Long-term follow-up review of patients with acute and subacute subdural hematomas

The authors present 149 patients suffering from acute (112) and subacute (37) subdural hematomas admitted during the 10-year period 1965 to 1974, with a follow-up period of 2 to 12 years. During the time of observation, 104 patients died and 45 survived; 73% of the patients with acute and 27% with subacute subdural hematomas died. Of the patients with an acute subdural hematoma, 11% went back to work, as against 32% of those with subacute subdural hematomas. The 5-year survival rate was 28% in patients with acute and 76% in patients with subacute subdural hematomas.     

Diffusion-weighted imaging of traumatic subdural hematoma in the subacute stage

Five cases of traumatic subdural hematomas in the subacute stage (from 7 to 20 days after head injury) were treated in one male and four females, aged from 63 to 82 years, with evacuation via craniotomy in three and aspiration via burr hole surgery in two. All hematomas were evaluated by T1-, T2-, and diffusion-weighted magnetic resonance imaging, and measurement of the apparent diffusion coefficient (ADC). Diffusion-weighted imaging showed the hematoma as a crescent high intensity area with a low intensity rim close to the brain surface (two-layered structure) in four cases and as high intensity with low intensity components in one case. The high intensity areas under the dura mater on diffusion-weighted imaging appeared as homogeneous high intensity on T1- and T2-weighted imaging in four cases, and inhomogeneous high intensity on T1- and isointensity on T2-weighted imaging in one case. The mean ADC value of the high intensity areas was 0.58 +/- 0.23 (mean +/- standard deviation) x 10(-3) mm2/sec. The operative findings revealed the high intensity areas as solid clots. The low intensity areas on diffusion-weighted imaging appeared as homogeneous high intensity in four cases and inhomogeneous isointensity with high intensity components in one case on T1- and T2-weighted imaging. The mean ADC value of the low intensity areas was 2.03 +/- 0.27 x 10(-3) mm2/sec. The operative findings revealed the low intensity areas as mixtures of resolved clot and cerebrospinal fluid. Diffusion-weighted imaging showed the characteristic two-layered structure in traumatic subdural hematomas in the subacute stage, and analysis of the ADC values was useful for differentiating solid from liquid hematoma and for selection of the surgical procedure.     

Combined epidural and intracerebral hematomas after evacuation of bilateral chronic subdural hematoma

Bleeding after surgery for chronic subdural hematoma far from the operative site is a rare phenomenon with possibly serious consequences. We report a case of combined epidural and intracerebral hemorrhage immediately after evacuation of bilateral chronic subdural hematoma. The epidural hematoma was evacuated by emergency craniotomy, but the deep parenchymal hematoma was treated conservatively. The patient recovered progressively with a good outcome. Approximately 30 cases of chronic subdural hematomas complicated by intracerebral hematoma were previously reported, but only seven cases of epidural hematoma. These complications could be avoided if slow, gradual decompression is used during surgery. Clinicians should suspect its occurrence without delay when a postoperative neurological deterioration is demonstrated. Possible mechanisms are discussed.     

Twist drill craniostomy and closed system drainage of chronic and subacute subdural hematomas

Based on reports in the literature on the success and low morbidity of twist drill craniostomy (TDC) and closed system drainage (CSD) for chronic subdural hematomas, a prospective study was initiated in 1981 and included all symptomatic patients presenting with a history and clinical and computed tomographic (CT) findings consistent with subacute or chronic subdural hematoma. A total of nine patients were treated with TDC and CSD as the initial procedure. An asymptomatic or progressively improving patient with greater than 50% reduction in subdural size by repeat CT scan was set as the end point of therapy. There were no complications, all patients improved with drainage, and seven were cured by this method alone. The results are compared retrospectively to surgically treated patients, and an overall decrease in morbidity and length of hospitalization are noted. The technique and CT scan correlations are described, and the rationale for use of this method is discussed in terms of our current understanding of the pathophysiology and complications of the disease.     

