J Korean Neurosurg Soc.  2013 Sep;54(3):211-219. 10.3340/jkns.2013.54.3.211.

Natural Course of Initially Non-Operated Cases of Acute Subdural Hematoma : The Risk Factors of Hematoma Progression

• Son S
• Yoo CJ
• Lee SG
• Kim EY
• Park CW
• Kim WK

• KMID: 2190900
• DOI: http://doi.org/10.3340/jkns.2013.54.3.211

Abstract

OBJECTIVE
The objectives of the present study were to characterize the natural course of initially non-operated traumatic acute subdural hematoma (ASDH) and to identify the risk factors of hematoma progression.
METHODS
Retrospective analysis was performed using sequential computed tomography (CT) images maintained in a prospective observational database containing 177 ASDH cases treated from 2005 to 2011. Patients were allocated to four groups as followings; 136 (76.8%) patients to the spontaneous resolution group, 12 (6.8%) who underwent operation between 4 hours and 7 days to the rapid worsening group (RWG), 24 (13.6%) who experienced an increase of hematoma and that underwent operation between 7 and 28 days to the subacute worsening group (SWG), and 5 (2.8%) who developed delayed aggravation requiring surgery from one month after onset to the delayed worsening group (DWG). Groups were compared with respect to various factors.
RESULTS
No significant intergroup difference was found with respect to age, mechanism of injury, or initial Glasgow Coma Scale. The presence of combined cerebral contusion or subarachnoid hemorrhage was found to be a significant prognostic factor. Regarding CT findings, mixed density was common in the RWG and the SWG. Midline shifting, hematoma thickness, and numbers of CT slices containing hematoma were significant prognostic factors of the RWG and the SWG. Brain atrophy was more severe in the SWG and the DWG.
CONCLUSION
A large proportion of initially non-operated ASDHs worsen in the acute or subacute phase. Patients with risk factors should be monitored carefully for progression by repeat CT imaging.

Keyword

Acute subdural hematoma; Chronic subdural hematoma; X-ray computed tomography

MeSH Terms

Atrophy
Brain
Contusions
Glasgow Coma Scale
Hematoma*
Hematoma, Subdural, Acute*
Hematoma, Subdural, Chronic
Humans
Prospective Studies
Retrospective Studies
Risk Factors*
Subarachnoid Hemorrhage
Tomography, X-Ray Computed

Figure

• 

  Fig. 1 Longitudinal proportion of the largest hematoma was defined as the ratio of hematoma convexity to cerebral hemisphere convexity (A/B).

• 

  Fig. 2 Measurement of frontal horn index (FHI), and sylvian fissure ratio (SFR). A : Frontal horn diameter (FHD), the distance between the tips of the frontal horns measured on the CT section depicting them best. B : Innner table diameter (ITD), the distance between the inner tables of the skull measured on the same section, and along the same line used to measure FHD. C1 and C2 : Maximum widths of the two sylvian fissures. D : Transpineal coronal inner table diameter. FHI was defined as the ratio of FHD to ITD (A/B). SFR was defined as the average of the maximum width of the two sylvian fissures on the section showing them at their widest, divided by the transpineal coronal inner table diameter [(C1+C2)/2D]. If the sylvian fissure was not visible in the hematoma side, the contralateral side×2 was used.

• 

  Fig. 3 Computed tomography (CT) scans showing an example of rapid worsening. A : Initial head CT reveals a mixed density, thick ASDH with cerebral contusion, traumatic SAH, and moderate midline shifting. B : Three hours later, head CT shows slight hematoma thinning and a midline shifting improvement. C : However, 3 days later, the patient showed a sudden neurologic deterioration (GCS score 8), and follow-up head CT reveals aggravated hematoma and midline shifting. Craniectomy was performed immediately. Her final GCS score was 10. ASDH : acute subdural hematoma, SAH : subarachnoid hemorrhage, GCS : Glasgow Coma Scale.

• 

  Fig. 4 Computed tomography (CT) scans showing an example of subacute worsening. A : Initial head CT reveals a mixed density, thick ASDH with mild midline shifting with moderate brain atrophy. B : One week later, head CT shows hematoma resolution transiently. C : However, at 2 weeks after admission, his symptoms worsened gradually to GCS score 10. Follow-up head CT reveals low-density subdural fluid collection with severe midline shifting. Trephination surgery was performed, and fortunately, his final GCS score recovered to 14. ASDH : acute subdural hematoma, GCS : Glasgow Coma Scale.

• 

  Fig. 5 Computed tomography (CT) scans showing an example of delayed worsening. A : Initial head CT reveals a homogeneous density ASDH in the right frontal and interhemispheric fissure. B : Two weeks later, head CT shows hematoma resolution but progression of bilateral subdural hygroma. C : Three months later, follow-up head CT reveals hydrocephalus and a ventriculo-peritoneal shunt procedure was performed. ASDH : acute subdural hematoma.

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