel loops and the intestinal wall was thickened. No tumor or lymphadenopathy was found within the abdominal cavity. The patient was diagnosed with primary small bowel volvulus (SBV) which is defined as the torsion of a segment of the small bowel mesentery without any apparent predisposing anatomical abnormalities.