Chronic subdural hematomas

Zusammenfassung Es wird an Hand klinischer und histologischer Untersuchungsergebnisse die Existenz chronischer, gekapselter subduraler Hämatome traumatischer Genese bestätigt und klar herausgestellt, daß sich dieses Krankheitsbild streng von dem der intraduralen Blutungen bei Pachymeningitis haemorrhagica interna trennen läßt. Weiter wird kurz auf die Diagnostik des Krankheitsbildes eingegangen und ein Überblick über die Möglichkeiten der Behandlung und die Indikationsstellungen hierzu gegeben. Hervorgehoben wird vor allem, daß Beobachtungen und Untersuchungen bezüglich des Entstehungsmechanismus der subduralen Hämatome zweifelsfrei erkennen lassen, daß es sich dabei um eine Blutung ex vacuo handelt, als deren auslösende Faktoren Durchblutungsstörungen und intrakranielle Druckschwankungen (Unterdruck!) als Traumafolge anzusehen sind. Es werden noch vergleichende Untersuchungsergebnisse über Liquordruckmessungen bei gekapselten, chronischen subduralen Hämatomen und intraduralen Blutungen angeführt und auf die unterschiedliche Alters- bzw. Geschlechtsverteilung des Krankheitsbildes hingewiesen.

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Summary Based on clinical and histological examinations, the existence of chronic capsular subdural hematomas of traumatic genesis is confirmed and it is pointed out that this clinical picture may be well distinguished from the one with intradural hemorrhage in hemorrhagic pachymeningitis. Besides, the A. briefly discusses the diagnosis of the clinical picture giving a review of the therapy. Above all he points out that the observations and researches regarding the mechanism of the development of subdural hematomas doubtlessly show that it is the result of a hemorrhage ex vacuo, the determinant factors of which are to be considered the disturbance of circulation and the oscillation of endocranial pressure (hypotension!). The A. also refers on the results of comparative measuring of the liquor pressure in chronic capsular subdural hematomas and in intradural hemorrhages, and indicates their classification regarding age and sex.

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Resumen En base a los examenes clinicos y istologicos, se conferma la existencia de ematómas subdurales capsuláres cronicos de genesis traumatica y se pone en evidencia que este cuardro clinico puede ser bien separado de aquello con emoragias entradurales en la paquiminingitis. Ademas se habla en corto de la diagnosis de el cuadro clínico haciendo una revista de el tratamiento. Se pone en evidencia sobre todo que las observaciones y indagaciones concernientes el mecanismo de el desarollo de los ematomas subdurales permiten sin duda el reconocimiento de que se trata de el resultado de una emoragía ex-vacuo; los factores determinantes son da eonsiderarse las molestias de circolo y las oscilaciones de la presión endocranica (ipotensión). El autor da noticias también de los resultados de las misuraciones comparativas de la presión licorál en el ematoma subdurál capsurál cronico, en las emoragiás entradurales y se hace alusión a la frecuencia con relación a la edad y al sexo.

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Résumé Sur la base des examens cliniques et histologiques, on confirme l'existence d'hématomes subduraux capsulaires chroniques d'origine traumatique et l'on met en évidence que cet aspect clinique peut facilement être distinct de celui avec hémorragies intradurales dans la pachyméningite hémorragique. En outre, on discute brièvement le diagnostic de l'aspect clinique, en faisant une revue du traitement. On met surtout en évidence que les observations et les recherches concernant le mécanisme du développement des hématomes subduraux permettent, sans le moindre doute, de reconnaître qu'il s'agit du résultat d'une hémorragie ex-vacuo; les troubles de circulation et les oscillations de la pression endocrânienne (hypotension) doivent être considérés comme les facteurs déterminants de cette hémorragie. L'A. parle aussi des résultats des mensurations comparatives de la pression liquorale dans l'hématome subdural capsulaire chronique, dans les hémorragies intradurales, et il fait allusion à la répartition par rapport à l'âge et au sexe.

