Clinical profile of subdural hematomas: dangerousness of subdural subacute hematoma

Subacute subdural hematomas are a poorly individualized nosological entity, often equated clinically to chronic subdural hematomas. Yet, their neurological deterioration which is usually rapid seems to distinguish them from chronic subdural hematomas. We wanted to show this dangerousness by establishing the clinically evolving profile of the three types of subdural hematomas. This was a prospective and retrospective study of 63 subdural hematoma (18 acute, 13 subacute, and 32 chronic) patients admitted between 2012 and 2014 in the neurosurgery unit of Lomé University Hospital. Hematomas were classified according to the elapsed time after head injury and blood density on CT. The main parameter studied was the evolution of the Glasgow Coma Score (GCS) in the 3 months following the trauma, enabling to establish an evolving profile of each type of hematoma. The average age of patients was 58.1 years for chronic subdural hematomas and 47.6 years for subacute subdural hematomas. Disease duration before admission was 13.1 days for chronic against 36.6 h for subacute hematoma. The clinical profile shows acute worsening within hours during the second week for patients with subacute hematoma, while it is progressive for patients with chronic hematoma. We noted two deaths, all victims of a subacute hematoma (one operated, one patient waiting for surgery). Iso-density hematoma on CT, especially in a young person, must be considered as a predictive factor of rapid neurological aggravation suggesting an urgent care or increased monitoring by paramedics.     

Unoperated subdural hematomas. Long-term follow-up study by brain scan and electroencephalography.

The authors report nine patients selected from over 100 patients with subdural hematomas successfully treated without surgery. These patients were followed for as long as 5 years. All had angiographically demonstrated subdural hematomas. Electroencephalograms (EEG) documented well the clinical improvement of the patient, but were poor guides to the true size of the hematoma, since EEG returns to normal early in the patient's course. Static scans are a better guide to the presence of a subdural hematoma, but they lag behind clinical improvement and usually remain abnormal for considerable periods of time after a major portion of the hematoma has been reabsorbed, and the patient is asymptomatic.     

Radiology of acute subtemporal subdural hematomas

Four cases of acute subtemporal hematoma are presented. The diagnostic appearance of this lesion on axial and coronal computed tomographic (CT) scans and at angiography is described.     

Reversible dementia in patients with chronic subdural hematomas

OBJECT: Neuropsychiatric changes following surgery for chronic subdural hematomas (CSDHs) were analyzed in 26 patients (21 men and five women) by using the Mini-Mental State Examination (MMSE) and the Hasegawa Dementia Scale-Revised (HDS-R) to determine factors that potentially contribute to neuropsychiatric recovery. METHODS: Burr hole irrigation was performed in every patient to treat the CSDH. The patients' profiles, including age and sex, neuroimaging findings (such as hematoma volume and thickness, as well as midline shift), and preoperative and postoperative scores on the MMSE, HDS-R, and activities of daily living (ADL) scale were recorded. According to preoperative MMSE scores, eight patients (30.8%) were classified as mentally healthy and 18 (69.2%) as suffering from dementia before surgery. Nine of the 18 patients with dementia recovered to a normal psychological state following surgery. Surgery improved not only the patients' independence in ADL (p = 0.0026), but also their neuropsychiatric functions such as orientation and calculation, as estimated by scores on the MMSE (p = 0.0002) and the HDS-R (p = 0.0008). Factors affecting neuropsychiatric status on admission were midline shift (p = 0.0398) and ADL score (p = 0.0124); factors that could be used to predict neuropsychiatric recovery after surgery were patient age (p = 0.0027) and ADL score (p = 0.0193). The results of a logistic regression analysis demonstrated that significant predictors of neuropsychiatric recovery after surgery include the following: patient age (p = 0.0049, odds ratio [OR] = 0.842) and preoperative ADL (p = 0.0056, OR = 0.471), MMSE (p < 0.0001, OR = 1.895), and HDS-R (p = 0.0073, OR = 1.303) scores. Results of subgroup analyses demonstrated that patients younger than 74 years of age and those who had preoperative scores lower than 5 on the converted ADL scale, higher than 10 on the MMSE, or higher than 9 on the HDS-R on admission were found to have a significantly better recovery of neuropsychiatric functions after surgery. CONCLUSIONS: Dementia is reversible in many patients with CSDH, and surgery can improve not only independence in ADL, but also neuropsychiatric functions. Patients who are younger and/or those who have lower preoperative ADL scores and/or higher preoperative MMSE or HDS-R scores will achieve a good recovery with regard to neuropsychiatric functions after surgery. Estimations of neuropsychiatric function based on MMSE and HDS-R scores were found to be useful in predicting functional outcomes in patients with CSDH.     

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.     

Symptomatic subacute subdural haematoma following spontaneous acute subdural haematoma

Summary Two patients with non-traumatic acute subdural haematoma were observed, initially without surgical intervention. Eleven days after the onset, each patient developed hemiparesis and an increase in severity of headache. Serial computed tomography scans demonstrated that the initial hyperdense haematomas became hypodense with a definite increase in volume. The term symptomatic subacute subdural haematoma was proposed to properly define this pathological process, which necessitated removal of the haematoma in the subacute stage. The mechanism of increase in the volume of the haematoma is discussed.     

