148
Clinical pattern of chronic subdural haematoma Z. Kouo ica, J Brzezitisk i Dep ar tmen t ofNe uros urge ry. Medica l Academy of L6di . Polan d
Ta as sess the clinical manifestation of chronic subdural haematoma (CSH) the au thors retrospectively an alysed the files of 131 adu lt patients treated in the Department of Neurosurgery Medical Academy of t 6di . In 14 patients the illness had a sudden onset, suggesting cerebral stroke. 50 % of pati ents had symptom s of raised Jep, the re wer e no difTerences between young an d older pati ents . In patients older than 40 yea rs foeal neurological deficits were more frequ ent , and in 13 % of them focal signs were homolateral to CSH, In 9 pat ients th e lesion produced symptoms of tra nstentorial herniation within a very sho rt period. Th e authors think that despite th e gr eat progress in neuroradiology and neurosurgery , the condition may still be overlooked ifthe elinieal picture does not suggest an intracra nial sp aceoccupying growth. Die Klinik des chronisc he n su bdurale n Haem atoms Um die klinische Manifestation des ch ronischen subduralen Haem atoms (CSH) zu beur teilen, analysiert en die Auto ren die Verläufe von 131 Patienten, die in der ne urochirurgischen Abteilung der Medizini sch en Akademie von Lodz behandelt wurden, Bei 14 Patient en begann die Erkrankung plötzlich mit den Zeichen eine s Schlagan falles. 50 % der Patienten boten Hinweise auf eine n erhöhten Iep, zwisch en ju ngen und älteren Patienten gab es keinen Unterschied. Bei den über 40jäh rigen waren foka le neuro logische Ausfalle häufiger , darunter 14 % homo lat eral zum CSH. Bei 9 Patie nten führte die Läsion in kurzer Zeit zu den Symptome n einer su praten toriellen Einklemmung. Die Autoren glauben, daß trotz der groß en Fortschritte der Neuroradiologie un d Neurochirurgie ein CSH dennoch übersehen werden kann, wenn da s klinische ' Bild nicht auf eine intr akranielle Raumford eru ng hinweist. Key-Words Chronic subdural ha ematoma - Intracranial pre ssure - Stroke - Focal ne uro logical deficit
Neuroehirurgia 34 (1 991) 148 - 150 © Geo rg Thieme Ve rlag Stuugart . New York
Etiopathogenesis of chronic su bdural haematoma (CSH)is a well-known entity. In last 30 years literatur e da ta conc entr ated mainly on ultrastructu ra l observations of th e development of the ca psule (12, 13) and on various surgical proc edures in the treatment ofthis lesion (3,12 , 13, 16, 17). Th e number ofpapers analyzingthe clinical course of CSH is limited (2, 17), despite ofthe fact , that the course of CSH can be atypical, not suggesting intracranial space occupying lesion (4, 5, 6, 7, 9). In ord er to ass ess clinica l manifestation of CSH we retrospectively analyzed the files of 131 consecutive adu lt patients treated in Department of Neurosurgery , Medical Academy of L ödz. Clinlcal material From 1980 till 1989 131 patients with CSH were trea ted in our Departm ent . For the diagnosis of CSB we took the presence ofwell-developed ea psule of hae matoma. Therewere 101 men and 30 women, 18 to 82 yea r old. 98 patient s (75%) were younger tha n 60, 55 oft hem youngerthan 50 years. From 33 (25%) patients older tha n 60 years, only 6 (4.6%) were above 70 yea rs. and 1 only was older than 80 years of age. 45 patient s (34 %) were chronic alcoholics. Clinical sta tus on admission was assessed according to IV grade scale described by Markwa lder (3, 13), 94 (72 %) patients were in a good state (grade I or II), a nd 38 (28 %) were in a bad state (grade III or IV), 11 of them (8.8 %) presented symptoms oft ra nstentorial herni ation (grade IV). Table 1 show s the age ofthe pat ients a nd clinical state on admission to Neur osurgical Department. 93 (71%)patients had a history ofh ead trauma, 3 weeks to 12 years before surgery. 69 (74%) had trauma within last 3 months , while in 9 (9.7%)this time period was Ionger than 1 yea r. Table 2 shows the age ofpatients and interval between trauma and diagnosis of CSH. There is no statistical correlation between these two par ameters . Table 3 shows the time of posttr aumat ic uncons ciousness in these 93 patients. 88% of patients had mild tra uma, only 6 pati ents had a severe head injury, with unconsciousness longer than 24 hours . The patients were ad mitted to neurosurgi cal un it with different initial diagnosis, and the diagnosis of CSH was esta blished after neuroradiological examinations, i. e. Cf-seen or cerebral angiograp hy.ln 61 (46.5 %)pati ents only, the initial diagnosis was posttr auma tie spaee oceupying lesion . In 34 (26 %)the dia gnosis was ehrenie cerebral ischa emia or dementia in the course of a rteriosclerosis or alcoholism . In 14 (10.7%) the diagnosls was a cerebral stroke - subar achnoid hemorrhage (SAH) in 7 a nd Ischemic stroke in 7. 9 patien ts (7 %) were admitted from horne with symptoms of herni ation due to spaee oceupying lesion of unknown
