ACTA NEUROCHIRURGICA

Acta Neurochirurgica 48, 231--236 (1979)

9 by Springer-Verlag 1979

Departments of Neurology and Neurosurgery, University of Helsinki, Helsinki, Finland

Chronic Bilateral Subdural H a e m a t o m a in Adults By M . K a s t e , O. W a l t i m o ,

and O . H e i s k a n e n

Summary Twenty-nine patients with chronic bilateral subduraI haematomas were surgically treated during 1966 to 1977. Twenty-four of them (830/0) had a history of head injury, which caused unconsciousness in eight cases. The mean interval from trauma to operation was eleven weeks. The mean age of the patients was 60 years. The prevalence of the most commonly encountered symptoms and signs was: headache 720/0, mental symptoms 480/0, papilloedema 41~ vertigo 31~ nausea 280/0, reduced consciousness 280/0, walking difficulties 240/0, hemiparesis 240/0, and paraparesis 14~ The aggregate thickness of haematomas was 34 mm, 36 mm, and 40 mm in age groups of 20-39, 40-59, and over 60 years, respectively. All patients were operated on, four of them only unilaterally. Three patients in the whole series died. Two of them had been operated upon only on one side in the first session, the haematoma of the other side being evacuated 8 89 hours and four days later, respectively. Unilateral operation is likely to cause severe distortion of the midline structures and the brain stem and thus aggravates the cerebral situation. Therefore the necessity of simultaneous evacuation of the haematomas on both sides is stressed. The reason for the death of the third patient was delay in diagnosis. All three patients who died belonged to the group of eight patients with a reduced level of consciousness before surgery. Twenty-three of the survivors were fully independent in their daily lives, and three needed some help after operative treatment.

Introduction

The diagnosis of chronic subdural haematoma often presents difficulties (Arseni and Stanciu 1969, Raskind et aI. 1972, Fogelholm et aI. t975). One third of the patients may die undiagnosed (Fogel= holm and Waltimo 1975). The diagnosis of bilateral chronic subdural haematoma is even more difficult, owing to characteristically nonspecific or even misleading symptoms and signs (Arseni and Stanciu 1969). Early diagnosis and proper surgical treatment results in 16 Acta Neurochirurgica, Vol. 48, Fasc. 3--4

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c o m p l e t e r e c o v e r y in m o s t cases. W e h a v e a n a l y s e d the clinical p r e s e n t a t i o n o f b i l a t e r a l chronic s u b d u r a l h a e m a t o m a in adults. C l i n i c a l M a t e r i a l and M e t h o d s During 1966 to 1977 twenty-nine adult patients with chronic bilateral subdural haematomas were examined and operated on at the Departments of Neurology and Neurosurgery, University of Helsinki. A haematoma was considered chronic if it was contained within a well-formed membrane (Fogelholm et al. 1975). The Table I. Age and Sex Distribution Age

20-29

30-39

40-49

50-59

60-69

70-79

80-89

Men Women

1

2

2

5 1

12 2

2 1

t

Total

1

2

2

6

14

3

1

age and sex distribution of the patients is shown in Table t. We extracted data from the case histories concerning head injury, as well as the presenting symptoms and signs. The time interval from trauma to operation was calculated, as well as that from diagnosis of haematoma on one side to correct diagnosis of bilateral haematoma, unless this was made immediately at the first carotid angiography. The aggregate maximum thickness of the haematomas, in miIlimetres, as visualized in angiograms, was used in the calculations. Student's t-test and the &i-square test were used in statistical comparisons. Results A h i s t o r y o f h e a d i n j u r y was o b t a i n e d in 24 p a t i e n t s (830/0). T h e t w o m o s t c o m m o n t y p e s o f t r a u m a w e r e f a l l i n g to the g r o u n d (10 cases) a n d t r a f f i c a c c i d e n t (5 cases). E i g h t p a t i e n t s lost consciousness in c o n n e c t i o n w i t h the t r a u m a . T h e r e w e r e no differences in p r e v a l e n c e o f t r a u m a b e t w e e n d i f f e r e n t age groups. T h e p a t i e n t ' s age d i d n o t c o r r e l a t e w i t h the i n t e r v a l f r o m t r a u m a to o p e r a t i o n . T h e m e d i a n i n t e r v a l was 9 weeks, a n d the m e a n 11 weeks. T h e a g g r e g a t e thickness o f h a e m a t o m a s a v e r a g e d 34 m m , 36 ram, a n d 4 0 m m in the age g r o u p s of 20-39, 40-59, a n d o v e r 60 years, respectively. T h e p r e v a l e n c e s o f the most c o m m o n l y e n c o u n t e r e d s y m p t o m s a n d signs are s h o w n in T a b l e 2. P a t i e n t s u n d e r the age o f s i x t y y e a r s c o m p l a i n e d o f headache m o r e o f t e n t h a n o l d e r p a t i e n t s . T h e y also m o r e o f t e n h a d o b j e c t i v e signs o f increased i n t r a c r a n i a l pressure, such as p a p i l l o e d e m a a n d r e d u c e d consciousness, t h a n o l d e r p a t i e n t s .

