Acute subdural hematomas. Review of 144 cases

Subdural hematomas. I. Acute subdural hematoma: progress in definition, clinical pathology, and therapy

A series of 206 patients with clotted subdural hematomas operated within 3 days of closed head injury is presented. Sixty-two percent (128) were operated within 24 hours of trauma (acute subdural hematoma) carrying a high incidence of sterotypic motor posturing, impaired oculomotor reflexes, and unilateral dilated fixed pupil. A functional recovery occurred in 27% and a vegetative state or death resulted in 62%. The remaining 38% were operated after 24 but within 72 hours from injury (early subacute subdural hematoma) and generally had less severe neurologic dysfunction. A functional recovery occurred in 54% and vegetative state or death in 34%. The 128 acute cases are presented in detail to establish a logical basis for time differential. The cases requiring operation within 12 hours of injury were the most challenging. Improved outcome is felt to result from prompt referral and large craniotomy in the earliest hours after injury, combined with careful postoperative monitoring. Clinical, operative and autopsy findings are presented and discussed in relation to pathogenesis.

Emergency presentation of subdural hematoma: a review of 85 cases diagnosed by computerized tomography

The emergency presentations of 85 patients diagnosed by computerized axial tomography (CT) as having subdural hematomas (SDH) were retrospectively reviewed to identify factors contributing to an early or delayed diagnosis. Sixty-one of 85 patients (72%) were diagnosed within 24 hours of presentation. Forty-five of 57 (79%) with definite history or signs of cranial trauma were diagnosed within 24 hours, while only 16 of 28 (57%) without historical or physical evidence of trauma were diagnosed promptly. Focal neurologic signs were present in 32 of 57 patients (56%) with head trauma and 24 of these patients (75%) had an early CT scan. Twenty-two of 50 patients (44%) with head trauma had skull fractures, but the presence or absence of skull fracture alone did not serve to hasten the diagnosis in this group. In patients without head trauma, 14 of 28 (50%) had focal neurologic signs, with eight of 14 (57%) undergoing CT scan within 24 hours. No patient in this group had an abnormal skull series. Thus despite the immediate availability of CT scanning, a significant number of patients, especially those without history or evidence of head trauma, had a delay in diagnosis exceeding 24 hours. The presence of a focal neurologic sign is a more sensitive indicator of the presence of SDH than is a positive skull series.

Acute subdural hematoma. Review of 39 consecutive cases with high incidence of cortical artery rupture

In a consecutive series of 39 cases of acute subdural hematoma (SDH), encountered since computerized tomography diagnosis became available, 61.5% were found to be the result of bleeding from a small cortical artery, 25.6% were of venous origin, 7.7% resulted from cerebral contusions, and 5% were acute bleeds into chronic subdural hematomas. Craniotomy was performed promptly on admission, but there was no difference in survival (overall 51.3%) between patients with arterial and venous bleeds. The only apparent factor affecting survival in this series was the preoperative neurological status: 67% of patients who were decerebrate and had fixed pupils prior to operation died. Of patients with less severe neurological dysfunction, only 20% failed to survive.

Can the out come from head injury be improved?

In the past few years, considerable progress has been made in describing patients with head injuries in such a manner that comparisons in morbidity and mortality can be made among neurosurgical centers according to the seriousness of the injury. Less progress had been made in classifying the type of pathology, especially by computerized tomography. The authors have introduced a classification that includes both the type and the seriousness of the injury. There appear to be two principal causes of the brian damage produced by head injury: 1) mechanical damage to neurons and their processes, especially axons and 2) ischemia. Mechanical damage produces axonal degeneration. Although central regeneration generally is quite limited, perhaps many of the axons damaged by head injury degenerate in continuity, a circumstance in which functional regeneration by axoplasmic outgrowth is much more likely to occur than in most experimental situations where the axons are physically divided. The ischemic brain damage that is so common in head injury appears to be mass lesions and brain swelling that both cause intracranial hypertension. The more the brain swells, and the higher the intracranial pressure, the more difficult it is to control the swelling and the pressure. In patients with acute subdural hematoma in particular, the brian swelling and the high mortality appear to be due to ischemic brain damage. There is recent evidence that the mortality rate in patients with acute subdural hematoma is a function of the time from injury to evacuation of the hematoma. Therefore, outcome from head injury can be improved by the earliest possible removal of space-occupying hematomas and by early, vigorous management of intracranial hypertension.

Surgically treated traumatic subacute and chronic subdural haematomas: a review of 132 cases

One hundred and thirty-two cases of surgically treated traumatic subacute and chronic subdural haematomas are reviewed. A high male to female ratio of 5:1 is noted. The age distribution and the clinical picture are comparable with the pattern in other reported studies. All patients were treated with simple burr holes and evacuation of blood without membranectomy, postoperative drainage or posturing. The results were excellent as 62 per cent made a good recovery, 33 per cent had mild disability, 4 per cent had severe disability and only 1 patient died. There were no recurrences. The simplicity of making burr holes recommends the method to more doctors, thereby extending the frontiers of treatment beyond the confines of neurosurgical centres.