Corr esponden ce should be addresse d to dr Zbigniew Kotwica, Department of Neurosurgery, Medical Aeadem y of L6di , Kopciriskiego 22, 90-1 53 t odi , Poland
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Summary
Clinical pa ueru 01 ehrenie subdural haematoma
N eur ochi ru r gia 34 (1991)
Tab. 1 I he age and clinical state of patients on acmtsscn to Neurosurgical
Department 111
20-30 31- 40 41-50 51- 60 61- 70 > 70
3 13
3 7
11
4
18 8
11 11
Total
53
o
IV
o o
1
2 8 8 7
40
7 22 26 43 27
3 6 1 1
1 27
4
Total
6
presentation of CSH /in 93 patients with a tustory of trauma
20- 30 31- 40 41- 50 51 -60 61 - 70 > 70
70
6 7 14 22 12
Total
1
15 12 21 15
7 22 26 43 27
3
3
6
64
67
131
> 12
Total
0 0 3 6 1
7 22 26 43 27 6 131
1
11
Tab. 6 The type of fccal neurological signs in comparison with the patient's age /consistent - signs contralateral to CSH, contradictory- signs homolateral to CS H, absent - no neurological signs
Focalneurological signs Age/y
20-30 31- 40 41- 50 51-60 61-70 > 70
3 12 15 34 15 5 84
Total Tab.3
Total
131
11
Tab.2 I he age of patients and the time penod between trauma and clinical Timeinterval/months Age/y
Tab. B The presence of symptomsct increased ICP
contradictory
absent
0 0 5 3 5 0 13
4 10 6 6 7 1 34
The period of posttraumatic unconsciousness
Period of posttraumatte unconsciousness
Number 01 patients
no 1055 of consciousness < 15 min 15- 60 rnin 1- 24 hou rs > 24 hou rs Total
33
symptoms . mainly dementia. Tab le 6 s hows the age of patients and the presence ofneurologieal synd romes . Focal neurologieal de flcits were signlfica ntly mo re frequent in older groups .
43 6 4
6
Discussio n
93
Initial diagnosis according to the presence or absence of trauma in anamnesis Tab. 4
History 01 trauma/ Initial diagnosis Posttraumatic space occupying lesion Brain tumor Subarachnoid haemorrhage Ischemic stroke Acute intracranialhypertension of unknowncause Dementia Total
Total
61 6 6 4
0 7 1 3
61 13 7 7
6 10 93
3 24 38
9 34 131
origin. It mean s that 23 patie nts (17 .7 %) had an acute pr esen ta tlon of c1inical sym ptoms, ab solutely at ypic al for CSl l. Table 4 s hows a n initial d iagnosis in corre lation w ith the presence or absence of tr auma in a namnesi s. 64 (48 %) patlents pr esented sym pto ms ofinc reased intracra nia l pre ssure (lCP) - headache. na usea or br ad ycardia , 40 of the m (30 %) had choked optic d iscs. Table 5 s hows the age of patie nts a nd the pre se nee of inerea sed ICP sym pto ms. Ther e is no statistieal ditTerenee between th ese two parameters in ditTerent age groups . 97 (74 %) patien ts presented foeal neurological s igns - central Iacial paresis . hemlp aresis. ani soeoria or aphasia. In 84 (64 %) patient s foeal signs properl y showed the atTeeted hemlsphe re, while in 13 (10 %) he miparesis was homolateral to CSII, in 3 ofthem also a nisocoria cont ral at eral to CSH wa s present. From 34 pati ents wit hout foeal neurologieal s igns, 16 showed inereased (CP syrnptom s. and 18 presented mental
In adults, CSH usuaJly presents In one of three ways (10. 11, 12): sympt oms ofraised ICP fluctuating drowsiness which can deteriorate to coma progressive dementia In our pat ients , like in other series 12,11 , 12, 14, 26, 27) only 74% of patients had a history of hea d trau ma , an d in most of them tra uma was mild with a short period of unconsciousness. The period from trau ma to surgery lasted from 3 weeks to 12 years. Although it was pointed out that a long interval - more than severa l month s is doubtful (10.12), we previously proved, that a possibility of a long course of CSH, lasting for severa l years cannot be excluded (6, 8). lt is commonly believed (2, 10, 12) th at in older patients, the time betwe en the initial hemorrh age and the presentation of clinical symptoms is longer tha n in younger. We did not find such cor relation in our group of CSH.
