Contralateral development of chronic subdural hematoma after evacuation of chronic subdural hematoma. A case report

Contralateral acute complications such as acute epi/subdural hematomas can be encountered after evacuation of a chronic subdural hematoma, though they are rare. We found only one case of chronic subdural hematoma following the surgery for contralateral chronic subdural hematoma, have been published in English language literature. A 73-year-old male admitted to our hospital with a right-sided subdural hematoma. The subdural hematoma was evacuated through a burr-hole. A left-sided subdural higroma appeared after operation and turned into classical subdural hematoma in the course of time. After evacuation of contralateral chronic subdural hematoma, the patient recovered completely. All stages of the development of contralateral chronic subdural hematomas were shown by serial computed tomograms. It was suggested that traumatic chronic subdural hematomas develop from mostly subdural higromas. If contralateral subdural higroma is seen after surgical evacuation of a chronic subdural hematoma, the possibility of development of contralateral chronic subdural hematoma must be kept on mind.     

Clinical factors of recurrent chronic subdural hematoma

The clinical, radiological, and operative factors of recurrent chronic subdural hematoma (CSDH) were retrospectively analyzed in 116 patients with CSDH in 134 hemispheres, treated by one burr hole surgery. The correlation of recurrence was evaluated with personal and clinical factors such as age, sex, history of head injury, and interval from onset of initial symptoms to hospitalization; laboratory findings such as bleeding tendency and liver function; computed tomography (CT) findings such as hematoma density and brain atrophy; and operative findings such as additional procedures and postoperative residual air. The recurrence group (RG) included 10 hemispheres (7.5%) in 10 patients (8.6%). The interval from onset of symptoms to hospitalization was significantly shorter in the RG than in the nonrecurrence group (NRG). Headache was more frequently seen in the RG than in the NRG. Density of hematoma on CT was classified into five types: Low, iso, and high density, niveau, and mixed, and the incidence of recurrence was 0%, 2.3%, 17.2%, 12.5%, and 6.5%, respectively. Larger amounts of residual air in the postoperative hematoma cavity were associated with recurrence of CSDH. CSDH that progresses rapidly in the acute stage and appears as high density on preoperative CT is associated with a high incidence of recurrence. Intraoperative air invasion to the hematoma cavity should be avoided to prevent recurrence.     

Exteriorization of the subdural pocket for chronic recurrent subdural hematoma

The author describes a new operative method for treating chronic recurrent subdural hematoma. The subdural pocket is exteriorized so that it is in continuity with the subgaleal space through a limited extradural pocket and an L-shaped linear craniectomy. This procedure has been carried out in two patients with recurrent chronic subdural hematoma, both of whom made complete recoveries despite initial recurrence of the subdural hematoma.     

A case of organized chronic subdural hematoma showing an early recurrence after craniotomy

A 64-year-old man who had undergone single burr hole drainage twice prior to this admission was hospitalized with a recurrent right chronic subdural hematoma. A head CT showed a mixed density subdural hematoma on the right frontotemporoparietal region. Based on the intraoperative findings of the previous surgeries, the hematoma was known to be organized. Therefore, we decided to do a small craniotomy under general anesthesia, and remove the organized subdural hematoma and thick outer membrane while leaving the thickened dura matter intact. The inner membrane was left untouched. One week later, despite adequate decompression, the hematoma recurred with midline shift on head CT. It is likely that the uniquely thick and vascular enriched outer membrane and dura contributed to such an early recurrence. Finally, we performed an extensive craniotomy, removing all the organized hematoma, outer membrane and dura. Again, the inner membrane was left intact. On one year follow-up the patient has been asymptomatic with complete resolution of the subdural hematoma on CT scan. The successful treatment of organized chronic subdural hematoma can be challenging. We strongly recommend an extensive removal of the organized hematoma, outer membrane and excision of the dura mater in order to achieve a successful outcome after failed burr hole evacuation.     

Ossified chronic subdural hematoma: case report

A case of ossified chronic subdural hematoma is presented in a 13-year-old male in whom the mass was surgically removed. His neurological deficits continued afterward but were less severe.     

