Encapsulated Unresolved Subdural Hematoma Mimicking Acute ...
Rapid Resolution of Acute Subdural Hematoma · Rapid Resolution of Acute Subdural Hematoma Akut...
Transcript of Rapid Resolution of Acute Subdural Hematoma · Rapid Resolution of Acute Subdural Hematoma Akut...
Tiirkish Neiirosiirgenj 7: 24 - 27, 1997
CASE REPORTS
KlI'ls: ResdIlition of ACi/te Siibdiirnl Hemotomo
Rapid Resolution of Acute Subdural Hematoma
Akut Subdural Hematomun I-Iizla Kaybolmasi
TALAT KIRIS, RAMAZAN ATABEY, HALIL TOPLAMAOGLU
i.Ü. Istanbul Tip Fakültesi, Nörosirürji Anabilim Dali (TK), Bakirköy Ruh ve Sinir Hastaliklari Hastanesi,III. Nörosirürji Klinigi (RA, HT), Istanbul, Turkey
Abstract: A patient with spontaneous resolutian of anacute traumatic subdural hematama within 6 hours is
reported. The patient was discharged two days afteradmission in normal neurological condition. Previouslypublished cases of acute subdural hematomas with rapidspontaneous resolution are reviewed and possiblemechanisms for rapid resolutian such as redistributionandi or washing out of the hematama due to an arachnoidtear are discussed.
Key Wards: Head injury, nonoperative treatment,spontaneous resolution, subdural hematama
INTRODUCTION
The natural course of acute subdural hematoma
(ASOH) is not always predictable despite thefrequency of its occurrence. Operative treatment isgeneraliy recommended since early operativeintervention improves the prognosis (14). Howeverspontaneous resolution of acute subdural hematomawith favorable clinical results are reported(3,11,13,16).The frequency of spontaneous resolutionof subdural hematomas is not known but rapidresolution is distinctly uncommon. The earliestresolution reported in the literature was in 6 hours(12,13). Recently, we observed a patient withspontaneous resolution of an acute subduralhematoma within 6 hours.
24
Özet: Akut travmatik subdural hematomu olan bir hastada
hematomun alti saat içinde kendiliginden kayboldugusaptandi. Hasta iki gün içinde normal nörolojik bulgularlataburcu edildi. Daha önce yayimlanmis, hizla vekendiliginden kaybolan akut subdural hematom olgularigözden geçirildi ve hematomm1 yeniden dagilimi ve/veyaaraknoid yirtigina bagli olarak yikanarak kaybolmasi gibiolasi mekanizmalar tartisildi.
Anahtar Sözcükler: Cerrahi olmayan tedavi, kafa travmasi,kendiliginden rezolüsyon, subdural hematom
CASE REPORT
A 12 year old boy was admitted to theemergency department two hours af ter a fall from aheight of two meters. According to his mother hewas alert shortly after the fall, but one hour later hevomited and his consciousness deteriorated. Onarrival physical examination revealed a smaIlsubgaleal hematoma in the right occipital region andhis Glasgow Coma Score (GCS) was noted to be 14(E3M6V5 ). He had neither pupillary abnormalitynor motor disturbance.
Computerized tomography (CT) waspedormed. The CT sean demonstrated a contre-couplesion, namely a 5 mm thick left frontal acute
Tiirkis/i Neiirosiirgenj 7: 24 - 27, 1997
subdural hematoma which extended to the parietalconvexity, and a smallleft frontal contusion withbilateral hemispheric swelling (Figure 1).
As the patient had no focal neurologic deficit,and the hematoma was thin without a midline shift,the patient was managed conserva tively und er closeobservation without any medication. The CT scanwas repeated 6 hours after the first examination. To
Figure I, a and b. CT-sean two hours after trauma showingleft frontoparietal aeute subdural hematama.Ventrides are compressed due to eerebralsweIling. Note the smaIl contusian in the leftfrontallabe.
Kiris: Resolutioii of ACi/te S lIbdlirnl Hematama
our surprise the subdural hematoma had completelydisappeared and the ventrides which werecompressed in the initial CT scan were normal in size(Figure 2). The patient's neurological examinationremained unchanged.
