Neuroradiology 10, 155-158 (1975) © by Springer-Verlag 1975
Postoperative A n g i o g r a p h i c Control of Chronic Subdural H e m a t o m a s in Adults L. M. Fogel, P. Capesius, R. Ludwiczak, L. Middleton, E. Babin and M. Dupuis Department of Neuroradiology, University Hospital, Strasbourg, France Received: August 7, 1975 Summary. After surgical evacuation of a subdural hematoma there is a constant relationship between the return of the deep veins to the midline, the clinical recovery and the absence of a new subdural collection, even when the anterior cerebral artery remains deviated across the midline. Controle angiographique postoperatoire des hematomes sous-duraux chroniques de l'adulte R~sumd. Apr~s cure chirurgicale d'un h~matome sous-
dural il y a une relation constante entre le retour des veines profondes sur la ligne mrdiane, la r~cuprration clinique et
The persistence of an avascular zone or a deviation of the medial structures, after evacuation of a subdural hematoma has been demonstrated by the application of clips on the cortex and the dura mater [9], by pneumoencephalography [2] and by angiography [5, 6]. These postoperative findings have been interpreted in various ways: persistence of subcortical localised oedema [1, 2, 5, 6], reproduction of a liquid subdural collection [5, 6]. However, it is generally admitted today, that the avascular zone is due mostly to an insufficient reexpansion of the brain, particularly in cases of cerebral atrophy [4]. It was not possible to infer any radiological argument which would determine from a practical standpoint, the attitude to be adopted by the neurosurgeon, i.e. whether there is any subdural liquid collection justifying a reintervention (repuncture via the bnrrhole, drilling of a supplementary hole, surgical exploration). We consider that the localization of deep veins by postoperative angiography might constitute a reliable criterion.
Material and Methods Our report concerns 45 cases of c21ronic subdural hematoma in adults, all having had angiographic control which was generally performed in the second week after the evacuation. These included: 33 cases of unilateral hematomas, vdth the following postoperative findings: 27 total clinical recoveries and 6 incomplete which justified a subsequent reinter-
l'absence de r6cidive m~me lorsque l'art~re c~r6brale ant~rieure reste dgvi~e vers le c6t6 oppos6. Postoperative angiographische Kontrolle bei chronischen subduralen Hiimatomen im Erwachsenen-Alter
Zusammen/assung. Nach chirurgischem Eingriff bei einem subduralen chronischen Hiimatom gibt es einen konstanten Zusammenhang zwischen der Riickkehr der tiefen HimVenen zur Mittellinie, der klinischen Besserung und dem Ausbleiben eines Rezidivs, sogar wenn die A. cerebri anterior auf die Gegenseite verschoben bleibt.
vention, revealing the persistence of a subdural liquid collection, and 12 bilateral hematomas with 11 surgical recoveries and 1 reintervention for sequelae, due to the persistence of a unilateral liquid subdural collection. In all cases, the postoperative evolution of each of the following two angiographic signs was considered: an avascular zone and deviation of the anterior cerebral artery (Fig. 1 a), and the deep median veins (Fig. 1 b). The aim has been to identify any significant correlation between the above angiographic findings and the clinical course. In the description of the avascular area, we have considered an intermediary type [3, 8] with irregular outlines, being neither parallel to the cranial vault ("crescent like") nor convex towards the brain ("biconvex").
Results 1. Avascular zone: chronic subdural hematoma may be of one of three types: "crescent", intermediary and biconvex [3, 8]. We found the following proportions: 50~o biconvex, 257o intermediary and 25~o "crescent". After operation we observed these proportion: 60~o without avascular zone, 25Yo "crescent" and 15g "intermediary". 2. Lateral deviation of the medial vessels (arteries and veins): In our. cases of unilateral hematomas, the anterior cerebral artery and the deep veins were all deviated concomitantly, with the exception of one,
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L.M. Fogel et al.: Postoperative Angiographie Control
Fig. 1. Angiographic control of an evacuated right subdural haematoma with clinical recovery, a) Avascular zone of the "crescent like" type with arterial displacement, b) Deep veins situated in the midline without deviation from the medial line, related to cerebral atrophy [4, 7]. After the evacuation, the anterior cerebral artery remained contralaterally shifted in 50Yo of the cases with clinical recovery and in 100~o when an incomplete recuperation was noted (Fig. 2 a, b). We have noted particularly the constancy of the return of the deep veins to the midline in cases of clinical recovery and the constancy of their deviation when a subdural hematoma persisted (Fig. 2 c, d).
