Interhemispheric subdural haematomas: seven cases and review of the literature

Clinical Characterization of Traumatic Acute Interhemispheric Subdural Hematoma

OBJECT

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

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 Interhemispheric Subdural Haematoma

Acute interhemispheric subdural haematoma (AISH) was considered extremely rare until identification with imaging studies. Interhemispheric subdural hematoma in adults is a rare complication of head injury with no more than 100 cases reported since 1940. The classical presentation of this disorder is a contralateral monoparesis of the leg or a hemiparesis more pronounced in the leg1. Treatment may consist of conservative observation or craniotomy and is dictated by the clinical course. Conservative management is the treatment of choice for patients without disturbances of consciousness and for patients with stable clinical conditions. Surgical treatment is necessary in patients with progressive neurological deterioration. We describe the case of traumatic AISH in a 31-year-old patient who presented a contralateral monoparesis of the leg.

Interhemispheric subdural hematoma in adults: case reports and a review of the literature

The interhemispheric subdural hematoma is a relatively uncommon type of subdural hematoma, especially seen in patients with blood clotting disturbances. When its mass becomes sufficiently large, specific neurological abnormalities such as hemiparesis and signs of the falx syndrome are seen. Treatment can consist of conservative observation or craniotomy and is dictated by the clinical course. Conservative management is the treatment of choice for patients without disturbances of consciousness and for patients with stable clinical conditions. Surgical treatment is necessary in patients with progressive deterioration. Three case reports are presented, as well as a review of 64 cases described in the literature. The salient aspects of this clinical entity are discussed.

Traumatic laceration of pericallosal artery resulting in interhemispheric subdural hematoma: a case report

Interhemispheric subdural hematoma (IHSDH) usually manifests itself in a delayed fashion after trauma as a slow neurological deterioration with signs of the falx syndrome (paresis or seizures of the lower extremity contralateral to the hematoma). Several etiologies of IHSDH have been described, with tearing of bridging veins being especially associated with trauma. We present the second reported case of IHSDH due to traumatic arterial laceration. This lesion demonstrates a benign and delayed initial presentation. Conservative observation has been employed in the past with mixed results. Patients receiving early definitive surgical treatment have a lower mortality rate then those treated similarly having convexity SDHs. This review of 31 cases discusses the salient aspects of this clinical entity, emphasizing the need for prompt diagnosis and treatment, despite the patient's seemingly stable neurological status.