Acute subdural hematoma and diffuse axonal injury after severe head trauma

The association of acute subdural hematoma (SDH) and diffuse axonal injury has received little attention in the literature. The authors report the clinicopathological findings in six patients who died of severe head injury in whom computerized tomography revealed acute SDH as the predominant lesion. All patients were injured in road traffic accidents and lost consciousness on impact. The mean total contusion index was 17.4 and sever contusions were seen in only two cases. All patients presented histological criteria of intracranial hypertension (pressure necrosis focus in one or both parahippocampal gyri). Hypoxic brain damage was evident in the postmortem examination of three patients. In three cases, macroscopic hematic lesions were observed in the corpus callosum. All patients had widespread axonal retraction balls disseminated in the white brain matter. Three patients who survived for more than 11 days had microglial clusters. In some patients with a head injury, acute SDH may be only an epiphenomenon of a primary impact lesion of variable severity: that is, a diffuse axonal injury. In these cases, the final outcome is fundamentally dependent on the severity of the subjacent diffuse axonal injury.     

Acute subdural hematoma due to minor head trauma in patients with a lumboperitoneal shunt

The cases of four patients treated with a lumboperitoneal shunt in whom acute subdural hematoma occurred after minor head trauma are presented. Three of the four patients had subdural fluid collection or widening of subarachnoid space observed on computed tomography scan after placement of the lumboperitoneal shunt. We report that patients with a lumboperitoneal shunt have the potential to develop acute subdural hematoma due to minor head trauma, and discuss its mechanism.     

Acute traumatic infratentorial subdural hematoma]

The case of an injured man, aged 54, is reported. On the basis of the neurological symptoms, without neuro-radiological contrast examinations, in presence of negative skull osteogram, on the day of the injury suboccipital craniectomy and removal of the subdural haematoma have been performed. The diagnostical difficulties of the occipital injury are pointed out, since both the occipital and infratentorial regions are "silent" regions for the carotis-angiography. In the case of subdural haematoma the suboccipital decompression performed in due time may be exactly as much successful as the supratentorial decompression.     

Acute epidural hematoma caused by contrecoup head injury--case report

A 50-year-old woman presented with a rare case of contrecoup epidural hematoma (EDH) associated with coup EDH. She was hit by a car while riding a bicycle, and struck the left parietal region of her head on the ground. She was dazed for a few minutes. On admission, she complained of nausea but exhibited no neurological deficits. Skull radiography revealed a linear fracture of the left temporal bone. Computed tomography (CT) demonstrated acute EDH in the right frontal region due to contrecoup injury, and thin EDH in the left temporal region due to coup injury. She vomited repeatedly after admission. She became lethargic and exhibited right hemiparesis. CT, taken 2 hours later, revealed enlargement of the left coup EDH, but no enlargement of the right contrecoup EDH. An emergent evacuation of the enlarged coup EDH was performed. Immediately after the operation, she became alert and the right hemiparesis subsided. The contrecoup EDH was conservatively treated, in the absence of enlargement. She was discharged 12 days after the injury without neurological deficits.     

Acute spontaneous subdural hematoma

A review of the literature reveals 20 reported cases of acute spontaneous subdural hematoma. We present an additional case with a tabulation of pertinent data. The prototype case is described, emphasizing the benign and insidious onset followed, invariably, by a deteriorating neurological status leading, almost always, to surgical evacuation. A high index of suspicion for this entity is of great importance, because a delay in diagnosis may lead to an increase in the morbidity and the mortality of this condition.     

