Interhemispheric Subdural Hematoma Research Articles

Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

Modified Clavipectoral Fascial Plane Block to The Rescue: Polytrauma Patient with Brachial Plexus Injury Undergoing Awake Clavicle Surgery

Traumatic Interhemispheric Subdural Hematomas – clinical significance, management and outcome. (2585)

Traumatic Interhemispheric Subdural Hematomas – clinical significance, management and outcome. (2585)

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma

Interhemispheric subdural hematomas (IHSDHs) are thought to be rare. Surgical management of these lesions presents a challenge as they are in close proximity to the sagittal sinus and bridging veins. IHSDHs are poorly characterized clinically and their exact incidence is unknown. There are also no clear guidelines for the management of IHSDH. This is a retrospective review of all admitted patients with a diagnosis of traumatic brain injury over a 4-year period at a Level I trauma centre. Clinical characteristics of all patients with subdural hematoma (SDH) and IHSDH were collected. Of 2165 admissions, 1182 patients had acute traumatic SDHs, 420 patients had IHSDHs (1.9% of admissions and 35.5% of SDH), 35 (8.3% of IHSDH) were ≥8 mm in width. IHSDH was isolated in 16 (3.8%) of the cases. Average age was 61.7 ± 21.5 years for all IHSDHs and 77.1 ± 10.4 for large IHSDH (p < 0.001). For large IHSDH, a transient loss of consciousness (LOC) occurred in 51.5% of individuals, post-traumatic amnesia (PTA) in 47.8% of cases, and motor weakness in 37.9% of patients. Five of the large IHSDH patients presented with motor deficits directly related to the IHSDH, and weakness resolved in four of these five individuals. None were treated surgically. Progression of IHSDH width occurred in one patient. IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is appropriate to manage most IHSDHs, as most resolve spontaneously, and their symptoms resolve as well.

Management and outcomes of isolated interhemispheric subdural hematomas associated with falx syndrome.

Large interhemispheric subdural hematomas (iSDHs) causing falx syndrome are rare; therefore, a paucity of data exists regarding the outcomes of contemporary management of iSDH. There is a general consensus among neurosurgeons that large iSDHs with neurological deficits represent a particular treatment challenge with generally poor outcomes. Thus, radiological and clinical outcomes of surgical and nonsurgical management for iSDH bear further study, which is the aim of this report. A prospectively collected, single-institution trauma database was searched for patients with isolated traumatic iSDH causing falx syndrome in the period from January 2008 to January 2018. Information on demographic and radiological characteristics, serial neurological examinations, clinical and radiological outcomes, and posttreatment complications was collected and tallied. The authors subsequently dichotomized patients by management strategy to evaluate clinical outcome and 30-day survival. Twenty-five patients (0.4% of those with intracranial injuries, 0.05% of those with trauma) with iSDH and falx syndrome represented the study cohort. The average age was 73.4 years, and most patients (23 [92%] of 25) were taking anticoagulants or antiplatelet medications. Six patients were managed nonoperatively, and 19 patients underwent craniotomy for iSDH evacuation; of the latter patients, 17 (89.5%) had improvement in or resolution of motor deficits postoperatively. There were no instances of venous infarction, reaccumulation, or infection after evacuation. In total, 9 (36%) of the 25 patients died within 30 days, including 6 (32%) of the 19 who had undergone craniotomy and 3 (50%) of the 6 who had been managed nonoperatively. Patients who died within 30 days were significantly more likely to experience in-hospital neurological deterioration prior to surgery (83% vs 15%, p = 0.0095) and to be comatose prior to surgery (100% vs 23%, p = 0.0031). The median modified Rankin Scale score of surgical patients who survived hospitalization (13 patients) was 1 at a mean follow-up of 22.1 months. iSDHs associated with falx syndrome can be evacuated safely and effectively, and prompt surgical evacuation prior to neurological deterioration can improve outcomes. In this study, craniotomy for iSDH evacuation proved to be a low-risk strategy that was associated with generally good outcomes, though appropriately selected patients may fare well without evacuation.

