Subacute spinal subdural hematoma associated with intracranial subdural hematoma

We describe a subacute spinal subdural hematoma in a patient with psot-traumatic subacute intracranial subdural hematoma. CT and MRI demonstrated hematoma within the interhemispheric subdural space and at the lumbar posterior subdural space which extended from the L1 to the S2 level. The lesion showed high signal intensity on both T1 and T2 weighted images. Surgical decompression of the spinal subdural hematoma was performed. The symptoms completely resolved after surgery. Spinal subdural hematoma may be concomitant with or may occur after intracranial subdural hematoma. If a patient with intracranial subdural hematoma complains of low back pain and weakness in both legs; lumbosacral MR examination should be performed to exclude spinal subdural hematoma.     

Interhemispheric subdural hematoma

Although relatively uncommon, interhemispheric subdural hematoma (ISDH) occurs more frequently than was suspected before the advent of computerized tomographic (CT) scanning. When its mass is sufficiently large to compress the medial cerebral hemisphere, specific focal neurological abnormalities may occur. These include weakness of the contralateral leg, or contralateral hemiparesis with the leg being weaker than the arm. On the unenhanced CT scan ISDH is seen as a crescent shaped, midline hyperdensity. Treatment is dictated by the clinical course. Evacuation of the hematoma by parasagittal craniotomy is recommended if the symptoms are pronounced.     

Contralateral acute subdural hematoma occurring after evacuation of subdural hematoma with coexistent contralateral subdural hygroma

Burr-hole craniostomy with closed-system drainage is a safe and effective method for the management of chronic subdural hematoma. However, contralateral acute subdural hematoma has been reported to be a rare and devastating complication. Only 3 cases have been described in the literature. Herein, we reported an 80-year-old male with chronic subdural hematoma and contralateral subdural hygroma. The burr-hole craniostomy with closed-system drainage was initially performed to treat the chronic subdural hematoma. Three days after surgery, weakness of the extremities developed, and contralateral acute subdural bleeding within the previous subdural hygroma was diagnosed by CT scan of the brain. The pathophysiological mechanism of this rare complication was discussed, and the relevant literature was also reviewed.Chronic subdural hematoma (SDH) is one of the most common entities managed in daily neurosurgical practice, and is known to have a good prognosis after minimal burr-hole craniostomy.1 Ipsilateral acute SDH or recurrence of hematoma is the most well-documented complication of this simple surgery.1-3 However, the development of a contralateral acute SDH following burr-hole craniostomy with closed-system drainage has been previously reported to be a rare but devastating postoperative complication.4,5 Herein, we report a case of contralateral acute SDH occurring after evacuation of chronic SDH with the coexistence of contralateral subdural hygroma. The relevant literature is also reviewed. Our objective in presenting this particular case is to highlight this rare but devastating complication in the management of this disease.     

A case of infected subdural hematoma following chronic subdural hematoma irrigation]

A 71-year-old female complicating Parkinson disease and diabetes mellitus was admitted to our medical center for urinary tract infection one month after burr hole irrigation and drainage of left chronic subdural hematoma. Klebsiella pneumonia was detected in the bacterial culture of her urine. As antibiotic therapy started, her condition and peripheral white blood cell counts were improved. But consciousness level got worsened and right hemiparesis appeared. A CT scan showed re-accumulation of left subdural fluid so an emergent irrigation was performed. The old hematoma with slightly yellowish, bloody purulent fluid was found and an intracapsular drain was inserted. Klebsiella pneumonia was detected from the bacterial culture of the hematoma. After 10 days, a CT scan showed subdural fluid collection again, so, total hematoma capsule removal was performed. After the operation, her neurological and serological condition improved and she was discharged without any neurological deficits. Klebsiella pneumonia existing urinary tracts rarely infected subdural hematoma cavity via hematogenous dissemination. We must keep in mind this complication may occur when we see compromised host like this case. Total removal of infected hematoma capsule is considered as radical treatment.     

Aphasia in subdural hematoma

The occurrence of aphasia as the only or dominant symptom of subdural hematoma (SDH) has not been emphasized in the literature. The possible confusion of traumatic aphasia with transient ischemic attacks or stroke has been the object of most recent investigations. Four patients with subacute SDH had aphasia as an initial symptom; the relevant pathophysiologic characteristics were noted in each. These patients had a rapid response to decompression with marked resolution of the aphasia irrespective of immediate or delayed drainage.     

Infantile acute subdural hematoma

A retrospective analysis of the infantile acute subdural hematoma was made with special reference to its pathogenesis. In 11 of 15 cases, the hematomas were bilateral or a contralateral subdural fluid collection was present. In 7 of 11 patients who underwent operation the collection was bloody fluid and/or clotted blood. In 3 patients, a subdural membrane, as seen in adult chronic subdural hematoma, was found. In only 1 patient with unilateral hematoma was clotted blood present without subdural membrane. The thickest collection of clotted blood was in the parasagittal region. It is postulated that in most cases hemorrhage occurs after minor head injury, from the bridging veins near the superior sagittal sinus, into a pre-existing subdural fluid collection such as chronic subdural hematoma or subdural effusion with craniocerebral disproportion, and that infants without intracranial disproportion are unlikely to have acute subdural hematoma caused by minor head injury.     

