Yonsei Med J.  2007 Apr;48(2):210-217. 10.3349/ymj.2007.48.2.210.

What are the Causative Factors for a Slow, Progressive Enlargement of a Chronic Subdural Hematoma?

• Shim YS
• Park CO
• Hyun DK
• Park HC
• Yoon SH

• KMID: 1779522
• DOI: http://doi.org/10.3349/ymj.2007.48.2.210

Abstract

PURPOSE
To test the hypothesis that chronic subdural hematoma (CSDH) enlarges by the causative factors, this study has performed. METERIALS AND METHODS: In 10 patients with CSDH, coagulation factors in venous blood taken at the time of surgery and hematomic contents aspirated from the CSDH were studied, using both laboratory assays and microscopy. RESULTS: When compared to the range of normal plasma, the hematoma fluids demonstrated a marked reduction in factor II, V, VII, VIII, and X, moderate reduction of factors IX and XI, and slight reduction of factor XII. Activated protein C and antithrombin III levels were decreased. The FDP (Fibrinogen Degradation Product) levels in chronic subdural hematoma were extremely high. The endothelial cells of the macrocapillaries (also called "sinusoid") showed numerous gap junctions between adjacent endothelial cells and a thinness or absence of the basement membrane, suggesting that the macrocapillaries are very fragile and susceptible to bleeding. CONCLUSION: Excessive coagulation in the hematoma, predominantly via the extrinsic clotting pathway, local hyperfibrinolysis, transmitted pulsations, and characteristics of the macrocapillaries play an important role in the leakage of blood and the enlargement of CSDH.

Keyword

Chronic subdural hematoma; coagulation; hyperfibrinolysis; transmitted pulsation; macrocapillary

Figure

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  Fig. 1 Photomicrographs of the dura mater. (A) The Compact lamella contains the tight fibrous tissue with fibroblasts, collagen of the meningeal layer(a), the loose lamellas contains the loose fibrous tissue with a few blood vessels(b). (B) Photographs of the outer membrane of subdural caopsule. Note the connective tissue proliferation at the outer side of the outer membrane (compact fibrous tissue, a) and multiple neo-vascular sinusoidal channels overlying fresh red blood cells (loose fibrous tissue; vascular layer, b) ×100.

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  Fig. 2 Electron micrograph of the external membrane of a subdural hematma showing a macrocapillary. Its lumen is as large as 40m in diameter with erythrocytes (Ec) and consisted of single layer of flattened endothelial cells with a faint or discontinuous basement membrane. Endothelial cells have hyper-chromatic, large nucleus with a high nucleus/cytoplasm ratio. There are two erythrocytes at the outside of the capillary wall. P, pseudopod-like protrusion; N, nucleus; L, lumen (×5,000).

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  Fig. 3 Electron micrograph of a portion of a macrocapillary with a endothelial gap junction. The endothelal gap junction is as large as 0.6m in diameter. Basement membrane is discontinuous and faint. Two extravasated erythrocytes can be seen. The endothelial cytoplasm contains many ribosomes. L, lumen; Ec, erythrocyte (×10,000).

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