lt is stressed, that CSH can imitate differ ent brain lesions (4, 9). On admission the initial diagnosis of CSH was made in less than 50% of patients. The most inter esting is the fact, that in 14 the acute onse t of clinical symptoms suggested cerebral strake, in 7 SAH, confirme d by lumb ar punctu re . It means, that such c1inical presentation is not so unusual as it is thought to be. In 9 pat ients CSH acutely led to tra nstentorial herni ation. Previously, these patien ts did not present any symptoms of the presence of intracranial space occupying lesion. Such clinical picture
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Olnical grade Age/y
149
Neurochirurgia 34 (1991)
usually means an acute fresh hleeding from the vessels of the caps ule to it' s cavity (3,1 5), and the sudden increase in the volume ofCSH, Symptoms of intra cra nial hypert ension were present in almost 50%of patie nts. with the same frequency in younger an d older patients. This findings are opposite to the liter ature (10, 11, 12) hecause it is usually stressed, that older patients rarely have increased ICP, due to cerebr al atrophy. Focal neurological deficits were more frequent in older patients, above 40 years of age. However, young patients have a higher incidence of sudden onset, suggesting cere bral stroke, hemorrh agic or ischemic. Focal deficits probably result from the reduction of cerebral blood flow within the area oft he brain compress ed by CSH(1), an d thu s in older patients with atherosclerosis furth er reduction ofCBF results in focal deficits. False neurological signs , i.e. homolater al to haem atoma appeared only in patients older than 40 years. Younger patients did not present such neurological syndrome an d this ditTer ence was statisticallysignificant.
Z. Kotwica. J Brzez itiski
References I
Broderson. P., F. Gjerris: Regional cerebral blood flow in patients with chro nic subdural hem atomas. Acta Neurol . Scand. 51 (197 5)
2
Fogelholm. H.. O. Heiskanen. O. Wallimo: Chronic subdural hema toma in adults . lnfluence of patie nt's age on symptcms. signs . and thickness of he ma toma . J. Neurosurg. 42 (1975) 43-46 Grisoli, F., N. Grazia ni, J . C. Peragut, F. Vincentel/i, A. P. Fobrizi. G. Ceruso. S. Bellard: Per ioperative lumbar injection of Ringer 's lacta te solution in ehrenie subdural hematomas: aseries of 100 cases. Neurosurgery 23 (1988 ) 616 - 621 Huk. w.. M. Gottschaldt : Zur Klinik des chronisch subdura len Hämatoms . Geriatr ie 6 (1976 1212- 220 Kotwica, Z., J . Brzezifiski: Chr onic subdural hematoma presenting as sponta neus subara chnoid hemorrhage . J. Neuros urg . 63 (1985)
233- 239
3
4
5
691-692 6
7 8
9
10
The results of our study suggest that CSH is still a lesion which can be overlooked and the sudden deterioration is not unexpected. Thus, an early diagnosis and proper surgical tr eatme nt should further reduce the number of disabled patients after the evacuation of CSH.
