Traumatic Parafalcine Subdural Hematoma: A Clinically Benign Finding

Traumatic Parafalcine Subdural Hematoma: A Case Report

Parafalcine subdural hematoma is a rare subtype of intracranial hematoma. Brain hemorrhage, or hematomas, can occur in the brain or within the three layers that cover the brain. A subdural hematoma is trapped blood that develops between the inner layers and the tough outer covering called the dura. Typically, this is due to the tearing of the subdural or bridging veins. The patient in this report is an 85-year-old male who came to the emergency department following a fall on the second day with complaints of headache, neck pain, bilateral leg weakness, nausea, and vomiting. A computed tomography scan was performed in the emergency department, demonstrating an acute parafalcine subdural hematoma measuring 11 mm in thickness. This report will discuss the findings of interhemispheric hematomas and the rare parafalcine subtype and shed light on the diagnostic approach, medical and surgical treatment modalities, and prognosis.

Risk factors, management, and outcomes in isolated parafalcine or tentorial subdural hematomas

INTRODUCTION

Indications for hospitalization in patients with parafalcine or tentorial subdural hematomas (SDH) remain unclear. This study derived and validated a clinical decision rule to identify patients at low risk for complications such that hospitalization can be avoided.

METHODS

A multicenter retrospective medical record review of adult patients with parafalcine or tentorial SDHs was completed. The primary outcome was significant injury, defined as injury that led to neurosurgery, discharge to another facility, or death. A multivariable logistic regression was performed to identify variables independently associated with the outcome in the derivation cohort. These variables were then validated on a separate cohort from a different institution abstracted without knowledge of the identified variables.

RESULTS

In the derivation cohort, 134 patients with parafalcine/tentorial SDHs were identified. The mean age was 63 ± 19 years with 82 (61%) male. Seventy-one (53%) had significant injuries. Variables independently associated with significant injury included: age over 60, adjusted odds ratio (aOR) 3.46 (95% CI 1.24, 9.62), initial Glasgow Coma Scale score below 15, aOR =7.92 (95% CI 2.78, 22.5), and additional traumatic brain injuries (TBIs) on computerized tomography (CT), aOR =5.97 (95% CI 2.48, 14.4). These three variables had a sensitivity of 71/71 (100%, 95% CI 96, 100%) and specificity of 12/63 (19%, 95% CI 10, 31%). The validation cohort (n = 83) had a mean age of 62 ± 22 years with 50 (60%) male. The three variables had a sensitivity of 36/36 (100%, 95% CI 92, 100%) and specificity of 7/47 (15%, 95% CI 6.2, 28%). All 39 (100%, 95% CI 93, 100%) patients from both cohorts who underwent neurosurgery had additional TBI findings on their CT scan.

CONCLUSIONS

Patients with parafalcine/tentorial SDHs who are under 60 years with initial GCS scores of 15 and no addition TBIs on CT are at low risk and may not need hospitalization. Furthermore, patients with isolated parafalcine/tentorial SDHs are unlikely to undergo neurosurgery. Prospective, external validation with a larger sample size is now recommended.

STUDY TYPE

Retrospective Cohort Study.

A case of traumatic acute interhemispheric subdural hematoma due to injured dural branch of anterior cerebral artery

Background:

The precise causes of traumatic acute interhemispheric subdural hematoma (AISDH) are unclear in most cases, and there are few cases, where the sources of bleeding are directly confirmed intraoperatively. We report a rare case of traumatic AISDH, in which a damaged dural branch of anterior cerebral artery (ACA) to the cerebral falx was identified as the cause of bleeding during hematoma removal.

Case Description:

A 61-year-old man with a history of craniotomy for the left putaminal hemorrhage at the age of 50 fell from a bed, bruised his head, and lost consciousness. Computed tomography of the head showed AISDH of 2.5cm in thickness, which was removed through a parietal parasagittal craniotomy under the microscope. Intraoperatively, the bleeding source was revealed to be a damaged dural branch from ACA to the cerebral falx. There was no rebleeding during his stay in our hospital.

Conclusion:

In this case, intraoperative findings revealed that the cause of bleeding was a damage to the dural branch of ACA. A vascular study is mandatory to rule out a vascular malformation in similar cases.