A case of convexity meningioma associated with chronic subdural hematoma

There are 5 reported cases of meningioma complicated by chronic subdural hematoma so far as we reviewed. Considering frequency of occurrence, association of meningioma and chronic subdural hematoma is very rare. Recently, we experienced with a case of convexity menigioma complicated by chronic subdural hematoma. The patient was a 61-year-old woman who complained of headache and numbness of the left hand. She received hysteromyomectomy 28 years before but had no past history of trauma of the head. She suffered from frequent profound pain in both orbits for one year, and she consulted a neighboring practitioner due to occurrence of numbness of the left hand and malaise. Then, CT scan revealed abnormalities, so that she was referred to our center. On admission, neurological oxamination revealed no abnormalities but plain X-ray film of the skull showed a round destruction in the right parieral bone. CT scan showed a round high density area of 3 cm in diameter in the right parietal region, this is markedly enhanced with contrast media. There is a crescent-shaped low density area extending forward from the high density area. The body of the right lateral ventricle is totally collapsed. Selective arteriography of the right external carotid revealed tumor stain in the parietal region. Therefore, under the diagnosis of association of chronic subdural hematoma and convexity meningioma, craniotomy of the right frontal, parietal and temporal regions was carried out and a meningioma of 10 g, and a subdural hematoma with its capsule touching the maningioma were entirely extirpated.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of chronic subdural hematoma in a hemodialyzed patient

In proportion to a rapid increase of dialysis patient, death caused by neurological complications is increasing annually among long-term hemodialyzed patients. A case of chronic subdural hematoma during long-term hemodialysis is presented. A 35-year-old male had undergone hemodialysis three times weekly for four years. He had marked changes in body-weight and blood pressure between hemodialysis. In March 1983, he had a headache, vomiting, and left hemiparesis. The CT scan showed a right subdural hematoma. He was admitted to our hospital 10 days later because of progressive hemiparesis and speech disturbance. The neurological examination showed left hemiparesis with sensory deficit and dysarthria. The CT scan showed an increase in the size of the subdural hematoma. Bleeding time was over 10 minutes. A right-sided burr hole was made and altered blood was removed and irrigated. After operation, headache and weakness rapidly subsided, but the next morning, attacks of convulsion occurred. The CT scan showed the rebleeding in the subdural space. After correcting the level of serum potassium by hemodialysis, a right parietal craniotomy was performed. Hematoma of about 100 g was removed and the capsule of the hematoma showed organized tissue histologically. Postoperatively, although attacks of convulsion occurred temporarily, he gradually improved. The levels of serum potassium and BUN were controlled by several treatments of hemodialysis. He was discharged with only mild hemiparesis. Subdural hematoma caused by hemodialysis is a very important complication. Chronic subdural hematoma is sometimes very difficult to differentiate from dysequilibrium syndrome or dialysis dementia. The CT scan is a very valuable examination to rule out subdural hematoma.     

Cerebral aspergillosis after burr-hole surgery for chronic subdural hematoma: case report

We report a case of aspergillosis in the subdural space and frontal lobe in an 83-year-old man. The clinical course simulated that of a brain tumor. The source for the infection was considered to be the previous burr-hole surgery for chronic subdural hematoma, which was performed 2.5 years before the onset of symptoms. The patient was treated by removal of the abscess and granuloma. The clinical features and treatment of aspergillosis after neurosurgical procedures are discussed.     

Organized chronic subdural hematoma requiring craniotomy--five case reports

Two child and three elderly patients underwent craniotomy for organized and/or partially calcified chronic subdural hematomas (CSHs). The characteristic feature of magnetic resonance imaging was a heterogeneous web-like structure in the hematoma cavity. Both children had undergone one side subduroperitoneal shunt for bilateral CSHs when infants. As a result, the opposite hematoma cavities persisted and developed into calcified CSHs after a couple of years. All three elderly patients with senile brain atrophy showed various systemic complications such as cerebral infarction, diabetes mellitus, leg ulceration, cirrhosis, and bleeding tendency. Craniotomy for removal of the hematoma and calcification achieved good results in all patients. Subdural space created by shunt, craniotomy, or brain atrophy and persisting for a certain period, and additional various brain damage such as microcirculatory disorder, meningitis, encephalitis, or premature delivery may be important in generating calcified or organized CSH.     

A case of infected subdural hematoma

A 87-year old male was admitted to our hospital due to generalized convulsion with loss of consiousness. He was afebrile and his blood sampling was not infectious. Computed tomography scan suspected left chronic subdural hematoma. Burr hole drainage was performed to remove the hematoma, but the abscess was aspirated in the subdural space. Infected subdural hematoma is rare. We discuss the clinical presentation, diagnosis and. treatment, and also briefly review the literature.     

Recurrence of chronic subdural hematoma after trepanation and drainage

Objective: To sum up the causes of recurrence of chronic subdural hematoma (CSDH) from failure of trepanation and drainage and explore its prevention and treatment. Methods- From October 1988 to June 2002 a total of 358 patients with CSDH were treated with trepanation and drainage in our hospital. Among them 15 patients had recurrence of CSDH after operation. The data of the 15 patients were reviewed retrospectively. Results: Of the 15 patients, 13 were cured by retrepanation and redrainage, one cured by removal of hematoma by craniotomy with bone flap, and one, a 1-year old child, gave up reoperation due to severe encephalatrophy. Conclusions: Most CSDHs which recur after trepanation and drainage can be cured by retrepanation and redrainage. For the patients with repeated recurrence of CSDH removal of hematoma capsule can be considered.The causes of recurrence of CSDH are related to disease course, the thickness of hematoma capsule, the severity of encephalatraphy and whether the hematoma cavity is drained or irrigated completely, and operation methods.     