Discussion After surgical evacuation of the chronic subdural hematoma, an avascular zone may persist, even in cases of complete clinical recovery. This phenomenon is generally related to cerebral atrophy or collapse [4], but in our observations it seems to be due to a subarachnoid collapse of the corresponding hemisphere. The radiological arguments are the following: Pneumoencephalography: postoperative pneumoencephalograms show normal sizes of the lateral ventricles and the absence of insufflation of the cortical sulci on the side of the hematoma (Fig. 3), which argues rather in favor of subarachnoid collapse than in favor of cerebral atrophy. As regards surgical conditions: one of us observed,
during a reintervention, that the arachnoid remains adherent to the cortex and is collapsed to such an extent that no CSF circulation is possible. It is interesting to note that our observations concerning the configuration of the avascular zone, before and after surgery, are compatible with the theory which holds that subdural chronic hematomas pass through three stages as far as the radiological appearance is concerned: "cresent", intermediary and biconvex [8, 10] and the spontaneously resolving cases through a reverse sequence. This sequence is also observed in postoperative angiography. The analysis of the avascular zone provides insufficient diagnostic evidence in favor of a new subdural collection. This is true for the anterior cerebral artery as well, since it may remain deviated irrespective of the surgical results. However, the position oJ deep veins constitute, in our opinion, a valuable sign in postoperative angiograms. In fact, there is a constant correlation between their return to the midline and the clinical recovery on the one hand, and the absence of subdural hematoma, verified surgically, on the other. However, this criterion cannot be applied in cases of bilateral subdural hematomas where the deep veins are usually median, or in the rare cases of unilateral hematoma without deviation of the deep veins (due to an associated cerebral atrophy).
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Fig. 2. A 62 year old patient operated upon for a chronic subdural haematoma, with incomplete recovery and subsequent angiographic control (a, c). A reintervention followed with a new angiographie control (b, d) and complete clinical recovery. a) Avascular area "intermediary type", arterial displacement across the midline, b) persistence of the above signs, c) displacement of deep veins, d) return of the deep veins to the midline
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Fig. 3. Pneumoencephalographic control of an evacuated subural hematoma - normal size of the ventricle and -- absence of insufflation of the cortical sulci on the left side
References 1. Browder, E. J., Rabiner, A. M.: Regional swelling of the brain in subdural hematoma, Ann. Surg. 134, 369-375 (1951)
2. Cook, A. W., Browder, E. J., Carter, W. B.: Cerebral swelling and ventricular alterations following evacuation of intracranial extracerebral hematoma. J. Neurosurg. 19, 4 1 9 - 423 (1962) 3. Gilday, D. L., Wortzman, G., Reid, M.: Subdural hematoma: is it or is it not acute? Radiology 110, 141--145 (1974) 4. Glickmann, M. G.: Angiography in head trauma in T. H. Newton and D. G. Potts. Radiology of the skull and brain. Angiography volume two, book 4, chapter 85, 2598--2658 (1975) 5. McLaurin, R. L.: Contributions of angiography to the pathophysiology of subdural Shematomas. Neurology 15, 866--873 (1965) 6. McLaurin, R. L., Helmer, F.: Angiographic observations following removal of subdural hematomas. Acta Radiol. (diagn.) 5, 381--387 (1966) 7. Nelson, S. W., Freimanis, A. K.: Angiographic features of convexity subdural hematomas with emphasis on the differential diagnosis between unilateral and bilateral hematomas. Amer. J. Roentgenol, Radium. Ther. Nucl. Med. 90, 445--461 (1963) 8. Norman, O.: Angiographic differentiation between acute and chronic subdural and extradural hematomas. Acta Radiol. 46, 371--378 (1956) 9. Parkinson, D., Chockinov, H.: Subdural hematomas: some observations on their postoperative course. J. Neurosurg. 17, 9 0 1 - - 9 0 4 (1960) 10. Radcliffe, W. B., Guinto, F. C., Adcock, D. F., Krigman, M. R.: Subdural hematoma shape. A new look at an old concept. Amer. J. Roentgenol. radium ther. nucl. reed. 115, 72--77 (1972) Dr. E. Babin Service de Neuroradiologie 1, place de l'Hopital F - 67005 Strasbourg-Cedex France