Hematoma subdural agudo bilateral sin hemorragia subaracnoidea secundario a ruptura de aneurisma comunicante anterior. Presentación de un caso y revisión de la bibliografía

Pure acute subdural haematomas caused by aneurysmal rupture are a highly infrequent event, with only 51 cases published in the literature to date, with only six cases due to the rupture of anterior communicating artery aneurysm. To describe a case of an acute subdural haematoma not associated with subarachnoid haemorrhage due to ruptured of an anterior communicating cerebral artery aneurysm. A 55-year-old woman without a traumatic history, who is found at home with a level of consciousness of 4 points on the Glasgow Coma Scale and a bilateral arreactive mydriasis, which are reversed with medical measures. Cranial CT shows an acute bi-hemispherical convexity and interhemispheric subdural haematoma with no evidence of associated subarachnoid haemorrhage. The angio-CT reveals an anterior communicating artery aneurysm. We proceed to urgent embolization of the aneurysm. The patient was admitted to the Intensive Care Unit, where intracranial pressure is monitored and controlled initially with medical treatment. Patient outcome was unfavorable, confirming in the control CT scan coincident with an increase of uncontrolled medically intracranial hypertension, established ischemic infarctions areas, which made any surgical treatment non-viable. In the case of an acute subdural haematoma without subarachnoid haemorrhage nor traumatic brain injury or its external stigmas, we must consider the rupture of a cerebral aneurysm as a possible cause. Likewise, the initial management of the acute subdural haematoma in patients with poor neurological condition should be priority and surgical.

Clinical Features of Interhemispheric Subdural Hematomas.

ObjectiveInterhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively.MethodsFrom 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes.ResultsThe male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment.ConclusionIHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.

Single Burr Hole and Drainage in Chronic Subdural Hematoma: Outcome in Consecutive 333 Cases

Chronic subdural hematoma (CSDH) is a common neurosurgical disease with incidence 3 in 100,000 in general population. Recorded or trivial head injury is the most common cause of CSDH with several predisposing factors like alcoholism, coagulopathy, seizure disorder, cerebrospinal fluid shunts, metastases and vascular malformations. Bilateral CSDH are common in infants and interhemispheric subdural hematomas are often associated with child abuse. Coagulopathy and intracranial tumors have been associated with spontaneous CSDH. 86 % were males with 47% of CSDH on left followed by 35% in right and 61 cases (18%) were bilateral. The most common age group was 61 to 80 years (45%) followed by the 41 to 60 year group. During admission headache was the most common symptom followed by neurological deficits that include, loss of speech (65%), mono or hemiparesis (20%), quadreparesis (5%), bowel and bladder dysfunction and loss of memory or altered sensorium. Statistical analysis did not show any significant p value between the Age group, Sex, Side of CSDH or chronic alcoholism as independent variables affecting outcome. GCS at admission was the only factor that had significant p value in terms of outcome prediction. Although there are multiple comorbidities associated with CSDH this study found that except GCS there was no relation to age, side, sex, alcoholism, hypertension or diabetes in the outcome after surgery. Meticulous care to remove all the CSDH followed by use of drain is the most efficient way to manage CSDH.Nepal Journal of Neuroscience 13:35-42, 2016

P.082 Traumatic inter hemispheric subdural hematomas – clinical presentation, management and outcome

Background: There is currently little data on the incidence, clinical outcome and management of traumatic interhemispheric subdural hematomas (IHSDHs). Methods: All patients admitted with an acute subdural hematoma (SDH) over a 5-year period at a Level I trauma center were included. A detailed review of all cases of large IHSDH (≥7 mm) was performed to document clinical presentation, management and outcomes. Results: Of 1182 patients with acute subdural hematomas (SDHs), 420 had IHSDHs (24%), and 50 were large IHSDHs. For patients with large IHSDH, the average age was 76 years (±11) and 44% were female. The average GCS was 12 on presentation (±4), and the average GOSE was 4 (±2). 66% of patients had associated cranial/ intracranial injuries (fracture, subarachnoid/epidural/SDH) and 26% required operations for acute convexity SDH. Three patients required operations for their IHSDH by inter hemispheric approach. By 10 weeks, 82% had a complete resolution of the IHSDHs. Conclusions: IHSDHs are often referred to as rare entities. Our results show they are common. Conservative management is often appropriate to manage even large IHSDHs, as most resolve spontaneously. This study will help document the occurrence of falx syndrome, as well as the management and outcomes of larger IHSDHs.