Acute subdural hematoma in infancy

BACKGROUND: Acute subdural hematoma in infants is distinct from that occurring in older children or adults because of differences in mechanism, injury thresholds, and the frequency with which the question of nonaccidental injury is encountered. The purpose of this study is to analyze the clinical characteristics of acute subdural hematoma in infancy, to discover the common patterns of this trauma, and to outline the management principles within this group. METHODS: Medical records and films of 21 cases of infantile acute subdural hematoma were reviewed retrospectively. Diagnosis was made by computed tomography or magnetic resonance imaging. Medical records were reviewed for comparison of age, gender, cause of injury, clinical presentation, surgical management, and outcome. RESULTS: Twenty-one infants (9 girls and 12 boys) were identified with acute subdural hematoma, with ages ranging from 6 days to 12 months. The most common cause of injury was shaken baby syndrome. The most common clinical presentations were seizure, retinal hemorrhage, and consciousness disturbance. Eight patients with large subdural hematomas underwent craniotomy and evacuation of the blood clot. None of these patients developed chronic subdural hematoma. Thirteen patients with smaller subdural hematomas were treated conservatively. Among these patients, 11 developed chronic subdural hematomas 15 to 80 days (mean = 28 days) after the acute subdural hematomas. All patients with chronic subdural hematomas underwent burr hole and external drainage of the subdural hematoma. At follow-up, 13 (62%) had good recovery, 4 (19%) had moderate disability, 3 (14%) had severe disability, and 1 (5%) died. Based on GCS on admission, one (5%) had mild (GCS 13-15), 12 (57%) had moderate (GCS 9-12), and 8 (38%) had severe (GCS 8 or under) head injury. Good recovery was found in 100% (1/1), 75% (8/12), and 50% (4/8) of the patients with mild, moderate, and severe head injury, respectively. Sixty-three percent (5/8) of those patients undergoing operation for acute subdural hematomas and 62% (8/13) of those patients treated conservatively had good outcomes. CONCLUSIONS: Infantile acute subdural hematoma if treated conservatively or neglected, is an important cause of infantile chronic subdural hematoma. Early recognition and suitable treatment may improve the outcome of this injury. If treatment is delayed or the condition is undiagnosed, acute subdural hematoma may cause severe morbidity or even fatality.     

Acute subdural hematoma caused by rupture of a peripheral aneurysm of the sylvian artery

A patient who suffered acute subdural hematoma secondary to rupture of intracranial aneurysm is reported. Cerebral angiography showed a subdural collection on the left hemisphere and a distal middle cerebral artery aneurysm. There was no history of head trauma, endocarditis or systemic infection, and physical examination was normal. Congenital etiology is presupposed. From our review of the literature this is a rare association. The author emphasizes on the continuing role of angiography to evaluate spontaneous subdural hematomas.     

Posterior fossa subdural hematoma in the newborn caused by birth injury

Among various cases of intracranial hemorrhage in the newborn caused by birth injury, posterior fossa subdural hematoma is of serious nature in many cases and often results in death after critical clinical course due to compression of the respiratory center of the medulla oblongata. We have recently experienced two cases of subdural hematoma in the posterior fossa caused by birth injury, which we successfully treated non-surgically. Herein, we report these two cases and present a sequential CT scan of each. The first case is a full-term (39 weeks gestation) male infant. Delivery was carried out spontaneously with double footling presentation. At 20 hours of age, cyanosis and convulsion occurred. CT scan was performed and revealed high density areas in the posterior fossa, quadrigeminal cistern and longitudinal cerebral fissure. Bloody CSF was discharged per lumbar puncture and glycerol was infused intravenously, but the ventricle became enlarged. At this point at 9 days of age, the infant was admitted to our hospital. While he showed poor activity on admission, hematoma was absorbed gradually and disappeared at 3 months of age by conservative treatment. Now, at 6 years and 6 months of age, the patient has no neurological deficits. The second case is a full-term (40 weeks gestation) twin female infant. Due to breech presentation, delivery was conducted per breech extraction. At three days of age, vomiting, fontanel bulging and hypotonia were observed. CT scan revealed hematoma similar to that seen in the first case, and steroid and glycerol were infused intravenously. Conservative treatment was performed in this case also, and changes shown by CT scan were almost the same as those seen in the first case. The patient has no neurological deficits at 5 years and 7 months of age. Since the introduction of CT scan, early diagnosis of a subdural hematoma in the posterior fossa has been possible. But reports of successful surgical treatment are not so frequent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Acute intestinal obstruction caused by gallstones in aged patients]

The results of treatment of 6 patients operated on for acute ileus caused by a gallstone have been analysed. The authors consider the elderly and senile age not to be a contraindication for operation.     

Acute brain swelling during evacuation of subdural hematoma caused by delayed contralateral extradural hematoma: report of two cases

Two patients experienced severe brain swelling during the evacuation of acute subdural hematomas. Postoperative computed tomographic (CT) scans revealed delayed extradural hematomas on the sides opposite the subdural hematomas. Extradural bleeding occurred in the area of the fractured skull. One patient improved neurologically after evacuation of the extradural hematoma, and the other was not operated because he was moribund. Drilling exploratory burr holes in the fractured area may have been a better strategy than awaiting a postoperative CT scan. The reduction of intracranial pressure after the removal of subdural hematoma was postulated to be the most important factor contributing to the formation of the extradural hematoma.     

Acute subdural hematoma: direct admission to a trauma center yields improved results

We studied 128 patients admitted over a 12 1/2-year period to the Cook County Hospital Trauma Unit with acute subdural hematoma (ASDH): 82 were admitted directly and 46 were admitted after transfer from another hospital; 59% of the entire group died and only 27% obtained a functional recovery. As a group, the transferred patients, who suffered delays of several hours before receiving definitive surgical care, fared significantly worse than the patients with equivalent trauma who were admitted directly. The mortality of the transferred patients was 76%, compared to 50% of the direct admit patients. The outcome was also worse for transfer patients who experienced a 'lucid interval' or with alcohol intoxication. We conclude that the delays associated with failure to admit patients with ASDH directly to a head trauma center cause an excessive mortality and morbidity which could potentially be avoided by proper triage.     

Acute non-traumatic extensive subdural spinal hematoma

Acute spinal subdural hematoma is a somewhat rare pathology. Its severity comes from the constitution of an acute spinal cord compression. In many cases MRI is useful for the differential diagnosis with the epidural hematoma. A 79-year-old patient was referred for emergency neurosurgery for acute spinal cord compression. The vascular risk in this patient was significant: hypertension, oral anticoagulants. Clinically, acute non-traumatic subdural spinal hematoma was suspected. The spinal cord MRI was in favor of the diagnosis which was confirmed intraoperatively. The surgical procedure revealed an extensive hematoma which infiltrated the spinal cord. The diagnosis of nontraumatic subdural spinal hematoma may be difficult in some cases and correctly established only during the surgical procedure. In comparison with reports in the literature, we discuss the underlying mechanisms of this hematoma. Spinal subdural haematoma must be considered in patients taking anticoagulant therapy or with a coagulation disorder who present signs of acute spinal cord compression. MRI sagittal T1 and T2-weighted images are adequate and reliable for diagnosis of spinal subdural hematoma. Prompt surgical evacuation of this hematoma is crucial.     

Acute epidural hematoma following evacuation of chronic subdural hematoma with continuous closed system drainage]

The authors report a case of acute epidural hematoma occurring after evacuation of chronic subdural hematoma with continuous closed system drainage. Laboratory data of the patient including bleeding time were within normal limits. The cause of the postoperative intracranial hematoma was the rapid surgical decompression of the initial lesion, and we considered that it could be prevented if chronic subdural hematoma was treated using closed system drainage and slow decompression. But acute epidural hematoma occurred after this operative procedure and it was accelerated by evacuation of the chronic subdural hematoma through the drain. An emergent craniotomy and removal of the hematoma was performed, so the patient was discharged from hospital with satisfactory neurological recovery. A careful check of the evacuated hematoma volume is very important, and CT scanning should be immediately performed if postoperative hematoma is suspected.