ACTA NEUROCHIRURGICA
Acta Neurochirurgica 51, 83--86 (1979)
9 by Springer-Verhg 1979
Division of Neurosurgery, Di Venere Hospital, Bari-Carbonara, Italy
Unusual Evolution of a Post-Traumatic Subdural Haematoma Case Report By
P. Ciappetta and P. Bruni
With 2 Figures Summary The authors describe a case of a post-traumatic subdural haematoma with an unusual evolution in two phases, one slow, the other very rapid. The rapidity of the evolution was caused by the rupture of a cortical dural artery, shown anglographically.
Keywords: Subdural haematoma; post-traumatic; contrast medium extravasation.
Post-traumatic subdural haematoma is of frequent occurrence in neurosurgical practice. This lesion is classified as acute, subacute, and chronic, according to the time between trauma and signs of cerebral involvement. The subdivision is arbitrary, however, and it is generally accepted that the acute form develops within about three days after trauma, the subacute usually between three days and three weeks after trauma, and the chronic form after three weeks. Our case is unusual in that it evolved in the first instance like a typical chronic subdural haematoma and, after a few days, rapidly due to the rupture of an artery, revealed by radiology with extravasation of contrast medium during angiography. Case Report This concerns a 60-years-old man who, 15 days prior to admission, fell from a tree, hitting his head. He did not, however, lose consciousness or wound himself. Following the accident, he complained of continuous headache and occasional vomiting. 6*
0001-6268/79/0051/0083/8 01.00
84
P. Ciappetta and P. Bruni:
The patient was first admitted to another hospital where his condition deteriorated markedly until he fell into a coma. Bilateral carotid angiography was, therefore, carried out. This revealed a left subdural haematoma of considerable size and an extravasation of contrast medium in arterial and arteriolar phases in the left temporal-parietal region (Figs. 1 and 2). After this examination the patient was transferred to our division. At the time of admission he was comatose and decerebrate. A surgical operation was
Fig. 1. Left carotid angiography, arterial phase, shows the presence of a subdural haematoma with an extravasation of contrast medium in the temporo-parietal region carried out immediately. A wide trephine hole was made in the left parietal region: when the dura was opened, a haematoma of considerable size was removed, and the rupture of a small artery was noted. This was clipped. During the postoperative period there were no complications, and there was a gradual improvement in the patient's condition, to the extent that after 18 days he was in good general health, and neurological tests showed no abnormality.
Discussion
The most common cause of haemorrhage in subdural haematoma is the rupture of bridging cortical veins or of venous sinuses, while rupture of cortical arteries is much rarer, even though cases are reported in the literature , - n
Unusual Evolution of a Post-Traumatic Subdural Haematoma
85
Extravasation of contrast medium during angiography has been described in the subdural haematomas whose aetiology was the rupture of cortical arteries. However, the frequency of this angiographical manifestation is much lower ~, 6, 8 Leohr 6 in 1936 was the first to describe a case of extravasation of contrast medium in a post-traumatic acute haematoma.