急性硬脑膜下血肿患者的生存率与血肿厚度、中线移位的关系

目的：分析急性硬脑膜下血肿的血肿厚度、中线移位及其差值在判断患者预后中的作用。方法：回顾性收集并分析95例急性硬脑膜下血肿患者的临床资料,计算血肿厚度、中线移位及其差值,用Kaplan-Meier、Wilcoxon-Mann-Whitney U检验分析它们与预后的关系。结果：本组患者血肿厚度5-40mm、中线移位0-35mm,两者差值-20-35mm;48例（51％）死亡,47例（49％）存活,存活患者中18例（19％）预后良好。Kaplan-Meier分析显示：血肿厚度在17.0mm、中线移位在15.0mm、中线移位超过血肿厚度2.2mm的患者生存率为50％;预后与这些因素之间有显著的相关性。结论：血肿厚度、中线移位及两者差值是判断急性硬脑膜下血肿患者预后的关键因素,并可作为指导临床治疗的依据。     

Mechanics of acute subdural hematomas resulting from bridging vein rupture

OBJECT: Based on data from primate experiments it is known that rotational acceleration in the sagittal plane and in a forward direction is most likely to produce acute subdural hematomas due to bridging vein rupture. For protection against these lesions, knowledge of rotational acceleration tolerance levels in humans is required. In the present study the authors analyze human tolerance levels for bridging vein rupture by performing head impact tests in cadavers. METHODS: Ten unembalmed cadavers were subjected to 18 occipital impacts producing head rotation in the sagittal plane with varying rotational acceleration magnitudes and pulse durations. Rotational acceleration was calculated from the linear acceleration histories recorded by three uniaxial accelerometers mounted on the side of the head. Bridging vein ruptures were detected by injecting contrast dye into the superior sagittal sinus under fluoroscopy and by autopsy procedures. Bridging vein ruptures were produced in six head impact tests: one test with a pulse duration of 5.2 msec and a peak rotational acceleration of 13,411 rad/second2; three tests with a pulse duration between 7 and 8 msec and a peak rotational acceleration of 12,558, 10,607, and 8567 rad/second2; and two tests with a pulse duration longer than 10 msec and a peak rotational acceleration as low as 5267 rad/second2. CONCLUSIONS: This is the only cadaveric study of bridging vein rupture focused on short pulse durations, which are usually associated with falls. The data suggest a tolerance level of approximately 10,000 rad/second2 for pulse durations shorter than 10 msec, which seems to decrease for longer pulse durations.     

Reduction in the number of repeated operations for the treatment of subacute and chronic subdural hematomas by placement of subdural drains

OBJECT: The aim of this study was to determine the influence of closed-system subdural drainage on repeated operation rates after burr hole evacuation of subacute and chronic subdural hematomas (SDHs). METHODS: Five hundred consecutive operations for the treatment of SDH via burr holes were performed between January 1, 1996, and April 15, 2002, at the Auckland Hospital. Hospital records were used to ascertain demographic data, operation, and repeated operation details. Rates of repeated surgeries were compared in patients with and without subdural drains. Repeated operations were performed less frequently in patients with subdural drains, occurring in 31 (10%) of 310 cases involving drains and in 35 (19%) of 188 cases without drains (p < 0.01). Demographics between the two groups were not significantly different except for mean patient age, which was higher among patients with a subdural drain. A lower rate of repeated operation was observed in patients who had undergone drain placement, regardless of whether there was visible evidence of brain reexpansion. CONCLUSIONS: Patients have lower rates of repeated surgeries if subdural drains are placed following evacuation of an SDH via a burr hole. To reach high clinical significance, 12 patients must undergo this simple intervention. If technically feasible, subdural drains should be inserted regardless of any occurrence of brain expansion during surgery.     

Interventional MRI-guided stereotactic aspiration of acute/subacute intracerebral hematomas

Surgical interventions for hypertensive intracerebral hematomas are still controversial. Many believe only hyperacute intervention is of any real utility. The majority of present interventions require a formal craniotomy with standard neurosurgical techniques. There are, however, a few reports on CT-guided stereotactic aspiration of these hematomas with favorable results. We report 10 patients treated with frameless fiduciless stereotactic means using an intraoperative MRI scanner (GE 0.5 T Signa SP). These patients were initially diagnosed as having hypertensive intracerebral hematoma and operated on within 1-34 days after hemorrhage. The actual operating time averaged less than 120 min, including intraoperative imaging. Clot volumes ranged from 2.5 to 75 cm(3) with a mean of 31 cm(3). There were 2 thalamic hematomas and 8 basal gangliar hematomas. Three patients had intraventricular hematoma extension and all 3, as well as an additional patient, required extraventricular drainage. However, no patients required permanent posthemorrhage ventriculoperitoneal shunting. Aspiration was successful in all cases to 70-90% of clot removal. Two cases utilized intrahematoma t-PA infusion with subsequent 80-90% clot removal. There were no complications or rehemorrhages. All patients showed some form of improvement that included either improved blood pressure control, speech or cognitive abilities. We conclude that using an intraoperative MRI scanner to perform frameless, fiduciless stereotactic aspiration of acute/subacute intracerebral hematoma is a safe and potentially effective means of treating intracerebral hematomas.     