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Hemiparesis and paraparesis were more frequent in the patients over sixty years of age than in the younger patients. None of the above mentioned differences is significant. Mental symptoms, such as memory loss, confusion, somnolence, and disturbances of mental status, were seen with equal frequency in all age groups. In four of our 29 patients the correct diagnosis of chronic bilateral subdural haematoma was not made at the first carotid angiography. Two of these patients died. One was a 28-year-old male patient. Table 2. Prevalence of Various Symptoms and Signs According to Age Symptoms and signs

Headache Mental symptoms Vertigo Vomiting/nausea Walking difficulties Sensory-motor Papilloedema Mental deterioration Reduced consciousness Hemiparesis Paraparesis

Age group (years) 20-39 40-59 (N 3) (N 8)

over 60 (N 18)

Total (N 29)

3 2 0 1 0 0 2 1 2 0 0

12 10 6 5 5 4 6 6 4 6 4

21 14 9 8 7 5 12 11 8 7 4

6 2 3 2 2 1 4 4 2 1 0

(72o/0) (480/0) (31~ (280/0) (240/0) (17~ (41~ (380/0) (280/0) (240/0) (14~

Carotid angiography at night was considered normal, there being no midline shift. The neuroradiologist discovered the error in the morning and second angiography was performed. The patient was transferred to the Department of Neurosurgery, and both haematomas were evacuated. Unfortunately, the delay in diagnosis yeas too much for this patient. The other patient was 33 years old and was male. In his case a contralateral chronic subdural haematoma was diagnosed and operated on 81/2 hours after the first operation, the patient failing to wake up normally after evacuation of the first haematoma. In this case, too, the first carotid angiography revealed no shift of midline, and no pictures with compression of the contralateral carotid artery were taken. In the other two cases operation on the second haematoma took place 14 days, and 32 days, after evacuation of the first. Both patients, who were 56 and 62 years old, made good recoveries. The third patient in our series who was lost was a 74-year-old male patient. In this case the diagnosis of chronic bilateral subdural 16"

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haematoma was established immediately after the first carotid angiography; each haematoma had a thickness of 25 mm. But at first only one side has been operated upon. The second haematoma was evacuated only four days after the first. The patient's conscious state regressed irreversibly during these four days. All three cases with fatal outcome are in the group of eight patients presenting with a reduced level of consciousness before surgical treatment. None of the patients with normal alertness before operation was lost. One such patient contracted a permanent reduction of the visual fields. All our 29 patients were operated on, four of them unilaterally only. Twenty-three of the 26 survivors were independent in their daily lives after the evacuation of haematomas. Three needed some assistance in their daily lives, but in one case assistance before the head injury had been required. Discussion

A history of head injury could be established more often in this study than in most earlier reports (McKissock et al. 1960, Arseni and Stanciu 1969, Raskind et al. 1972, Fogelholm et al. 1975) even though the median interval from trauma to surgical treatment was not shorter than reported earlier (Fogelholm et al. 1975). This may be attributable to the fact that the severity of trauma able to cause bilateral chronic subdural haematomas would be greater than that one causing merely unilateral chronic subdural haematoma, and would therefore be better remembered. In half of our cases head injury had been caused by falling to the ground or by a traffic accident. However, only one third of our patients were unconscious after the head injury. In association with unilateral chronic subdurat haematoma one half of the cases have been reported as having lost consciousness after trauma (Fogelholm et al. 1975). The aggregate thickness of bilateral haematomas was greater than that encountered in unilateral haematomas (Fogelholm et aI. 1975). It is conceivable that bilateral haematomas do not cause distortion of the midline structures and brain stem as readily as unilateral haematomas. Headache and mental symptoms are classical symptoms of chronic subdural haematoma and they were also the two most common symptoms in our series. One third of our patients complained of vertigo, not an uncommon symptom in older people. Furthermore, one fourth complained of walking difficulties, and four patients actually had paraparesis. The last-mentioned sign has occasionally