11
12 13
H 15
16
17
Kotwica, Z.•J. Brzezinski: Along course ofc hronic sub dural haematomas . Acta Neurochir . (Wien ) 85 (1987) 44- 45 Kouo ica. z.. 1. Brzez iriski: Chronic subdura l hemat omas presen ting as cerebral st roke . Zent. bl. Neurochir. 49 (1988) 54-55 Kotwica, Z.. M. Chmielowski: Bilatera l calcified ch ron ic subdu ra l hem atoma. Case report. Rev. Roum. Med-Neurol. Psychiat. 25
(1 987) 257-258 l.aumer. R.: Das chro nisch sub du rale Hämatom unter de m Bild der zerebrovaskuläre n Insuffizienz. Nervenh eilkunde 5 (198 6) 238-240 Loew, F., R. Kivelitz: Chro nic sub du ra l haematomas . lIa ndbook of Clinica l Neurology. Eds. P. J. vinke n. G. W. Bruyn. North- Holland, Amste rdam Oxford 24 (19757 297-327 Loeto. F.. S. Wüstn er: Dia gnose, Behand lung und Prognose der traumat ischen Hämatome des Schädeli nneren . Acta Neuroch ir. (Wien), su ppt. 8 0 9601Springer. Wien Markwalder. T. M.: Chro nic sub dura l hem atomas: a review. J . Neurosurg. 54 (1981l 637- 645 Markwalder, T. M., Jf. J . Reuten: lnfluence of neome mb ra nous orga nisanon . cortica l expa ns ion and subdu ral pr essur e on the postoperative course of chronic subdu ral haematorna : an ana lysis of 20 1 cases. Acta Neurochir. (Wien) 79 ( 986 ) 100-106 McKissock. w., A. Richardson. W. H. Bloom: Subdural hem atomas. A rev iew of 389 cases. Lancet 1 (1960) 1365- 1369 Moussa, A. JI. , N. Joshy: Impact of computed tomogra phy on the treatment of eh renie subdu ra l haematoma. J. Neurol. Neurosurg. Psychlatr y 45 (198 2) 1156- 1158 Richter. 11. P., 1/. J. Klein, M. Sch öfer: Chronic subdu ra l haematomas treated by burr- hole craniotomy and closed syste m d rain age. Retrospective stu dy of 120 patlents. Acta Neurochir. 71 (1984) 179- 188 Robinson, R. G.: Chrome sub du ral hematom a. Surg ical ma nagemen t in 133 patien ts. J. Neurosurg. 61 (1984 ) 263-268
Dr. Zbigniew Kotwica Depa rtment of Neurosu rge ry Medica l Academ y of l:.6di Kopclrisk lego 22 90- 153 l6di Polan d
Downloaded by: Universite de Sherbrooke. Copyrighted material.
150
Clinical pattern of chronic subdural haematoma Z. Kouo ica, J Brzezitisk i Dep ar tmen t ofNe uros urge ry. Medica l Academy of L6di . Polan d
Ta as sess the clinical manifestation of chronic subdural haematoma (CSH) the au thors retrospectively an alysed the files of 131 adu lt patients treated in the Department of Neurosurgery Medical Academy of t 6di . In 14 patients the illness had a sudden onset, suggesting cerebral stroke. 50 % of pati ents had symptom s of raised Jep, the re wer e no difTerences between young an d older pati ents . In patients older than 40 yea rs foeal neurological deficits were more frequ ent , and in 13 % of them focal signs were homolateral to CSH, In 9 pat ients th e lesion produced symptoms of tra nstentorial herniation within a very sho rt period. Th e authors think that despite th e gr eat progress in neuroradiology and neurosurgery , the condition may still be overlooked ifthe elinieal picture does not suggest an intracra nial sp aceoccupying growth. Die Klinik des chronisc he n su bdurale n Haem atoms Um die klinische Manifestation des ch ronischen subduralen Haem atoms (CSH) zu beur teilen, analysiert en die Auto ren die Verläufe von 131 Patienten, die in der ne urochirurgischen Abteilung der Medizini sch en Akademie von Lodz behandelt wurden, Bei 14 Patient en begann die Erkrankung plötzlich mit den Zeichen eine s Schlagan falles. 50 % der Patienten boten Hinweise auf eine n erhöhten Iep, zwisch en ju ngen und älteren Patienten gab es keinen Unterschied. Bei den über 40jäh rigen waren foka le neuro logische Ausfalle häufiger , darunter 14 % homo lat eral zum CSH. Bei 9 Patie nten führte die Läsion in kurzer Zeit zu den Symptome n einer su praten toriellen Einklemmung. Die Autoren glauben, daß trotz der groß en Fortschritte der Neuroradiologie un d Neurochirurgie ein CSH dennoch übersehen werden kann, wenn da s klinische ' Bild nicht auf eine intr akranielle Raumford eru ng hinweist. Key-Words Chronic subdural ha ematoma - Intracranial pre ssure - Stroke - Focal ne uro logical deficit
Neuroehirurgia 34 (1 991) 148 - 150 © Geo rg Thieme Ve rlag Stuugart . New York