Abstracts from The 12th Symposium of the International Neurotrauma Society February 1-4, 2016 Cape Town, South Africa.

Abstracts from The 12th Symposium of the International Neurotrauma Society February 1-4, 2016 Cape Town, South Africa.

Interhemispheric Acute Subdural Hematoma: A Distinct Entity of Subdural Hematoma.

We wish to notify the readers on a rare case of interhemispheric acute subdural hematoma (ASH) who presented to our emergency department (ED) with a falx syndrome of contralateral hemiparesis in lower extremity and severe headache. A 25-year-old previously healthy man was involved in a traffic accident and presented to our ED with complaints of repeated vomiting and severe headache. On arrival to the ED, he had an initial Glasgow coma scale (GCS) of 14 (opening her eyes with verbal stimuli, obeys commands, orientated) and normal vital signs (blood pressure: 130/85 mm Hg; heart rate: 86 bpm). No other injuries were noted. Neurological examination revealed mild weakness of the right lower extremity (strength score: 4/5). His routine blood tests, including complete blood counts, prothrombin time, and thromboplastin time were unremarkable. The plain films of the skull were normal. Non-enhanced cranial (CT) scan performed 4 h after the accident revealed a small left-sided acute interhemispheric subdural hematoma, which was posteriorly located (Fig. 1a). Magnetic resonance imaging (MRI) of the brain during the first 24 h after admission confirmed minimal ASH in the posterior interhemispheric fissure with subacute subdural hematoma in the left parietooccipital cortex and occipital regions (Fig. 1b). Considering the clinical condition of the patient, surgery was not planned by the neurosurgical department but the patient was kept under observation in the ED. He was discharged home 48 h after the trauma with a normal neurological examination and mild intermittent headaches. Interhemispheric ASH is a relatively uncommon type of ASH because of their unusual location [1]. They usually occur in patients with bleeding disorders and are associated with trauma in the majority of cases [2]. Computed tomography (CT) and MRI are important neuroradiological techniques for the accurate diagnosis of interhemispheric ASH [1, 2]. Although interhemispheric ASH is a rare form of subdural hematoma, early diagnosis and treatment is of great importance because of its emergent condition [2, 3]. CT and MRI are important diagnostic tools, as it was in this case. MRI may have the advantage rather than CT due to the absence of beam-hardening and multiplanar imaging. The best management modality for interhemispheric ASH depends upon the neurologic status on admission and clinical course [2]. If the patient is neurologically stable, conservative treatment is generally preferred. Surgical treatment is reserved in patients with disturbances of consciousness and for patients with progressive neurological deterioration [3].

Bilateral Interhemispheric Subdural Hematoma After Inadvertent Lumbar Puncture in a Parturient

Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma. A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient’s headache subsequently became less position-dependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache. Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is < 1 cm in thickness, a conservative approach to ISH is recommended in the absence of mental status changes, seizure activity, or focal deficits, but with larger ISH or evidence of progressive neurological deterioration, surgical evacuation is most often required to prevent mortality.

An uncommon complication of a fall in the elderly: Interhemispheric subdural hematoma

A 93-year-old woman with an episode of nonsyncopal fall with occipital head injury suffered from left interhemispheric subdural hematoma, which presented as simple partial seizures with Jacksonian march and falx syndrome. She had been taking aspirin and was managed conservatively with platelet transfusion, with a favorable outcome.