Fig. 2. Same examination, early venous phase. Persistence of extravasation of contrast medium and notable displacement of the venous angle towards the right. The lateral view of the angiograms (not shown here) clearly excludes an a.v.angioma
Rudikoff 8 has described a case of acute subdural haematoma with rupture of many arterial branches of the ascending frontoparietal group. Ito 4 has observed two acute subdural haematomas with cerebral contusion and extravasation of contrast medium. In one of these cases there was no relationship between the accumulation of contrast medium shown angiographically and the operative findings. In a case described by Smith and Kempe 9 there was an accumulation of contrast medium in the region of the middle cerebral artery which, angiographically, had provided a false aneurysmal picture. From an examination of the literature it can be seen that our case
86
P. Ciappetta et al.: Unusual Evolution of a Subdural Haematoma
is unique in its evolution in two phases, the first slow, the second extremely rapid. This drastic change in the evolution of the symptomatology was caused by the rupture of a cortical artery, shown anglographically, due to expansion of the haematoma. The rupture of the artery could not be verified in the first phase, as otherwise the haematoma would have evolved in an acute form. References
1. Bisgaard-Frantzen, C. F., Dalby, M., Acute subdural hematoma. Acta psychiat. neurol, scand. 32 (1957), 117--124. 2. Drake, C. G., Subdural hematoma from arterial rupture. J. Neurosurg. 18 (1963), 597--601. 3. Krauland, W., Verletzungen der Schlagaderzweige an der Mantelfl~iche des GroBhirns dutch stumpfe Gewalt ohne Sch~idelbruch als Quelle t/~dlicher subduraler Blutungen. Dtsch. Z. Nervenheilk. 175 (1956), 54--65. 4. Ito, J., Ueki, K., Ishikawa, H., Angiographic extravasation of contrast medium in acute traumatic subdurai hematoma from arterial rupture. J. Neurosurg. 37 (1972), 226--228. 5. Laudig, G. H., Browder, E. J., Watson, R. A., Subdural hematoma: a study of one hundred forty-three cases encountered during a five year period. Ann. Surg. 113 (1941), 170--188. 6. Loehr, W., Hirngef~if~verletzungen in arteriographlscher Darstellung. Zbl. Chir. 63 (1936), 2466--2468. 7. Loew, F., Wiistner, W., Diagnose, Behandlung und Prognose der traumatischen H~imatome des Sch~delinneren. Acta Neurochir. (Wien) Suppl. 8. Wien: Springer. 1960. 8. Rudikoff, J. C., Ferris, E. J., Shapiro, J. H., Intracerebral vascular rupture. Radiology 90 (1968), 288--291. 9. Smith, D. R., Kempe, L. G., Cerebral false aneurysm formation in closed head trauma: case report. J. Neurosurg. 32 (1970), 357--359. 10. Vance, B. M., Ruptures of surface blood vessels on cerebral hemispheres as a cause of subdural hemorrhage. Arch. Surg. 61 (1950), 992--1006. 11. Voris, H. C., Subdural hematoma. J. Amer. reed. Ass. 132 (1946), 686--692. Authors' address: P. Ciappetta, M.D., Division of Neurosurgery, Di Venere Hospital, Bari-Carbonara, Italy.
Acta Neurochirurgica 51, 83--86 (1979)
9 by Springer-Verhg 1979
Division of Neurosurgery, Di Venere Hospital, Bari-Carbonara, Italy
Unusual Evolution of a Post-Traumatic Subdural Haematoma Case Report By
P. Ciappetta and P. Bruni
With 2 Figures Summary The authors describe a case of a post-traumatic subdural haematoma with an unusual evolution in two phases, one slow, the other very rapid. The rapidity of the evolution was caused by the rupture of a cortical dural artery, shown anglographically.
Keywords: Subdural haematoma; post-traumatic; contrast medium extravasation.
Post-traumatic subdural haematoma is of frequent occurrence in neurosurgical practice. This lesion is classified as acute, subacute, and chronic, according to the time between trauma and signs of cerebral involvement. The subdivision is arbitrary, however, and it is generally accepted that the acute form develops within about three days after trauma, the subacute usually between three days and three weeks after trauma, and the chronic form after three weeks. Our case is unusual in that it evolved in the first instance like a typical chronic subdural haematoma and, after a few days, rapidly due to the rupture of an artery, revealed by radiology with extravasation of contrast medium during angiography. Case Report This concerns a 60-years-old man who, 15 days prior to admission, fell from a tree, hitting his head. He did not, however, lose consciousness or wound himself. Following the accident, he complained of continuous headache and occasional vomiting. 6*
0001-6268/79/0051/0083/8 01.00
84
P. Ciappetta and P. Bruni:
The patient was first admitted to another hospital where his condition deteriorated markedly until he fell into a coma. Bilateral carotid angiography was, therefore, carried out. This revealed a left subdural haematoma of considerable size and an extravasation of contrast medium in arterial and arteriolar phases in the left temporal-parietal region (Figs. 1 and 2). After this examination the patient was transferred to our division. At the time of admission he was comatose and decerebrate. A surgical operation was
Fig. 1. Left carotid angiography, arterial phase, shows the presence of a subdural haematoma with an extravasation of contrast medium in the temporo-parietal region carried out immediately. A wide trephine hole was made in the left parietal region: when the dura was opened, a haematoma of considerable size was removed, and the rupture of a small artery was noted. This was clipped. During the postoperative period there were no complications, and there was a gradual improvement in the patient's condition, to the extent that after 18 days he was in good general health, and neurological tests showed no abnormality.
