Chronic or subacute subdural hematoma due to indirect head trauma; report of two cases.

Abstract

Practically all cases of chronic subdural hematoma are due to some type of direct head injury. Grinker 9 well epitomizes most modern accounts of the lesion u~der consideration in his book: Chronic subdural hematoma occurs after head t rauma with severe skull fracture, or very mild concussion. Alcoholism and psychosis, conditions which afford frequent opportunities for head injury, are predisposing causes, Cases of chronic or of subacute subdural hematoma not due to a direct blow on the head appear to be rare, or a t least a survey of current literature having to d o with a consideration of head injury in all its aspects, or to neurology and neurosurgery in general, would lead one so to believe. In a careful survey of the world's current medical literature as listed in the Quarterly Cumulative Index Medicus for the past 10 years, only a single instance of a chronic subdural hematoma due to indirect t r auma was encountered and the mode of the indirect injury was not given in the title of the paper, I~ which was inaccessible to the writer. Likewise, in a thorough review of a number of recent books 5,7,9,tI,I2 on neurology, neuropathology and neurosurgery, including two 4,14 devoted entirely to head and spinal injuries, only one reference 7 to chronic subdural hematoma from indirect trauma (not including the head) was encountered: Loyal Davis 7 mentions a fall on the buttocks as the only known t rauma in certain cases of chronic subdural hematoma. He refers to this type of injury in general terms in a discussion in his book of the causes of chronic subdural hematoma, not detailing a specific case. I t happens tha t the ~ cases to be described in this paper were due to this etiological factor. Neither pat ient was an alcoholic or psychotic, and both were highly intelligent, so tha t an accurate history with respect to t rauma of any kind was possible in each of the two cases. I t seems certain tha t neither of the patients had a direct blow on the head in the immediate or remote past before being admit ted to the hospital for operation. This was determined by repeated questioning of the patients and their families. Both pat ients had had a fall on the buttocks as the precipitating factor in the production of symptoms and signs due to a chronic or subacute subdural hematoma. This is of considerable interest as it is generally believed today tha t this lesion in adults is almost invariably caused by a direct blow on the head, usually in an anteroposterior direction, thus tearing one or more of the short communicat ing veins between the dura and the cortex near the falx, resulting in a subdural hematoma. There are, of course, reports of subdural hematoma scattered throughout the literature of the last decade or more describing its development in children or adults with no definite t raumat ic history, tha t is, spontaneous 8 in type, the clot being ascribed to scurvy, blood dyscrasia, meningitis or other intracranial infection, etc.