Intrauterine chronic subdural hematoma

We discuss a newborn delivered by elective cesarean section who had macrocephaly with severe anemia. The anemia was corrected by exchange transfusion, and the infant, at first, appeared stable but manifested poor feeding and seizures. Transillumination of the skull was negative, although the anterior fontanel was tense. Computerized tomography demonstrated mild hydrocephalus and suggested subdural fluid. Bilateral subdural taps yielded fluid typical for chronic subdural hematoma. To our knowledge, this is the first documented case of intrauterine subdural hematoma developing in the absence of trauma. An analogy is made to the pathogenesis of subdural hematoma after rapid decompression of the ventricular system by shunting procedures for obstructive hydrocephalus.     

Immediate development of a contralateral acute subdural hematoma following acute subdural hematoma evacuation

Contralateral hematoma formation following acute subdural hematoma (ASDH) evacuation is a well-described complication. The most common type of contralateral hematoma is an epidural hematoma. Rarely, ASDH develops on the contralateral side. We report an elderly woman who presented with a post-traumatic ASDH and underwent ipsilateral hematoma evacuation by craniotomy and subsequently developed a contralateral ASDH. Because of the potential consequences of a delayed ASDH, there should be a low threshold for early post-operative imaging following ASDH evacuation, especially in elderly patients and those with additional associated intracranial injuries.     

Chronic subdural hematoma preceded by traumatic subdural hygroma

Patients with traumatic subdural hygroma (SDG) are at an increased risk of developing chronic subdural hematoma (CSDH). However, the mechanism by which this occurs is still not fully understood. The purpose of this paper is to investigate the clinical characteristics and pathogenesis of CSDH, as well as the relationship between CSDH and SDG. We review the pertinent literature and retrospectively examine a series of cases in which CSDH had been preceded by SDG to understand the natural history and developmental mechanisms of these lesions. We discuss the cases of 24 patients in whom CSDH developed from traumatic SDG between 2001 and 2005. Headache was the most common symptom, and the mean Glasgow Coma Scale score was 14.1. Increases in SDG volume were observed in CT scans of 17 patients, and increased density and volume was observed in five patients. The mean interval between the two diseases was 57.6 days, and 13 patients developed new symptoms after the development of CSDH. The most common symptoms at that time were headache and hemiparesis. All patients underwent an operation, which resulted in good recovery in all but one case. The cycle of persistent SDG, rebleeding, coagulation and fibrinolysis contributes to the development of CSDH from SDG. It is important to understand the natural history of CSDH and carefully follow up patients with head injury, especially if it is associated with SDG, and the potential for the development of CSDH should be considered.     

Contralateral acute subdural hematoma occurring after removal of calcified chronic subdural hematoma.

Supratentorial craniotomy for a nontraumatic lesion complicated by an acute subdural hematoma on the opposite side is rare. A 47-year-old woman presented with progressive headache and dizziness with no significant past history. Neuroimaging studies revealed a very large calcified chronic subdural hematoma over the entire right hemisphere with prominent mass effect. Despite a near total excision of the hematoma including the inner membranes by a large craniotomy with meticulous dissection, the brain parenchyma remained depressed. The dead space was therefore filled with saline and the operation was completed as usual. Repeat computed tomography scan for signs of left tentorial herniation demonstrated an acute contralateral subdural hematoma with severe shift of midline structures. We propose a prevention strategy for this event, which has not been previously described. We also discuss possible mechanisms involved in this unexpected complication.     

Conservative treatment of subdural hematoma

The authors report the results of conservative treatment of subdural hematomas in 8 cases. In 6 of them the treatment was begun 1 to 7 days after head trauma, the other two with no history of trauma had complained of intracranial disease for two to four weeks before admission to hospital. All patients were treated with dexamethasone and 6 of them with Lasix, and two with mannitol. In 7 cases a quick improvement was observed, one patient, after 7 days treatment without good result was operated on. Control CT-scan, performed 2 weeks to 6 months after conservative treatment revealed the resolution of previously detected subdural hematomas.     

慢性硬脑膜下血肿与癫痫

以癫痫为首发症状的慢性硬脑膜下血肿１２例，男９例，女３例。大发作３例，局灶性发作９例。对以癫痫为首发的临床症状、体征、脑电图、ＣＴ等资料作了分析；对慢性硬脑膜下血肿所致癫痫发作的病因、血肿包膜的病理生理及临床处理作了讨论，认为早期手术术后继服用抗癫痫药物治疗效果良好。     

Chronic subdural hematoma in utero

A case of chronic subdural hematoma and hydrocephalus diagnosed in utero is presented. No history of trauma could be elicited. Laboratory investigations failed to show a coagulation disorder. Both the hematoma and hydrocephalus were surgically treated 8 days after delivery. At 14 months of age the child is showing moderately delayed development. The literature is reviewed and discussed. The importance of correct antenatal diagnosis is stressed.     

Traumatic acute subdural hygroma mimicking acute subdural hematoma.

Subdural hygroma is a frequent delayed complication of head trauma. Most hygromas are clinically 'silent' and a few cases have shown slow deterioration in the chronic stage. We report a case of subdural hygroma showing unique radiological findings and rapid deterioration. A 74-years-old female presented with a mild headache and consciousness disturbance after head injury. Computed tomography showed a midline shift as a result of two components piling up in the subdural space; the outer components showed low density, the inner components high density. Magnetic resonance imaging demonstrated that these two subdural components were subdural hygroma and subarachnoid hematoma. Simple burr hole irrigation, rather than large craniotomy, was thought to be more appropriate treatment to reduce the mass effect. Simple burr hole irrigation was performed to remove the subdural hygroma and the patient showed an excellent recovery. Careful examination of the radiological findings prevented an unnecessary procedure in this case. A possible mechanism of this phenomenon is discussed.