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Riassunto In base agli esami clinici ed istologici si conferma l'esistenza di ematomi subdurali capsulari cronici di genesi traumatica e si mette in evidenza che questo quadro clinico può essere ben distinto da quello con emorragie intradurali nella pachimeningitis emorragica. Inoltre si discute brevemente la diagnosi del quadro clinico, facendo una rassegna del trattamento. Si mette in evidenza sopratutto che le osservazioni e indagini riguardanti il meccanismo dello sviluppo degli ematomi subdurali permettono senza dubbio il riconoscimento che si tratti del risultato di una emorragia ex vacuo, i cui fattori determinanti sono da considerare i disturbi di circolo e le oscillazioni della pressione endocranica (ipotensione!). L'A. dà notizia anche dei risultati delle misurazioni comparative della pressione liquorale nell'ematoma subdurale capsulare cronico, nelle emorragie intradurali, e si accenna alla distribuzione in rapporto all'età ed al sesso.

     

A modified technique to treat chronic and subacute subdural hematoma: technical note

BACKGROUND: We present a patient on warfarin in whom a drainage port system was attached to the skull, successfully draining a subacute subdural hematoma. CASE DESCRIPTION: An elderly male presented to our institution with right hemiparesis a week following a motor vehicle accident. He was on warfarin for recurrent pulmonary emboli and suffered from severe coronary artery disease. Physical examination demonstrated a grade 3/5 hemiparesis and a computerized tomography (CT) scan confirmed the diagnosis of subacute subdural hematoma. He underwent twist drill craniostomy and attachment of the subdural evacuating port system. Recovery in this patient was dramatic. CONCLUSION: The subdural evacuating port system (SEPS) permits the neurosurgeon to drain subacute or chronic hematomas by a method that is minimally invasive, simple, and safe. The SEPS appears to promote brain expansion without the potential biohazards of other standard techniques.     

Clinical features of chronic subdural hematoma: neuropsychiatric and neuropsychologic changes in patients with chronic subdural hematoma

This article provides a background review of the cognitive and behavioral symptoms associated with chronic subdural hematoma (CSH). The areas addressed include the initial cognitive and behavioral symptom presentation, lateralization and localizing signs, differences between older and younger patients, and differential diagnosis. Although it is clear that behavioral and cognitive abnormalities are seen in CSH, further work is needed to objectively clarify the range of symptoms and signs.     

Intracerebral hematoma following evacuation of chronic subdural hematomas. Report of two cases

Two cases of intracerebral hemorrhage occurring after evacuation of bilateral chronic subdural hematomas are reported. Possible pathogenic mechanisms included hemorrhage into previously undetected areas of contusion, damage to cerebral vasculature secondary to rapid perioperative parenchymal shift, and sudden increase in cerebral blood flow combined with focal disruption of autoregulation; of these, the latter mechanism seemed most likely to be responsible for the hematoma formation. The need for clinical awareness of this nearly uniformly devastating complication, as well as prompt use of computerized tomography scanning in assessing the postoperative course, are stressed.     

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.     

外伤性硬膜下积液演变成慢性硬膜下血肿的临床分析

本院自1993年1月至2003年1月,共收治外伤性硬膜下积液(TSE)135例,其中17例转化为慢性硬膜下血肿(CSDH)。现结合患者的临床资料和有关文献报道如下。1临床资料1.1一般资料:17例中,男12例,女5例;年龄1～10岁6例,11～60岁2例,60岁以上9例。受伤原因:坠落伤6例,打击伤3例,车祸伤8例。其中减速性损伤12例。患者均否认在外伤性硬膜下积液演变为慢性硬膜下血肿期间有头部再次受伤史。1.2临床表现:17例患者均表现为在外伤性硬膜下积液症状的基础上,出现症状加重或新症状、体征,或原症状、体征减轻或消失后再次出现或加重。患者演变为慢性硬膜下血…     