Etiopathogenesis of chronic su bdural haematoma (CSH)is a well-known entity. In last 30 years literatur e da ta conc entr ated mainly on ultrastructu ra l observations of th e development of the ca psule (12, 13) and on various surgical proc edures in the treatment ofthis lesion (3,12 , 13, 16, 17). Th e number ofpapers analyzingthe clinical course of CSH is limited (2, 17), despite ofthe fact , that the course of CSH can be atypical, not suggesting intracranial space occupying lesion (4, 5, 6, 7, 9). In ord er to ass ess clinica l manifestation of CSH we retrospectively analyzed the files of 131 consecutive adu lt patients treated in Department of Neurosurgery , Medical Academy of L ödz. Clinlcal material From 1980 till 1989 131 patients with CSH were trea ted in our Departm ent . For the diagnosis of CSB we took the presence ofwell-developed ea psule of hae matoma. Therewere 101 men and 30 women, 18 to 82 yea r old. 98 patient s (75%) were younger tha n 60, 55 oft hem youngerthan 50 years. From 33 (25%) patients older tha n 60 years, only 6 (4.6%) were above 70 yea rs. and 1 only was older than 80 years of age. 45 patient s (34 %) were chronic alcoholics. Clinical sta tus on admission was assessed according to IV grade scale described by Markwa lder (3, 13), 94 (72 %) patients were in a good state (grade I or II), a nd 38 (28 %) were in a bad state (grade III or IV), 11 of them (8.8 %) presented symptoms oft ra nstentorial herni ation (grade IV). Table 1 show s the age ofthe pat ients a nd clinical state on admission to Neur osurgical Department. 93 (71%)patients had a history ofh ead trauma, 3 weeks to 12 years before surgery. 69 (74%) had trauma within last 3 months , while in 9 (9.7%)this time period was Ionger than 1 yea r. Table 2 shows the age ofpatients and interval between trauma and diagnosis of CSH. There is no statistical correlation between these two par ameters . Table 3 shows the time of posttr aumat ic uncons ciousness in these 93 patients. 88% of patients had mild tra uma, only 6 pati ents had a severe head injury, with unconsciousness longer than 24 hours . The patients were ad mitted to neurosurgi cal un it with different initial diagnosis, and the diagnosis of CSH was esta blished after neuroradiological examinations, i. e. Cf-seen or cerebral angiograp hy.ln 61 (46.5 %)pati ents only, the initial diagnosis was posttr auma tie spaee oceupying lesion . In 34 (26 %)the dia gnosis was ehrenie cerebral ischa emia or dementia in the course of a rteriosclerosis or alcoholism . In 14 (10.7%) the diagnosls was a cerebral stroke - subar achnoid hemorrhage (SAH) in 7 a nd Ischemic stroke in 7. 9 patien ts (7 %) were admitted from horne with symptoms of herni ation due to spaee oceupying lesion of unknown
Corr esponden ce should be addresse d to dr Zbigniew Kotwica, Department of Neurosurgery, Medical Aeadem y of L6di , Kopciriskiego 22, 90-1 53 t odi , Poland
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Summary
Clinical pa ueru 01 ehrenie subdural haematoma
N eur ochi ru r gia 34 (1991)
Tab. 1 I he age and clinical state of patients on acmtsscn to Neurosurgical
Department 111
20-30 31- 40 41-50 51- 60 61- 70 > 70
3 13
3 7
11
4
18 8
11 11
Total
53
o
IV
o o
1
2 8 8 7
40
7 22 26 43 27
3 6 1 1
1 27
4
Total
6
presentation of CSH /in 93 patients with a tustory of trauma
20- 30 31- 40 41- 50 51 -60 61 - 70 > 70
70
6 7 14 22 12
Total
1
15 12 21 15
7 22 26 43 27
3
3
6
64
67
131
> 12
Total
0 0 3 6 1
7 22 26 43 27 6 131
1
11
Tab. 6 The type of fccal neurological signs in comparison with the patient's age /consistent - signs contralateral to CSH, contradictory- signs homolateral to CS H, absent - no neurological signs
Focalneurological signs Age/y
20-30 31- 40 41- 50 51-60 61-70 > 70
3 12 15 34 15 5 84
Total Tab.3
Total
131
11
Tab.2 I he age of patients and the time penod between trauma and clinical Timeinterval/months Age/y
Tab. B The presence of symptomsct increased ICP
contradictory
absent
0 0 5 3 5 0 13
4 10 6 6 7 1 34
The period of posttraumatic unconsciousness
Period of posttraumatte unconsciousness
Number 01 patients
no 1055 of consciousness < 15 min 15- 60 rnin 1- 24 hou rs > 24 hou rs Total
33
symptoms . mainly dementia. Tab le 6 s hows the age of patients and the presence ofneurologieal synd romes . Focal neurologieal de flcits were signlfica ntly mo re frequent in older groups .