Discussion
The most common cause of haemorrhage in subdural haematoma is the rupture of bridging cortical veins or of venous sinuses, while rupture of cortical arteries is much rarer, even though cases are reported in the literature , - n
Unusual Evolution of a Post-Traumatic Subdural Haematoma
85
Extravasation of contrast medium during angiography has been described in the subdural haematomas whose aetiology was the rupture of cortical arteries. However, the frequency of this angiographical manifestation is much lower ~, 6, 8 Leohr 6 in 1936 was the first to describe a case of extravasation of contrast medium in a post-traumatic acute haematoma.
Fig. 2. Same examination, early venous phase. Persistence of extravasation of contrast medium and notable displacement of the venous angle towards the right. The lateral view of the angiograms (not shown here) clearly excludes an a.v.angioma
Rudikoff 8 has described a case of acute subdural haematoma with rupture of many arterial branches of the ascending frontoparietal group. Ito 4 has observed two acute subdural haematomas with cerebral contusion and extravasation of contrast medium. In one of these cases there was no relationship between the accumulation of contrast medium shown angiographically and the operative findings. In a case described by Smith and Kempe 9 there was an accumulation of contrast medium in the region of the middle cerebral artery which, angiographically, had provided a false aneurysmal picture. From an examination of the literature it can be seen that our case
86
P. Ciappetta et al.: Unusual Evolution of a Subdural Haematoma
is unique in its evolution in two phases, the first slow, the second extremely rapid. This drastic change in the evolution of the symptomatology was caused by the rupture of a cortical artery, shown anglographically, due to expansion of the haematoma. The rupture of the artery could not be verified in the first phase, as otherwise the haematoma would have evolved in an acute form. References
1. Bisgaard-Frantzen, C. F., Dalby, M., Acute subdural hematoma. Acta psychiat. neurol, scand. 32 (1957), 117--124. 2. Drake, C. G., Subdural hematoma from arterial rupture. J. Neurosurg. 18 (1963), 597--601. 3. Krauland, W., Verletzungen der Schlagaderzweige an der Mantelfl~iche des GroBhirns dutch stumpfe Gewalt ohne Sch~idelbruch als Quelle t/~dlicher subduraler Blutungen. Dtsch. Z. Nervenheilk. 175 (1956), 54--65. 4. Ito, J., Ueki, K., Ishikawa, H., Angiographic extravasation of contrast medium in acute traumatic subdurai hematoma from arterial rupture. J. Neurosurg. 37 (1972), 226--228. 5. Laudig, G. H., Browder, E. J., Watson, R. A., Subdural hematoma: a study of one hundred forty-three cases encountered during a five year period. Ann. Surg. 113 (1941), 170--188. 6. Loehr, W., Hirngef~if~verletzungen in arteriographlscher Darstellung. Zbl. Chir. 63 (1936), 2466--2468. 7. Loew, F., Wiistner, W., Diagnose, Behandlung und Prognose der traumatischen H~imatome des Sch~delinneren. Acta Neurochir. (Wien) Suppl. 8. Wien: Springer. 1960. 8. Rudikoff, J. C., Ferris, E. J., Shapiro, J. H., Intracerebral vascular rupture. Radiology 90 (1968), 288--291. 9. Smith, D. R., Kempe, L. G., Cerebral false aneurysm formation in closed head trauma: case report. J. Neurosurg. 32 (1970), 357--359. 10. Vance, B. M., Ruptures of surface blood vessels on cerebral hemispheres as a cause of subdural hemorrhage. Arch. Surg. 61 (1950), 992--1006. 11. Voris, H. C., Subdural hematoma. J. Amer. reed. Ass. 132 (1946), 686--692. Authors' address: P. Ciappetta, M.D., Division of Neurosurgery, Di Venere Hospital, Bari-Carbonara, Italy.