Postoperative A n g i o g r a p h i c Control of Chronic Subdural H e m a t o m a s in Adults L. M. Fogel, P. Capesius, R. Ludwiczak, L. Middleton, E. Babin and M. Dupuis Department of Neuroradiology, University Hospital, Strasbourg, France Received: August 7, 1975 Summary. After surgical evacuation of a subdural hematoma there is a constant relationship between the return of the deep veins to the midline, the clinical recovery and the absence of a new subdural collection, even when the anterior cerebral artery remains deviated across the midline. Controle angiographique postoperatoire des hematomes sous-duraux chroniques de l'adulte R~sumd. Apr~s cure chirurgicale d'un h~matome sous-
dural il y a une relation constante entre le retour des veines profondes sur la ligne mrdiane, la r~cuprration clinique et
The persistence of an avascular zone or a deviation of the medial structures, after evacuation of a subdural hematoma has been demonstrated by the application of clips on the cortex and the dura mater [9], by pneumoencephalography [2] and by angiography [5, 6]. These postoperative findings have been interpreted in various ways: persistence of subcortical localised oedema [1, 2, 5, 6], reproduction of a liquid subdural collection [5, 6]. However, it is generally admitted today, that the avascular zone is due mostly to an insufficient reexpansion of the brain, particularly in cases of cerebral atrophy [4]. It was not possible to infer any radiological argument which would determine from a practical standpoint, the attitude to be adopted by the neurosurgeon, i.e. whether there is any subdural liquid collection justifying a reintervention (repuncture via the bnrrhole, drilling of a supplementary hole, surgical exploration). We consider that the localization of deep veins by postoperative angiography might constitute a reliable criterion.
Material and Methods Our report concerns 45 cases of c21ronic subdural hematoma in adults, all having had angiographic control which was generally performed in the second week after the evacuation. These included: 33 cases of unilateral hematomas, vdth the following postoperative findings: 27 total clinical recoveries and 6 incomplete which justified a subsequent reinter-
l'absence de r6cidive m~me lorsque l'art~re c~r6brale ant~rieure reste dgvi~e vers le c6t6 oppos6. Postoperative angiographische Kontrolle bei chronischen subduralen Hiimatomen im Erwachsenen-Alter
Zusammen/assung. Nach chirurgischem Eingriff bei einem subduralen chronischen Hiimatom gibt es einen konstanten Zusammenhang zwischen der Riickkehr der tiefen HimVenen zur Mittellinie, der klinischen Besserung und dem Ausbleiben eines Rezidivs, sogar wenn die A. cerebri anterior auf die Gegenseite verschoben bleibt.
vention, revealing the persistence of a subdural liquid collection, and 12 bilateral hematomas with 11 surgical recoveries and 1 reintervention for sequelae, due to the persistence of a unilateral liquid subdural collection. In all cases, the postoperative evolution of each of the following two angiographic signs was considered: an avascular zone and deviation of the anterior cerebral artery (Fig. 1 a), and the deep median veins (Fig. 1 b). The aim has been to identify any significant correlation between the above angiographic findings and the clinical course. In the description of the avascular area, we have considered an intermediary type [3, 8] with irregular outlines, being neither parallel to the cranial vault ("crescent like") nor convex towards the brain ("biconvex").
Results 1. Avascular zone: chronic subdural hematoma may be of one of three types: "crescent", intermediary and biconvex [3, 8]. We found the following proportions: 50~o biconvex, 257o intermediary and 25~o "crescent". After operation we observed these proportion: 60~o without avascular zone, 25Yo "crescent" and 15g "intermediary". 2. Lateral deviation of the medial vessels (arteries and veins): In our. cases of unilateral hematomas, the anterior cerebral artery and the deep veins were all deviated concomitantly, with the exception of one,
156
L.M. Fogel et al.: Postoperative Angiographie Control
Fig. 1. Angiographic control of an evacuated right subdural haematoma with clinical recovery, a) Avascular zone of the "crescent like" type with arterial displacement, b) Deep veins situated in the midline without deviation from the medial line, related to cerebral atrophy [4, 7]. After the evacuation, the anterior cerebral artery remained contralaterally shifted in 50Yo of the cases with clinical recovery and in 100~o when an incomplete recuperation was noted (Fig. 2 a, b). We have noted particularly the constancy of the return of the deep veins to the midline in cases of clinical recovery and the constancy of their deviation when a subdural hematoma persisted (Fig. 2 c, d).