外伤性硬膜下积液演变的慢性硬膜下血肿

目的 探讨外伤性硬膜下积液演变为慢性硬膜下血肿的几率、机理和临床特点。方法 回顾性分析32例外伤性硬膜下积液演变为慢性硬膜下血肿患者的临床资料及有关文献。结果 本组16.7%的外伤性硬膜下积液病例演变为慢性硬膜下血肿;积液演变为血肿的时间为伤后22－100d;经钻颅血肿引流均治愈。结论 外伤性硬膜下积液是慢性硬膜下血肿的来源之一。发病年龄两极化,常发生在积液量少、保守治疗的慢性型病例中,致病方式常为减速性损伤及合并的颅脑损伤很轻微是外伤性硬莫膜下积液演变为慢性硬膜下血肿患者的临床特点。     

Acute spontaneous subdural hematomas

Fifteen cases of spontaneous subdural hematoma are presented. A review of the literature reveals the rarity of this pathology. Symptomatological onset cannot be distinguished from the other cerebrovascular lesions. High mortality is connected with patient's consciousness level. CT scan performed in all patients presenting symptoms of cerebral stroke permitted to demonstrate this clinical entity is not so rare as the literature asserted.     

Bilateral chronic subdural hematomas without communication between the hematoma cavities: treatment with unilateral subdural-peritoneal shunt

Communication between bilateral subdural hematoma cavities was not demonstrated by metrizamide computed tomography subdurography in three patients with bilateral chronic subdural hematomas. Because unilateral subdural tapping yielded a slack fontanel without untoward neurological findings, patients were treated by the placement of unilateral subdural-peritoneal shunts, resulting in resolution of the bilateral hematomas.     

Clinical consideration of the pathogenesis of subdural hematoma

Zusammenfassung Zusammenfassend möchten wir also auf Grund unserer klinischen Beobachtungen an 39 Patienten mit subduralen Hämatomen sagen, daß grundsätzlich eine Unterscheidung zwischen der akuten traumatischen subduralen Blutung und dem chronischen subduralen Hämatom gemacht werden muß. Es kann nicht gesagt werden, ob sich aus einer frischen traumatischen subduralen Blutung jemals das Krankheitsbild des chronischen subduralen Hämatoms entwickelt, da dazu eine Reihe von Faktoren notwendig sind, die insgesamt als eine krankhafte Allgemeinreaktion des Gehirnes und seiner Häute zu bezeichnen sind.Es ist nach unseren Untersuchungen als sicher anzunehmen, daß die Anfänge der Blutung beim chronischen subduralen Hämatom bereits kurze Zeit nach dem Trauma einsetzen. Die nun folgende Allgemeinreaktion des Gehirnes entscheidet dann, ob sich daraus das Krankheitsbild des chronischen subduralen Hämatoms entwickelt oder ob der subdurale Bluterguß im Laufe der Zeit resorbiert wird. Letzteres ist dann der Fall, wenn posttraumatisch eine Überdruckreaktion des Gehirnes einsetzt. Kommt es jedoch, wie unsere Arteriogramme und Enzephalogramme beweisen, zu einer Verlangsamung der Hirndurchblutung und einem damit verbundenen Entquellungszustand am Hirngewebe mit gleichzeitiger Herabsetzung des Schädelinnendruckes, so sind die Voraussetzungen dafür gegeben, daß die Blutung fortschreitet und sich ein chronisches subdurales Hämatom ausbildet.

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Summary Based on their clinical observations of 39 patients with subdural hematoma, the AA. report that a fundamental distinction must be made between an acute traumatic subdural hemorrhage and a chronic subdural hematoma. It is not possible to say if a recent traumatic subdural hemorrhage will develop into a chronic subdural hematoma, because a certain amount of factors are necessary which must be regarded as a general pathologic reaction of the brain and its meninges.According to the AA.'s observations, it is taken for granted that the hemorrhage in chronic subdural hematomatas begins shortly after the trauma. It is the subsequent reaction of the brain that decides if a clinical picture of chronic subdural hematoma develops or if the subdural effusion of blood is gradually reabsorbed. The latter occurs when a posttraumatic overpressure of the brain takes place. But if there is, as it is confirmed on hand of the AA.'s arteriograms and encephalograms, a slowing down of the circulation in the brain and a contemporary condition of Entquellung in the brain tissues, and at the same time a decreasing of the pressure in the cranial cavity, then we have the elements for an increase of the hemorrhage and the establishing of a chronic subdural hematoma.