After an uneventful clinical course and two
days of hospitalization the patient was in goodcondition. His follow - up examinations at 15 days,one month, and three months yielded no abnormalfindings.
Figure 2. CT-sean six hours after admissian showingresolutian of subdural hematama with normalsized ventrides. Note that the frontal contusianis more remarkable.
DISCUSSION
it has been shown that early operatiyeintervention improves the prognosis in acutesubdural hematoma (14). On the other hand thesuccess of conservative management reported in non- acute hematomas presenting several days afterinjury shows that an intracranial extracerebralhematoma may resolve spontaneously (1,5,8,15).Thisresolution has been followed by serial angiographyand CT scanning and usually takes weeks to months.In recent years several reports have been publishedwith an eve n more rapid resolution of an ASDH(4,6,9,10,12, 13).
In addition to our report there are thirteen casesof ASDH with rapid resolution in the literature
25
Tiirkis/i Neiirosiirgenj 7: 24 - 27, 1997
(4,6,9,10,12,13). The details of these cases are
summarized in Table i. Makiyama et aL. speculatedthat ASDHs may have been spread and dissipatedby the coexistent brain swelling (9). They furtherhypothesized that spontaneous disappearance ofASDH may not be a ra re occurrence (lO). Niikawa etaL. assume that in one of their four cases brain
swelling resulted in pressure induced redistributionof the ASDH (l2). In contrast to Makiyama et al.(9),Joki et aL. (6) suggested that the rapid resolution ofASDH may have been attributable to redistributiondue to a decrease of intracranial pressure and
Kiris: Resoliitioii of ACllte Silbd iirnl Hematonin
washing out by cerebrospinal fluid . The washingout of ASDH by cerebrospinal fluid secondary totearing of the arachnoid membran e was pointed outby other authors also ( 4,11,12 ). Fujioka et aL.observed the resolution of the hematoma and
appearance of a thin high-density layer in thesubdural space adjacent to the tentorium in thecontrol CT seans of their two cases ( 4 ). Polman et
aL.elearly showed with magnetic resonance imagingthat the hematoma in their patient did not disappearas shown on CT sean but was redistributed (13).
Kaufman, in his comment to this artiele pointed out
Table i. Summary of 14 cases of rapid spontaneous resolution of acute subdural hematoma.
Interva\Conseious-Foeal neur-AssociatedCerebralIntervalOuteome
Author &Age, sexbetweenness level onologiealeranialswelling onbetween(GOS)*
year of
trauma andadmissiondefieitfraeturethe first CTtwoCTs
publieation
first CT
Makiyama
61, F60 mineomatose(-)(?)(+)72 hoursdead
et aL.(9)
............................
............................................................................................................................................................................................................
17,M 50 minalert(+)(?)(+)12 hoursgood
Polman
26, F30 minalert(+)(?)(+)6 hoursgoodet aL.
(13)
Nagao
4,F120 minstuporous(-)(-)(?)48 hoursgoodet aL.
(11)................ - ...........
.............................................................................................................................................................................................................Same 30 mineomatose(-)(?)(?)17 hoursgood
patient Niikawa
63, Mno traumaGCS 13(-)(?)(?)24 hoursgoodet aL.
(L2) history............................
.............................................................................................................................................................................................................16, M (?)GCS3(-)(?)(?)48 hourssevere
disability............................
.............................................................................................................................................................................................................27, M (?)GCS 10(-)(?)(?)6 hoursgood
............................
............................................................................................................................................................................................................
48,M (?)GCS9(+)(+) eontre-(?)6 hoursmoderate
eoup
disability
Fujioka
78, M5 hoursalert(-)(?)(?)33 hours(?)
et aL.
(4)............................
.............................................................................................................................................................................................................
84, F 60 mindrowsy(-)(?)(?)14 hours(?)
Joki
21, F120 minGCS9( -)(?)(+)24 hours(?)
et aL.(6)
............................
.............................................................................................................................................................................................................
23,M 120 minGCS 14(+)(?)(+)8 hours(?)
Kins
12,M120 minGCS 14(-)(+) contre-(+)6 hoursgood
et aL.
coup
*GOS : Glasgow Outeome Seale
26
Turbsh Neiirosurgenj 7: 24 - 27, 1997
that if there were dural tears and skull fractures such
clots may be pushed into the diploe of the skull orinto soft tissues where they may be more rapidlyabsorbed (7).
In our case, we noted a contre-coup linearfracture with compressed ventricles which suggestedbrain swelling. In the control CT sean the ventricleswere in normallimits. It is possible that the bleedinghas stopped due to compression of the swelling brain,and the hematoma was then redistributed probablywith the flow of cerebrospinal fluid due to a tear inthe arachnoid membrane. The fracture did not playa role in the resolution of the hematoma since it was
on the opposite side.
Selected cases of ASDH ( GCS 11-15, a thinhematoma <lcm, no focal neurologic deficits ) canbe safely managed non-surgically under closeobservation and repeated seans (2). The non-surgicalmanagement of these cases will provide knowledgeabout the natural history of ASDH.
Correspondence: Dr. Talat KirisAtaköy 5. Kisim E2-5 BlokD Kapisi Daire: 7234750 Istanbul Turkey
REFERENCES
1. Bender MB, ChristoH N: Nonsurgical treatment ofsubdural hematoma. Arch Neurol 31:73-79, 1974
2. Croce MA, Dent OL, Menke PG, Robertson JT: Acutesubdural hematoma: Nonsurgical management ofselected patients. J Trauma 36: 820 - 827, 1994
3. Cuacito W, Yamamoto R, Howeiler B, Smith R:Spontaneous resolution of subdural hematomas. JNeurosurg Sci 35: 139 - 145, 1991
Kiris: Resaliition of Aciite Subdiirnl Hematama
4. Fujioka S, Hamada J, Kaku M, Ushio Y: Rapidresolution of acute subdural hematoma. Report of twocases. Neurol Med Ch ir (Tokyo) 30: 827 - 831,1990
5. iiiingworth R, Shawdon H: Conservative managementof intracranial extradural hematoma presenting Iate. JNeurol Neurosurg Psychiatry 46: 558 - 560, 1983
6. Joki T, Hashimoto T, Akachi K, Suzuki K, NakamuraN: Rapid resolution of acute subdural hematoma.Report of two cases. No Shinkei Geka 20: 915 - 919,1992
7. Kaufman HH: Comment. Rapid spontaneousresolution of an acute subdural hematoma.Neurosurgery 19: 446 - 448,1986
8. Kemperman CJF, den Hartog MR, Thijssen HOM:Spontaneous resolution of epidural hematomasdetected after the first day. Ann Neurol 16: 623 - 624,1994
9. Makiyama Y, Katayama Y, Ueno Y, Koike Y,Tsubokawa T: Acute subdural hematomas
spontaneously disappearing within 3 days followingclosed head injury. Report of two cases. Nihon Univ JMed 27: 123 - 127, 1985
10. Makiyama Y, Katayama Y, Tsubokawa T: Rapidspontaneous disappearance of acute subduralhematoma. Neurosurgery 21: 42, 1987
11. Nagao T, Aoki N, Mizutani H, Kitamura K: Acutesubdural hematoma with rapid resolution in infancy:Case report. Neurosurgery 19: 465 - 467, 1986
12. Niikawa S, Sugimoto S, Hattori T, Ohkuma A, KimuraT, Shinoda J, Funakoshi T: Rapid resolution of acutesubdural hematoma. Report of four cases. Neurol MedChir (Tokyo) 29: 820 - 824,1989
13. Polman CH, Gijsbers Cl, Heimans H, Ponssen H, ValkJ: Rapid spontaneous resolution of an acute subduralhematoma. Neurosurgery 19: 446 - 448,1986
14. Seelig G, Becker DP, Miller JD, Greenberg RP, WardJD, Choi SC: Traumatic acute subdural hematoma:major mortality reduction in comatose patients treatedwithin four hours. N Engl J Med 304: 1511 - 1518, 1981
15. Suzuki J, Takaku A: Nonsurgical treatment of chromesubdural hematoma. J Neurosurg 30: 827 - 831,1970
16. Victoratos GC, Bligh AS: A more systematicmanagement of subdural hematoma with the aid ofCT sean. Surg Neurol 15: 158 - 160, 1981
27