Ultra fast resolution of acute post-traumatic subdural haematoma
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1 Department of Neurosurgery, Celal Bayar University, School of Medicine, Manisa, Turkey
2 Department of Radiology, Celal Bayar University, School of Medicine, Manisa, Turkey
Correspondence to:
Dr Hasan Mirzai
2040 Sok. Pamukkale 4/60 D:67, Mavisehir, Atakent, 35540, Izmir Turkey; hmirzai@yahoo.com
Keywords: Acute subdural haematoma; CT scan; spontaneous resolution
Post-traumatic acute subdural haematoma (ASDH) is a life threatening condition. The traditional approach is urgent surgery in haematomas with a mass effect. We report a case with a large post-traumatic ASDH whose haematoma disappeared markedly within 2 hours.
A 19 year old man sustained a head trauma at 22:30 and presented with Glasgow Coma Scale (GCS) score of 9 to the state hospital. CT scan showed a right hemispheric ASDH and a marked midline shift (panel A). He was transferred to our hospital for urgent surgery. In our hospital his GCS score was 12. A repeat CT scan at 00:30 showed substantial decrease of ASDH and oedema (panel B). Six hours later CT revealed total resolution of ASDH and the appearance of subarachnoidal haemorrhage (panel C). On the third day he was completely alert with a GCS of 15. MRI on the fifth day showed mild subarachnoidal haemorrhage (panel D). He was discharged on the tenth day with excellent neurological condition.
Although infrequently reported, rapid spontaneous resolution of an ASDH may be underestimated.1–5 Two possible hypotheses for spontaneous resolution have been proposed: (1) the haematoma is diluted by cerebrospinal fluid and is washed out; (2) the haematoma is compressed by the pressure produced by acute cerebral swelling and redistributed.2 Some authors have demonstrated redistribution and dispersal of blood in the subdural space with MRI.4,5
We think that a tear in the arachnoid membrane and connection between the subdural and subarachnoidal spaces results in dilution of haematoma. Thus not only redistribution and dispersal but also washing out of haematoma by retrograde flow into the subarachnoidal space may be the causes of ultra fast spontaneous resolution of an ASDH. In cases showing rapid improvement of neurological status a subsequent control CT is indicated before surgery.
Figure 1 (A) Initial CT scan shows subdural haematoma in the right frontoparietal region and a marked midline shift; (B) Post-traumatic second hour CT shows substantial decrease in oedema and size of subdural haematoma; (C) Post-traumatic eighth hour CT shows total resolution of the subdural haematoma and the appearance of subarachnoidal haemorrhage; (D) Fifth day MRI shows mild subarachnoidal haemorrhage.
REFERENCES
Fernandez-Portales I, Gomez-Perals L, Cabezudo JM, et al. Rapid spontaneous resolution of acute subdural hematoma. Neurocirugia (Astur) 2002;3:491–4.
Kuroiwa T, Tanabe H, Takatsuka H, et al. Rapid spontaneous resolution of acute extradural and subdural hematomas. Case report. J Neurosurg 1993;78:126–8.
Berker M, Gulsen S, Ozcan OE. Ultra-rapid spontaneous resolution of acute posttraumatic subdural hematomas in patient with temporal linear fracture. Acta Neurochir 2003;145:715–7.
Polman CH, Gijsbers CJ, Heimans JJ, et al. Rapid spontaneous resolution of an acute subdural hematoma. Neurosurgery 1986;19:446–8.
Kato N, Tsunoda T, Matsumura A, et al. Rapid spontaneous resolution of acute subdural hematoma occurs by redistribution – two case reports. Neurol Med Chir (Tokyo) 2001;41:140–3.(H Mirzai1, C Yaldiz1, M E)
2 Department of Radiology, Celal Bayar University, School of Medicine, Manisa, Turkey
Correspondence to:
Dr Hasan Mirzai
2040 Sok. Pamukkale 4/60 D:67, Mavisehir, Atakent, 35540, Izmir Turkey; hmirzai@yahoo.com
Keywords: Acute subdural haematoma; CT scan; spontaneous resolution
Post-traumatic acute subdural haematoma (ASDH) is a life threatening condition. The traditional approach is urgent surgery in haematomas with a mass effect. We report a case with a large post-traumatic ASDH whose haematoma disappeared markedly within 2 hours.
A 19 year old man sustained a head trauma at 22:30 and presented with Glasgow Coma Scale (GCS) score of 9 to the state hospital. CT scan showed a right hemispheric ASDH and a marked midline shift (panel A). He was transferred to our hospital for urgent surgery. In our hospital his GCS score was 12. A repeat CT scan at 00:30 showed substantial decrease of ASDH and oedema (panel B). Six hours later CT revealed total resolution of ASDH and the appearance of subarachnoidal haemorrhage (panel C). On the third day he was completely alert with a GCS of 15. MRI on the fifth day showed mild subarachnoidal haemorrhage (panel D). He was discharged on the tenth day with excellent neurological condition.
Although infrequently reported, rapid spontaneous resolution of an ASDH may be underestimated.1–5 Two possible hypotheses for spontaneous resolution have been proposed: (1) the haematoma is diluted by cerebrospinal fluid and is washed out; (2) the haematoma is compressed by the pressure produced by acute cerebral swelling and redistributed.2 Some authors have demonstrated redistribution and dispersal of blood in the subdural space with MRI.4,5
We think that a tear in the arachnoid membrane and connection between the subdural and subarachnoidal spaces results in dilution of haematoma. Thus not only redistribution and dispersal but also washing out of haematoma by retrograde flow into the subarachnoidal space may be the causes of ultra fast spontaneous resolution of an ASDH. In cases showing rapid improvement of neurological status a subsequent control CT is indicated before surgery.
Figure 1 (A) Initial CT scan shows subdural haematoma in the right frontoparietal region and a marked midline shift; (B) Post-traumatic second hour CT shows substantial decrease in oedema and size of subdural haematoma; (C) Post-traumatic eighth hour CT shows total resolution of the subdural haematoma and the appearance of subarachnoidal haemorrhage; (D) Fifth day MRI shows mild subarachnoidal haemorrhage.
REFERENCES
Fernandez-Portales I, Gomez-Perals L, Cabezudo JM, et al. Rapid spontaneous resolution of acute subdural hematoma. Neurocirugia (Astur) 2002;3:491–4.
Kuroiwa T, Tanabe H, Takatsuka H, et al. Rapid spontaneous resolution of acute extradural and subdural hematomas. Case report. J Neurosurg 1993;78:126–8.
Berker M, Gulsen S, Ozcan OE. Ultra-rapid spontaneous resolution of acute posttraumatic subdural hematomas in patient with temporal linear fracture. Acta Neurochir 2003;145:715–7.
Polman CH, Gijsbers CJ, Heimans JJ, et al. Rapid spontaneous resolution of an acute subdural hematoma. Neurosurgery 1986;19:446–8.
Kato N, Tsunoda T, Matsumura A, et al. Rapid spontaneous resolution of acute subdural hematoma occurs by redistribution – two case reports. Neurol Med Chir (Tokyo) 2001;41:140–3.(H Mirzai1, C Yaldiz1, M E)