An Unusual Head Computed Tomography in an Elderly Patient With Head Trauma

An 80-year-old man with asthma, diabetes, hypertension and Parkinson’s disease was admitted due to refusal to eat, increased somnolence and pain over right side of head, neck and body following a fall from his bed. There was no history of unconsciousness, vomiting, convulsions or any bleeding. The patient had a Glasgow Coma Score of 12/15 (spontaneous eye opening, uttering inappropriate words and localizing painful stimuli), both pupils were equal and reactive to light, tone was increased in all limbs and bilateral Babinski signs were present. A noncontrast computed tomography of brain (Figure 1) showed an acute interhemispheric subdural hematoma (ISH, white arrows), with a left occipital acute epidural hematoma (black arrow), dilated cortical sulci containing cerebrospinal fluid (gray arrow head) and longstanding subdual hygromas (black arrow heads, based on previous computed tomographies).

Surgical management of traumatic interhemispheric subdural hematoma.

To review our experience in the surgical treatment of TISH, and to analyze prognostic factors. Clinical and imaging data, surgical modalities, and outcomes of 21 patients with TISH who were treated with microsurgery were analyzed retrospectively. Prognostic factors for outcome were analyzed by univariate analysis. Long-term follow up with outcome assessment according to the Glasgow Outcome Scale (GOS) showed good recovery in 16 cases, moderate disability in two cases, severe disability in one case, and death in two cases. During surgery the origin of bleeding could be identified in all 21 cases. A rupture of the distal anterior cerebral artery or veins in the interhemispheric fissure was seen more frequently in patients with whole interhemispheric fissure hematoma, while hemorrhage from brain tissue laceration was seen more frequently in patients with more localized hematomas. The outcome in patients with an identified rupture of a vessel was better than in those with cortical laceration. Preoperative GCS score and thickness of the interhemispheric hematoma were correlated with outcome (P=0.001 and P=0.004, respectively). Outcome after surgical treatment for TISH can be good, and careful surgical planning and microsurgical techniques to preserve venous drainage are essential.

Bilateral interhemispheric subdural hematoma after accidental lumbar puncture and epidural blood patch

We read with interest the article of Demetriades et al. [1] concerning bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient. I congratulate them on the presentation of the case. Likewise, I would like to address the issue of the performing epidural blood patch (EBP) in the presence of subdural intracranial hematoma (SIH). The authors recommended EBP as one of the treatments of this complication. We should say it is risky to make this claim. Subdural intracranial hematoma is a very rare, but lifethreatening complication of accidental dural puncture caused by cerebral hypotension associated with excessive traction on the bridging veins secondary to cerebrospinal fluid (CSF) leak through a dural hole [2]. The incidence of this problem is unknown. Factors that increase the imbalance between production and loss of CSF (e.g., peripartum dehydration, labor contractions, bearing-down efforts, obstetric bleeding, postpartum dieresis or early ambulation) can increase its incidence in obstetric patients. Initial clinical presentation of SIH is most often an atypical headache (absence of postural component, persistence for more than 7 days, and unresponsiveness to analgesic therapy). Sometimes, the headache is accompanied by the signs of increased intracranial pressure or mass effect on the brain parenchyma such as vomiting, seizure activity, and altered level of consciousness, psychiatric or focal motor and sensory disturbances. Post dural puncture headache (PDPH) may initially mimic or unmask these symptoms, further complicating the diagnosis. A typical PDPH is exacerbated in the upright position and relieved by the horizontal position. When conservative management of PDPH is unsatisfactory or headache intensity is severe, an EBP is frequently performed. EBP relieves the headache restoring intracranial CSF volume and pressure by two basic mechanisms [2]. First, the blood injected clot and seal the dural perforation, preventing further CSF leak. Second, the volume injected into the epidural space increases epidural pressure and compresses the dura elevating adjacent subarachnoid pressure and, through continuity, the intracranial pressure. This increase in pressure is dependent on the rate and volume of injection and level injected. Thus, early EBP may decrease the risk of subdural bleeding by preventing a fall in CSF volume and subsequent intracranial hypotension. However, when EBP is performed in the presence of intracranial hemorrhage, rebound intracranial hypertension and neurological deterioration can result [2–6]. An early differential diagnosis is needed to provide the adequate treatment, which may influence the prognosis of this complication. EBP should not be performing when there is suspicion or evidence of the existence of SIH.