[Delayed traumatic intracerebral hemorrhage. Report of 5 cases]

Five cases of traumatic delayed intracerebral hemorrhage are reported. At the admission two patients showed only contusional injury and three had acute intracranial hematomas, one with an extradural infratentorial and two with supratentorial hematomas, which were immediately removed. Repeated CT-scans revealed the delayed intracerebral hemorrhage. Three patients developed an intracerebral hemorrhage within the first 24 hours after admission. The possible mechanisms producing these lesions are discussed. The high mortality of these patients (four in our series) is associated with severe brain damage after the traumatism.

The outcome from acute subdural haematoma following decompressive hemicraniectomy

Retrospective analysis of 15 cases with acute subdural haematoma receiving decompressive hemicraniectomy was carried out in an effort to clarify the beneficial effect and limitation of this operative procedure. The patients in this series were divided into three groups according to postoperative intracranial pressure (ICP). Decompressive hemicraniectomy was effective in lowering ICP in all patients except for the cases that developed acute brain swelling. Overall mortality rate was 66.7% in this series. Preoperative clinical status, and intra- and postoperative ICP and CT findings obtained within 24 hours of operation were correlated with the operative outcome.

Outcome following acute subdural haematoma

An analysis and long-term follow-up of 136 patients with acute subdural haematoma diagnosed or operated on within 72 hours after injury confirmed the poor outcome: 27 patients (20 percent) made a useful recovery, 13 (10 percent) are severely disabled, and 95 died (70 percent). One patient is still in a vegetative state. The poor outcome in those injuries requiring surgery in the first 24 hours suggests that the term "acute subdural haematoma" should be limited to this group. Earlier diagnosis and operation on acute subdural haematomas without severe primary brain injury may obviously save a few more patients. However, with very early admissions the number of patients with severe primary brain injury goes up; thus the poor outcome for acute subdural haematoma is likely to remain high.

Outcome following head injuries in the aged

An analysis of 420 patients 60 or more years of age showed that even very mild brain injuries may be dangerous for the aged. Only one third of 174 patients with cerebral contusion made a useful recovery; of the 101 patients with cerebral contusion unconscious for six hours or more, 78 died, and only 11 made a useful recovery. The outcome in patients with acute intracranial haematomas or depressed skull fractures was poor. Even the aged with brain injuries may benefit from an intensive effort at treatment. This effort should, however, be strictly limited in time. With the present means of treating brain injury it seems futile to use limited intensive treatment resources for an acute brain injury in a patient over 70 years of age who is unconscious on admission. In contrast to acute injuries, subacute and chronic subdural haematomas should be operated on promptly in spite of severe neurological impairment or advanced age.

Contribution to the surgical treatment of acute supratentorial subdural haematomas

Acute traumatic subdural haematoma suspected of extending over an entire hemisphere must be treated with all speed. To obviate unnecessary skin incisions and subsequent craniectomies and craniotomies during the operation, we think it advantageous to plan a series of burrholes at set points in order to; a) begin to clear the haematoma; b) assess its extent and possible origin; c) decide whether a hemicranial or smaller craniotomy is called for.

Delayed traumatic intracerebral hematomas. Report of three cases

Three patients are reported who developed delayed intracerebral hematomas following closed head injuries. Two patients showed hematomas within 24 hours after a normal computerized tomogram. All three were treated surgically, and two had good results.

Long-term follow-up review of patients with acute and subacute subdural hematomas

The authors present 149 patients suffering from acute (112) and subacute (37) subdural hematomas admitted during the 10-year period 1965 to 1974, with a follow-up period of 2 to 12 years. During the time of observation, 104 patients died and 45 survived; 73% of the patients with acute and 27% with subacute subdural hematomas died. Of the patients with an acute subdural hematoma, 11% went back to work, as against 32% of those with subacute subdural hematomas. The 5-year survival rate was 28% in patients with acute and 76% in patients with subacute subdural hematomas.

The outcome from severe head injury with early diagnosis and intensive management

In the belief that secondary cerebral compression, hypoxia, and ischemia materially influence the outcome from severe head injury, a standardized protocol was followed in 160 patients, with emphasis on early diagnosis and evacuation of intracranial mass lesions by craniotomy, artificial ventilation, control of increased intracranial pressure, and aggressive medical therapy. Of these patients, 36% made a good recovery, 24% were moderately disabled, 8% were severely disabled, 2% were vegetative, and 30% died. The mortality rate compares favorably with outcomes in similar patients reported from other centers and there has been no increase in the numbers of severely disabled or vegetative patients. It is proposed that vigorous surgical and medical therapy, by preventing or reversing secondary cerebral insults, enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients.