Roentgenologic signs of resolving subdural hematomas.

Abstract

Subdural hematoma has been a recognized entity since the eighteenth century and possibly earlier (1). In spite of its long history, many questions concerning this condition remain unanswered. Among these is: Does a subdural hematoma ever undergo spontaneous resolution? Occasional reports (2–4) have appeared in the literature concerning subdural collections diagnosed by cerebral angiography or pneumography which subsequently cleared. The nature of these collections, however, whether cerebrospinal fluid or blood, has remained unknown. Cerebral atrophy may give the angiographic appearance of an acute subdural collection (5). Occlusion of several small branches of the middle cerebral artery may also simulate an acute subdural collection on the anteroposterior view. The purpose of the investigation to be reported here was to determine whether subdural hematomas ever regress spontaneously. It was not meant to offer a new mode of therapy for this condition. The patients were selected because of their good clinical condition. They were observed constantly and if, at any time, this had worsened, they would have been subjected immediately to surgery—burr holes and/or craniotomy. The clinical aspects of these cases will be included in another report. Case I: A 29-year-old man was well until two weeks prior to admission, when he first experienced frontal headaches and low back pain. He was drowsy upon entering the hospital and exhibited a left central facial palsy and slight nuchal rigidity. The left upper extremity was a little weak, the deep tendon reflexes were increased on the left, and the superficial abdominal reflexes were absent on that side. Lumbar puncture revealed xanthochromic fluid. On the seventh hospital day a left carotid angiogram (Fig. 1) demonstrated an acute subdural collection. The following day a left parietal burr hole was made. A 20-gauge needle was inserted through the dura, 0.4 c.c, of brownish-red material resembling old blood was aspirated, and the wound closed. The benzidine test of this fluid was positive. The patient was then followed with serial angiograms. He became alert, coherent, and oriented, and his neurological deficit disappeared. After eight weeks all angiographic signs of subdural hematoma had vanished. Case II: A middle-aged man was confused, disoriented, and drowsy upon admission to the hospital. No history could be obtained. Physical and neurological examinations were negative. After a bout of delirium tremens he was alert and oriented by the fourth hospital day. A lumbar puncture at that time revealed grossly bloody spinal fluid with a xanthochromic supernatant. During the following days the patient remained alert and exhibited only a “glove and stocking” sensory impairment of the limbs. Ten weeks after admission a right carotid angiogram (Fig. 2) revealed a chronic subdural fluid collection. Six days later a right parietal burr hole was made and a 20-gauge needle was inserted through the dura.