Cerebral atrophy after acute traumatic subdural orextradural hematomas in adults

Cerebral atrophy is one of the serious sequelae ofsevere head injury. 1 Neuropathologicalinvestigation has revealed that cerebral atrophy iscaused by either diffuse axonal injury or cerebralhypoxia and ischemia. Secondary ipsilateral cerebralatrophy caused by acute subdural hematomas in infantshas been reported recently, but this unilateral cerebralatrophy after head injury in adult patients has rarelybeen reported.     

Peritoneal drainage of chronic subdural hematomas in older patients

Most patients with chronic subdural hematoma are successfully treated with trephination and external drainage. However, hematomas with thick membranes may persist or recur, needing reoperation or major surgery such as craniotomy with membranectomy. In 14 patients aged over 60 years, internal peritoneal drainage of the hematoma by a low-pressure shunt system proved to be a reliable method of treatment with the following advantages: rapid neurological improvement; immediate mobilization; little stress for the patient; no recurrence; disappearance of the membranes; and slow and well-tolerated cerebral reexpansion without hypotension. Successful use of this method has been reported previously in children, but not in adults.     

Prognosis of chronic subdural hematomas

This article considers factors that may be of prognostic value in evaluating the chronic subdural hematoma (CSH) patient. It also examines conditions that predispose the development of a CSH. Variables such as admission neurologic status and presenting symptomatology are reviewed. Radiologic parameters (i.e., CSH density and midline shift) and intraoperative findings (i.e., pressure and pulse) are discussed.     

Analysis of ischemic brain damage in cases of acute subdural hematomas

BACKGROUND: Ischemic damage of the brain is one of the most important factors for the sequelae of acute subdural hematomas (ASDHs). However, ischemic damage is infrequently addressed in a systematic manner in the clinical setting. METHODS: The analysis of ischemic brain damage was performed based on serial computed tomography (CT) scans in 80 patients with traumatic ASDHs. Single photon emission computed tomography (SPECT) for regional blood flow and/or magnetic resonance imaging (MRI) were also performed. RESULTS: Follow-up CT scans showed ischemic brain damage in 19 patients and no significant damage in 35 patients. The remaining 26 patients progressively deteriorated to the point of brain death. The ischemic brain damage was seen most frequently in the territory of the anterior cerebral artery (13 cases), followed by the territory of the posterior cerebral artery (12 cases). The ischemic damages in the pallidum, the hypothalamus and the thalamus were demonstrated in 4, 8, and 4 cases, respectively. The ischemic damage in the underlying brain that was probably because of the direct compression of the hematoma was seen in only two cases. CONCLUSIONS: Most of the ischemic brain damage noted in this study was because of arterial compression secondary to the brain shift and brain herniation, rather than the direct effect of the hematoma upon the underlying brain. Ischemic brain damage adversely affects outcome morbidity, and the difficulty in preventing ischemic damage in cases with marked brain shift leads to poor outcome in patients with ASDHs.     

Acute nontraumatic spinal subdural hematomas in three patients.

STUDY DESIGN: The clinical data, magnetic resonance imaging, intraoperative findings, and functional outcome were reviewed for three patients under anticoagulant therapy who experienced acute nontraumatic spinal subdural hematoma. OBJECTIVES: To draw attention to this rare complication of anticoagulant therapy and to assess the magnetic resonance findings and clinical outcome of patients with spinal subdural hematoma after surgical evacuation. SUMMARY OF BACKGROUND DATA: Among intraspinal hematomas, spinal subdural hematomas are by far the least common. Magnetic resonance findings have been demonstrated in only a few cases of spinal subdural hematomas. The timing of the operation and the anatomic location of the hematoma essentially determine the functional outcome. METHODS: Three case reports of spinal subdural hematomas in patients receiving anticoagulant therapy are presented. Particular interest was given to the clinical and magnetic resonance data, the intraoperative findings, and the functional outcome. RESULTS: The three patients each had a complete preoperative neurologic deficit. Sagittal T1- and T2-weighted magnetic resonance images of the spine proved to have high sensitivity for defining the type of bleeding and delineating the craniocaudal extension of the hematoma. Surgical evacuation was performed within 26 hours after the onset of symptoms. Intraoperative findings showed the hematoma to be confined between the dura and the arachnoid in two patients, and to be associated with rupture into the subarachnoid space in one patient. Postoperative recovery was incomplete in two patients, and did not improve in the remaining patient. CONCLUSIONS: Spinal subdural hematoma must be considered in patients under anticoagulant therapy with spontaneous signs of acute spinal cord or cauda equina compression. Magnetic resonance imaging with sagittal T1- and T2-weighted images were adequate and reliable for diagnosis of spinal subdural hematoma. On the basis of previous studies and the authors' intraoperative findings, spinal subdural hematomas could be viewed as spinal dural border hematomas. The level of preoperative neurologic deficit seemed to be critical for recovery despite prompt surgical evacuation.