43 6 4
6
Discussio n
93
Initial diagnosis according to the presence or absence of trauma in anamnesis Tab. 4
History 01 trauma/ Initial diagnosis Posttraumatic space occupying lesion Brain tumor Subarachnoid haemorrhage Ischemic stroke Acute intracranialhypertension of unknowncause Dementia Total
Total
61 6 6 4
0 7 1 3
61 13 7 7
6 10 93
3 24 38
9 34 131
origin. It mean s that 23 patie nts (17 .7 %) had an acute pr esen ta tlon of c1inical sym ptoms, ab solutely at ypic al for CSl l. Table 4 s hows a n initial d iagnosis in corre lation w ith the presence or absence of tr auma in a namnesi s. 64 (48 %) patlents pr esented sym pto ms ofinc reased intracra nia l pre ssure (lCP) - headache. na usea or br ad ycardia , 40 of the m (30 %) had choked optic d iscs. Table 5 s hows the age of patie nts a nd the pre se nee of inerea sed ICP sym pto ms. Ther e is no statistieal ditTerenee between th ese two parameters in ditTerent age groups . 97 (74 %) patien ts presented foeal neurological s igns - central Iacial paresis . hemlp aresis. ani soeoria or aphasia. In 84 (64 %) patient s foeal signs properl y showed the atTeeted hemlsphe re, while in 13 (10 %) he miparesis was homolateral to CSII, in 3 ofthem also a nisocoria cont ral at eral to CSH wa s present. From 34 pati ents wit hout foeal neurologieal s igns, 16 showed inereased (CP syrnptom s. and 18 presented mental
In adults, CSH usuaJly presents In one of three ways (10. 11, 12): sympt oms ofraised ICP fluctuating drowsiness which can deteriorate to coma progressive dementia In our pat ients , like in other series 12,11 , 12, 14, 26, 27) only 74% of patients had a history of hea d trau ma , an d in most of them tra uma was mild with a short period of unconsciousness. The period from trau ma to surgery lasted from 3 weeks to 12 years. Although it was pointed out that a long interval - more than severa l month s is doubtful (10.12), we previously proved, that a possibility of a long course of CSH, lasting for severa l years cannot be excluded (6, 8). lt is commonly believed (2, 10, 12) th at in older patients, the time betwe en the initial hemorrh age and the presentation of clinical symptoms is longer tha n in younger. We did not find such cor relation in our group of CSH.
lt is stressed, that CSH can imitate differ ent brain lesions (4, 9). On admission the initial diagnosis of CSH was made in less than 50% of patients. The most inter esting is the fact, that in 14 the acute onse t of clinical symptoms suggested cerebral strake, in 7 SAH, confirme d by lumb ar punctu re . It means, that such c1inical presentation is not so unusual as it is thought to be. In 9 pat ients CSH acutely led to tra nstentorial herni ation. Previously, these patien ts did not present any symptoms of the presence of intracranial space occupying lesion. Such clinical picture
Downloaded by: Universite de Sherbrooke. Copyrighted material.
Olnical grade Age/y
149
Neurochirurgia 34 (1991)
usually means an acute fresh hleeding from the vessels of the caps ule to it' s cavity (3,1 5), and the sudden increase in the volume ofCSH, Symptoms of intra cra nial hypert ension were present in almost 50%of patie nts. with the same frequency in younger an d older patients. This findings are opposite to the liter ature (10, 11, 12) hecause it is usually stressed, that older patients rarely have increased ICP, due to cerebr al atrophy. Focal neurological deficits were more frequent in older patients, above 40 years of age. However, young patients have a higher incidence of sudden onset, suggesting cere bral stroke, hemorrh agic or ischemic. Focal deficits probably result from the reduction of cerebral blood flow within the area oft he brain compress ed by CSH(1), an d thu s in older patients with atherosclerosis furth er reduction ofCBF results in focal deficits. False neurological signs , i.e. homolater al to haem atoma appeared only in patients older than 40 years. Younger patients did not present such neurological syndrome an d this ditTer ence was statisticallysignificant.