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Resumen Los AA basándose sobre sus observaciones clínicas, sobre 39 enfermos de hematoma subdural, han constatado que se tiene que hacer una distinción fundamental entre la hemorragia subdural aguda y el hematoma subdural crónico. No se puede decir si de una hemorragia traumática subdural reciente, se desarollará jamás el cuadro clínico del hematoma subdural crónico porque se necestian varios factores, los cuales en conjunto deben de considerarse como una reacción general morbosa del cerebro y de sus tegumentos. Según las averiguaciones de los AA., debe de suponerse que el comienzo de las hemorragias en el hematoma subdural crónico se produce poco tiempo después del trauma. Sólo la reacción posterior del encéfalo podrá determinar después el desarollo del cuadro clínico del hematoma subdural crónico o la reabsorción de la sangre en el curso del tiempo.Esta última condición llega cuando existe después del trauma un estado de presión endocranea aumentada. Pero si después del trauma se produce una disminución de la circulación cerebral, y por consecuencia se verifica una condición de deshidratación en el tejido cerebral con la consiguiente disminución de la persión intracraneana, como prueban los arteriogramas y encéfalogramas de los AA., entonces existen las condiciones que favorecen la continuación de la hemorragia y la formación de un hematoma subdural crónico.

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Résumé Les AA., après l'observation clinique de 39 malades d'hématome subdural, ont trouvé que l'on doit faire une distinction fondamentale entre l'hémorragie traumatique subdurale aigüe, et l'hématome subdural chronique. Il n'est pas possible de dire si d'une hémorragie traumatique subdurale récente, se developpera un jour l'aspect clinique de l'hématome subdural chronique, puisque divers facteurs sont nécessaires qui complessivement doivent être considérés comme une réaction générale morbide du cerveau et des méninges. Selon les recherches des AA., il faut retenir pour certain que le début des hémorragies dans l'hématome subdural chronique a lieu peu de temps après le choc. La seule successive réaction de l'encéphale pourra déterminer ensuite le développement du tableau clinique de l'hématome subdural chronique, ou bien par la suite la réabsorption du sang. Cette dernière condition se vérifie lorsqu'il existe, après le choc, un état de pression endocrânienne augmentée. Mais si, après le choc, il y a un rallentissement de la circulation cérébrale et que par conséquence, il se vérifié une condition de déshydratation dans le tissu cérébral avec contemporaine diminution de la pression intra-crânienne, comme le prouvent les artériogrammes et les encéphalogrammes des AA., alors existent les conditions qui favorisent la continuation de l'hémorragie et la formation d'un hématome subdural chronique.

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Riassunto Gli AA., sulla base delle loro osservazioni cliniche su 39 malati con ematoma subdurale hanno trovato che si deve fare una distinzione fondamentale tra l'emorragia traumatica subdurale acuta e l'ematoma subdurale cronico. Non si può dire se da una emorragia traumatica subdurale recente si svilupperà mai il quadro clinico dell'ematoma subdurale cronico, perchè ocorrono diversi fattori i quali complessivamente sono da considerare come una reazione generale morbosa del cervello e dei suoi involucri. Secono le ricerche degli AA., è da ritenere accertato che l'inizio delle emorragie nell'ematoma subdurale cronico avvenga poco tempo dopo il trauma. Soltanto la successiva reazione dell'encefalo potrà determinare poi lo sviluppo del quadro clinico dell'ematoma subdurale cronico, oppure il riassorbimento nel corso del tempo del sangue. Quest'ultima condizione avviene quando esiste dopo il trauma uno stato di aumentata pressione endocranica. Ma se in seguito al trauma si ha un rallentamento del circolo cerebrale e di conseguenza si verifica una condizione di desidratazione nel tessuto cerebrale con contemporanea diminuzione della pressione intracranica, corne provano gli arteriogrammi ed encefalogrammi degli AA., allora esistono le condizioni che favoriscono il proseguire della emorragia e la formazione di un ematoma subdurale cronico.