Calcified chronic subdural hematoma with intracerebral rupture forming a subcortical hematoma. A case report

We report a calcified chronic subdural hematoma which ruptured intracerebrally forming an acute subcortical hematoma in the frontal lobe in a 59-year-old woman with long-standing liver cirrhosis. Both hematoma cavities communicated each other through a small defect within the inner membrane of the subdural hematoma. The content of both hematomas was identical and was of a clay-like clot. The inner membrane around this communication consisted of thick, very vascular granulation tissue with many hemosiderin deposits and was tightly adherent to the cortex. We speculated that a fresh bleeding into the granulation tissue resulted in formation of a subcortical hematoma through a rupture of the inner membrane. Disseminated intravascular coagulation likely played an important role in this unusual condition.     

A case of bilateral interhemispheric subdural hematoma

Interhemispheric subdural hematoma (ISDH), although not infrequent in children, has been rarely encountered in adults. Spread of CT, ISDH has been reported sporadically, and so far more than 40 cases have been reported. But bilateral ISDH is an extremely rare lesion, with only 5 cases reported in the literature. We report a sixth case of bilateral ISDH in adults. A 68-year-old woman was admitted because of headache and vomiting. Two days before admission she had fallen, striking her occiput, and had lost consciousness for a few minutes. Neurological examination on admission revealed hyperreflexia of her extremities, especially in her left leg. However, motor weakness was not recognized. There was no fracture visible on the plain X ray films of the skull. Axial CT scan demonstrated a high density lesion along the falx and its extension down over the tentorium. Coronal CT scan also demonstrated a convexo-convex high density lesion beside the falx, and its extension onto the tentorium. Cerebral angiogram showed lateral displacement of the callosomarginal artery, and an avascular area beside the falx and onto the tentorium. After admission she was managed conservatively, but on the 14th day after head trauma, paraparesis and left arm paresis were recognized. This condition deteriorated and she developed an inability to stand. On the 19th day parasagittal craniotomy and evacuation of the hematoma were performed. Her postoperative course was uneventful and she was discharged with no neurological deficits.     

Calcified chronic subdural hematoma. A case report in an old patient

Calcified chronic subdural hematoma is a well-known disease to many neurosurgeons as it is diagnosed with only a plain skull X-ray film. Although several reports on this condition are seen, many of them are dealing with those in children or young people, and those in the aged are only few. One case of calcified chronic subdural hematoma in an old man is described. An 86-year-old man with a sudden attack of left hemiparesis was admitted to the Kanto Rosai Hospital. Two years before, he had had a history of head injury on his right temporal area, which caused no neurological deficit before this attack. Neurological examination on admission revealed mild confusional state and severe left hemiparesis. A plain skull film of A-P projection showed a linear calcification in the right temporal area. CT scan revealed a right temporal chronic subdural hematoma with some calcification in the internal membrane, which caused moderate midline shift. Right temporal small craniotomy was performed. The hematoma contained no fluid as usual but paste-like substance, and was partially removed. Postoperatively, he showed an improvement in unstability, but the left hemiparesis remained. On the 23rd postoperative day, he expired of severe pneumonia. Autopsy showed 14.0 X 8.0 X 1.2cm sized subdural hematoma in the right temporal area. Microscopically, the internal layer of the dura markedly thickened, and the appearance of "pachymeningitis hemorrhagica interna" was clearly seen. The thicked internal layer was devided into two layers, and the hematoma was existed just between the two layers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Contents of chronic subdural hematoma

Analysis of chronic subdural hematoma membranes and contents has revealed a complex process of blood breakdown forming a milieu that stimulates neovascularization and repeated hemorrhage.     

Physiopathology of chronic subdural hematoma

Coagulation, fibrinolysis and kinin-kallicrein system disorders could explain chronic subdural hematoma pathophysiology. The marked decrease in antithrombin III in the hematoma suggest that the decreased levels of clotting factors were caused by excessive coagulation resulting in clotting factors consumption. The decrease in alpha 2-antiplasmin with the increase of fibrin degradation products suggest that hyperfibrinolytic activity of the subdural hematoma. Coagulation and fibrinolysis disorders could explain repetitive hemorrhages from the outer membrane, which cause progressive enlargement of the hematoma. Kinin-kallicrein system disorders raise the hemorrhage by its action on the outer membrane. Nowadays, the earliest osmotic theory should reasonably be abandoned.