Discussion After surgical evacuation of the chronic subdural hematoma, an avascular zone may persist, even in cases of complete clinical recovery. This phenomenon is generally related to cerebral atrophy or collapse [4], but in our observations it seems to be due to a subarachnoid collapse of the corresponding hemisphere. The radiological arguments are the following: Pneumoencephalography: postoperative pneumoencephalograms show normal sizes of the lateral ventricles and the absence of insufflation of the cortical sulci on the side of the hematoma (Fig. 3), which argues rather in favor of subarachnoid collapse than in favor of cerebral atrophy. As regards surgical conditions: one of us observed,
during a reintervention, that the arachnoid remains adherent to the cortex and is collapsed to such an extent that no CSF circulation is possible. It is interesting to note that our observations concerning the configuration of the avascular zone, before and after surgery, are compatible with the theory which holds that subdural chronic hematomas pass through three stages as far as the radiological appearance is concerned: "cresent", intermediary and biconvex [8, 10] and the spontaneously resolving cases through a reverse sequence. This sequence is also observed in postoperative angiography. The analysis of the avascular zone provides insufficient diagnostic evidence in favor of a new subdural collection. This is true for the anterior cerebral artery as well, since it may remain deviated irrespective of the surgical results. However, the position oJ deep veins constitute, in our opinion, a valuable sign in postoperative angiograms. In fact, there is a constant correlation between their return to the midline and the clinical recovery on the one hand, and the absence of subdural hematoma, verified surgically, on the other. However, this criterion cannot be applied in cases of bilateral subdural hematomas where the deep veins are usually median, or in the rare cases of unilateral hematoma without deviation of the deep veins (due to an associated cerebral atrophy).
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Fig. 2. A 62 year old patient operated upon for a chronic subdural haematoma, with incomplete recovery and subsequent angiographic control (a, c). A reintervention followed with a new angiographie control (b, d) and complete clinical recovery. a) Avascular area "intermediary type", arterial displacement across the midline, b) persistence of the above signs, c) displacement of deep veins, d) return of the deep veins to the midline
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Fig. 3. Pneumoencephalographic control of an evacuated subural hematoma - normal size of the ventricle and -- absence of insufflation of the cortical sulci on the left side
References 1. Browder, E. J., Rabiner, A. M.: Regional swelling of the brain in subdural hematoma, Ann. Surg. 134, 369-375 (1951)
2. Cook, A. W., Browder, E. J., Carter, W. B.: Cerebral swelling and ventricular alterations following evacuation of intracranial extracerebral hematoma. J. Neurosurg. 19, 4 1 9 - 423 (1962) 3. Gilday, D. L., Wortzman, G., Reid, M.: Subdural hematoma: is it or is it not acute? Radiology 110, 141--145 (1974) 4. Glickmann, M. G.: Angiography in head trauma in T. H. Newton and D. G. Potts. Radiology of the skull and brain. Angiography volume two, book 4, chapter 85, 2598--2658 (1975) 5. McLaurin, R. L.: Contributions of angiography to the pathophysiology of subdural Shematomas. Neurology 15, 866--873 (1965) 6. McLaurin, R. L., Helmer, F.: Angiographic observations following removal of subdural hematomas. Acta Radiol. (diagn.) 5, 381--387 (1966) 7. Nelson, S. W., Freimanis, A. K.: Angiographic features of convexity subdural hematomas with emphasis on the differential diagnosis between unilateral and bilateral hematomas. Amer. J. Roentgenol, Radium. Ther. Nucl. Med. 90, 445--461 (1963) 8. Norman, O.: Angiographic differentiation between acute and chronic subdural and extradural hematomas. Acta Radiol. 46, 371--378 (1956) 9. Parkinson, D., Chockinov, H.: Subdural hematomas: some observations on their postoperative course. J. Neurosurg. 17, 9 0 1 - - 9 0 4 (1960) 10. Radcliffe, W. B., Guinto, F. C., Adcock, D. F., Krigman, M. R.: Subdural hematoma shape. A new look at an old concept. Amer. J. Roentgenol. radium ther. nucl. reed. 115, 72--77 (1972) Dr. E. Babin Service de Neuroradiologie 1, place de l'Hopital F - 67005 Strasbourg-Cedex France