Bilateral interhemispheric subdural hematoma after inadvertent lumbar puncture in a parturient

Interhemispheric subdural hematomas (ISH) are rare in adults and occur most often after cranial trauma. We describe a parturient who developed bilateral acute ISH after inadvertent dural puncture associated with placement of an epidural catheter for labour analgesia. We discuss the features, pathophysiology, and management of this type of subdural hematoma. A 38-yr-old woman requested epidural analgesia for relief of labour pain. An inadvertent dural puncture occurred during placement of a 17G Tuohy needle. After labour and delivery, the patient developed symptoms of a postdural puncture headache, which responded only partially to an epidural blood patch. The patient's headache subsequently became less position-dependent and was associated with episodes of sharp pain radiating down her legs and paresthesias on the left side of her body. A computed tomography (CT) scan showed right frontal and left parietal acute ISH without an intracranial mass effect. The patient was monitored in the intensive care unit and treated conservatively because of the relatively small size of the ISH and the absence of progressive neurological deficits on serial examinations. Daily CT scans showed gradual decreases in the size of the ISH concomitant with improvement of the headache. Rupture of bridging veins between the cerebral cortex and the superior sagittal sinus is the usual mechanism by which ISH occur. Nearly one-quarter of patients with ISH do not survive, although those with smaller hematomas have a better outcome. If the hematoma is < 1 cm in thickness, a conservative approach to ISH is recommended in the absence of mental status changes, seizure activity, or focal deficits, but with larger ISH or evidence of progressive neurological deterioration, surgical evacuation is most often required to prevent mortality.

Spinal Subdural Hematoma Associated With Traumatic Intracranial Interhemispheric Subdural Hematoma

A 78-year-old female fell and hit the back of her head on the floor. Head computed tomography (CT) showed right acute interhemispheric subdural hematoma (ISDH). Her left hemiparesis worsened, so partial removal of ISDH was performed. The hemiparesis was improved, but leg monoparesis persisted. Lumbar magnetic resonance imaging showed spinal subdural hematoma (SSDH) at the S1-2 level. Nerve conduction velocity measurements at the knee joint to lower limb showed disappearance of the left peroneal nerve conduction wave, indicating that one of the causes of drop foot was common peroneal nerve palsy. With conservative therapy, her drop foot was gradually improved, then she recovered to walk with a stick and moved to a rehabilitation hospital. Lumbar MR imaging should be performed to rule out SSDH in a patient with posterior fossa subdural hematoma on initial head CT who develops leg palsy.

Acute inter-hemispheric subdural hematoma in a kabaddi player: A comment

Acute inter-hemispheric subdural hematoma in a kabaddi player: A comment

Traumatic interhemispheric subdural haematoma: Study of 35 cases

The clinical and radiological findings, management, and outcomes in 35 patients with traumatic interhemispheric subdural haematoma (ISH) were reviewed retrospectively. Twenty-five patients had favourable outcomes and 10 had poor outcomes. All patients were treated conservatively for ISH. Univariate analysis found that the Glasgow Coma Scale (GCS) score ( p < 0.001), hypovolemic shock ( p = 0.018), skull fracture ( p = 0.008), convexity or posterior fossa subdural haematoma ( p = 0.008), and subarachnoid haemorrhage (SAH) were correlated with outcome ( p < 0.001). Multivariate analysis showed that GCS score ( p = 0.031; odds ratio [OR], 0.6; 95% confidence interval [CI], 0.3–0.9) and the presence of SAH ( p = 0.023; OR, 14.2; 95% CI, 1.5–138.2) were significantly related to poor outcome. This study provides important information on the clinicoradiological findings and prognoses in patients with traumatic ISH.

Acute inter-hemispheric subdural hematoma in a Kabaddi player

Acute inter-hemispheric subdural hematoma in a Kabaddi player