Z. Kotwica. J Brzez itiski
References I
Broderson. P., F. Gjerris: Regional cerebral blood flow in patients with chro nic subdural hem atomas. Acta Neurol . Scand. 51 (197 5)
2
Fogelholm. H.. O. Heiskanen. O. Wallimo: Chronic subdural hema toma in adults . lnfluence of patie nt's age on symptcms. signs . and thickness of he ma toma . J. Neurosurg. 42 (1975) 43-46 Grisoli, F., N. Grazia ni, J . C. Peragut, F. Vincentel/i, A. P. Fobrizi. G. Ceruso. S. Bellard: Per ioperative lumbar injection of Ringer 's lacta te solution in ehrenie subdural hematomas: aseries of 100 cases. Neurosurgery 23 (1988 ) 616 - 621 Huk. w.. M. Gottschaldt : Zur Klinik des chronisch subdura len Hämatoms . Geriatr ie 6 (1976 1212- 220 Kotwica, Z., J . Brzezifiski: Chr onic subdural hematoma presenting as sponta neus subara chnoid hemorrhage . J. Neuros urg . 63 (1985)
233- 239
3
4
5
691-692 6
7 8
9
10
The results of our study suggest that CSH is still a lesion which can be overlooked and the sudden deterioration is not unexpected. Thus, an early diagnosis and proper surgical tr eatme nt should further reduce the number of disabled patients after the evacuation of CSH.
11
12 13
H 15
16
17
Kotwica, Z.•J. Brzezinski: Along course ofc hronic sub dural haematomas . Acta Neurochir . (Wien ) 85 (1987) 44- 45 Kouo ica. z.. 1. Brzez iriski: Chronic subdura l hemat omas presen ting as cerebral st roke . Zent. bl. Neurochir. 49 (1988) 54-55 Kotwica, Z.. M. Chmielowski: Bilatera l calcified ch ron ic subdu ra l hem atoma. Case report. Rev. Roum. Med-Neurol. Psychiat. 25
(1 987) 257-258 l.aumer. R.: Das chro nisch sub du rale Hämatom unter de m Bild der zerebrovaskuläre n Insuffizienz. Nervenh eilkunde 5 (198 6) 238-240 Loew, F., R. Kivelitz: Chro nic sub du ra l haematomas . lIa ndbook of Clinica l Neurology. Eds. P. J. vinke n. G. W. Bruyn. North- Holland, Amste rdam Oxford 24 (19757 297-327 Loeto. F.. S. Wüstn er: Dia gnose, Behand lung und Prognose der traumat ischen Hämatome des Schädeli nneren . Acta Neuroch ir. (Wien), su ppt. 8 0 9601Springer. Wien Markwalder. T. M.: Chro nic sub dura l hem atomas: a review. J . Neurosurg. 54 (1981l 637- 645 Markwalder, T. M., Jf. J . Reuten: lnfluence of neome mb ra nous orga nisanon . cortica l expa ns ion and subdu ral pr essur e on the postoperative course of chronic subdu ral haematorna : an ana lysis of 20 1 cases. Acta Neurochir. (Wien) 79 ( 986 ) 100-106 McKissock. w., A. Richardson. W. H. Bloom: Subdural hem atomas. A rev iew of 389 cases. Lancet 1 (1960) 1365- 1369 Moussa, A. JI. , N. Joshy: Impact of computed tomogra phy on the treatment of eh renie subdu ra l haematoma. J. Neurol. Neurosurg. Psychlatr y 45 (198 2) 1156- 1158 Richter. 11. P., 1/. J. Klein, M. Sch öfer: Chronic subdu ra l haematomas treated by burr- hole craniotomy and closed syste m d rain age. Retrospective stu dy of 120 patlents. Acta Neurochir. 71 (1984) 179- 188 Robinson, R. G.: Chrome sub du ral hematom a. Surg ical ma nagemen t in 133 patien ts. J. Neurosurg. 61 (1984 ) 263-268
Dr. Zbigniew Kotwica Depa rtment of Neurosu rge ry Medica l Academ y of l:.6di Kopclrisk lego 22 90- 153 l6di Polan d
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