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235

been reported in connection with bilateral chronic subdural haematoma (Bortni& and Murphy 1963, Arseni and Stanciu 1969) and should be kept in mind as a rare cause of paraparesis. The observation that older patients had thicker haematomas on the average at the time of surgery or autopsy was also known to earlier authors (Aronson and Okazaki 1963, Fogelholm et aI. 1975). This is a logical result of the atrophic changes in the aging brain. This age-dependent change in brain weight and intracranial free space (Kivalo 1957, McMenemey 1963, Minckler and Boyd 1968) also explains why the age seems to correlate with the patient's symptoms and signs. The greater prevalence of motor signs in older patients is probably due to their more massive haematomas compressing the motor cortex. Younger patients complained more often of headache and had signs of increased intracranial pressure more often than older patients, in spite of their smaller average haematomas. Younger patients without atrophic changes do not tolerate large haematomas as well as older patients (Fogelholm et aI. 1975). When the reserve capacity of younger patients is consumed an irreversible decompensation takes place sooner than in older patients. This is probably one of the reasons why two of our three patients who were lost belonged to the youngest age group. If the midline shift on carotid angiography does not correlate with the thi&ness of a chronic subdural haematoma, bilateral haematoma must be suspected and excluded. Even with computerized axial tomography the diagnosis of bilateral chronic subdural haematoma may be missed (Potter and Fruin 1977). When chronic bilateral subdural haematomas are found in adults, they should as a rule be operated on bilaterally at the same time if both haematomas are of considerable size. If this is not done, the haematoma which is left may cause severe distortion of midline structures and brain steam. This may be the main reason why we lost our two patients. All our patients with normal consciousness before the operation survived and most of them were independent in their daily life after the evacuation of the haematomas. Three of the eight patients with reduced consciousness before surgical treatment died. This emphasizes the importance of early diagnosis and proper surgical treatment of chronic bilateral subdural haematoma in adults (McKissock et al. 1960). In young adults the time factor is even more important. Acknowledgements This study was supported by Paavo Nurmi Foundation, Finland,

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M. Kaste et al.: Chronic Bilateral Subdural Haematoma in Adults References

1. Aronson, S. M., Okazaki, H., A study of some factors modifying response of cerebral tissue to subdural hematomata. J. Neurosurg. 20 (1963), 89--93. 2. Arseni, C., Stanciu, M., Particular clinical aspects of chronic subdurai hematoma in adults. Europ. Neurol. 2 (1969), 109--122. 3. Bormick, R. I., Murphy, P. I., Paraparesis with incontinence bowel and bladder. A syndrome of bilateral subdural hematomas. J. Neurosurg. 20 (1963), 352--353. 4. Fogelholm, R., Heiskanen, O., Waltimo, O., Chronic subdural hematoma in adults. Influence of patient's age on symptoms, signs and thickness of hematoma. J. Neurosurg. 42 (1975), 43--46. 5. Fogelholm, R., Waltimo, O., Epidemiology of chronic subdural hematoma. Acta Neurochir. (Wien) 32 (1975), 247--250. 6. Kivalo, E., On the weight of Finnish brains. Ann. Acad. Sci. Fenn. (Med.) 66 (1957). 7. McKissock, W., Richardson, A., Bloom, W. H., Subdural haematoma. A review of 389 cases. Lancet 1 (1960), 1365--1369. 8. McMenemey, W. H., The dementias and progressive diseases of the basal ganglia. In: Greenfield's neuropathology, pp. 520--580 (Blackwood, W., McMenemey, W. H., Meyer, A., et al., eds.). London: E. Arnold. 1963. 9. Minckler, T. N., Boyd, E., Physical growth of the nervous system and its coverings. In: Pathology of the nervous system, vol. 1, pp. 120--137 (Minckler, J., ed.). New York-Toronto-Sydney-London: McGraw-Hill Book Co. 1968. 10. Potter, J. F., Fruin, A. H., Chronic subdural hematoma--the "great imitator". Geriatrics 32 (1977), 61--66. 11. Raskind, R., Glover, M. B., Weiss, S. R., Chronic subdural hematoma in the elderly: a challenge in diagnosis and treatment. J. Amer. Geriat. Soc. 20 (1972), 330--334. Authors' addresses: M. Kaste, M.D., and O. Waltimo, M.D., Department of Neurology, University of Helsinki, SF-00290 Helsinki 29, Finland; O. Heiskanen, M.D., Department of Neurosurgery, University of Helsinki, SF-00260 Helsinki 26, Finland.

Chronic bilateral subdural haematoma in adults.

ACTA NEUROCHIRURGICA Acta Neurochirurgica 48, 231--236 (1979) 9 by Springer-Verlag 1979 Departments of Neurology and Neurosurgery, University of He...
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