J Neurosurg 48:345-349, 1978
Long-term follow-up review of patients with acute and subacute subdural hematomas JARL ROSEN~RN, M . D . , AND FLEMMING GJERRIS, M.D.
Department of Neurosurgery, Bispebjerg Hospital, Copenhagen, Denmark o,' The authors present 149 patients suffering from acute (112) and subacute (37) subdural hematomas admitted during the 10-year period 1965 to 1974, with a follow-up period of 2 to 12 years. During the time of observation, 104 patients died and 45 survived; 73% of the patients with acute and 27% with subacute subdural hematomas died. Of the patients with an acute subdural hematoma, 11% went back to work, as against 32% of those with subacute subdural hematomas. The 5-year survival rate was 28% in patients with acute and 76% in patients with subacute subdural hematomas. KEY WORDS
9 subdural h e m a t o m a
S
UBDURAL hematomas are arbitrarily grouped as acute, subacute, or chronic. This distinction is of value in determining the prognosis, and is based on the interval from t r a u m a to development of symptoms from the h e m a t o m a s . 7,13,14,21,22 The overall mortality of patients with acute and subacute subdural hematomas has always been high, ~8 and this is still the most common finding in reports from the last decade, in spite of the introduction of steroids, diuretics, hyperventilation, and decompression to treat edema? ,6'9,11,~5 The mortality reported is about 50% to 70% in patients with acute and 25% to 35% in patients with subacute subdural hematomas, but in most reports the follow-up study is very short and includes less than 100% of the series. The main purpose of the present investigation was to study the symptoms and treatment of a consecutive series of patients with acute and subacute subdural hematomas, and to evaluate the quality of survival and the long-term prognosis resulting from a 100% study. J. Neurosurg. / Volume 48 / March, 1978
9 prognosis
9 survival rate
Clinical Material and M e t h o d s
The case material comprises 149 patients with traumatic acute or subacute subdural hematomas admitted to our department during the 10-year period from April, 1965, to March, 1974. This study is partly retrospective and partly prospective, inasmuch as each of these patients was seen by one of the authors within the last 3 years of the study period. All patients have been followed up either to their death or to the spring of 1976, 2 to 12 years after operation. All hematomas were more than 10 mm thick. N o patients with more extensive lacerations of the brain, with an epidural or intracerebral hematoma, or with an acute subdural hygroma were included in this material. Based on the distinction generally accepted, namely, that a subdural h e m a t o m a is acute if the symptoms caused by it develop within 3 days of trauma, and subacute if the symptoms develop within 3 days to 3 weeks of trauma, 112 of our patients (75%) had an acute subdural hematoma, and 37 had a sub345
j. RosenCrn and F. Gjerris TABLE 1 Distribution of age and sex in 149 patients with acute and subacute subdural hematomas
Age (years) 64 total
Acute Subdural Hematomas Males Females 5 57 15 77
2 21 12 35
acute subdural h e m a t o m a . 14,~a Only a few of our patients with subacute subdural h e m a t o m a s had s y m p t o m s lasting more than 10 days? 3 There were 108 men and 41 women, with ages ranging from 8 months to 88 years (Table 1). The average age at the time of operation was 52 years (50 years for men and 55 for women). In 122 patients the h e m a t o m a was demonstrated by carotid angiography and in 27 by operation alone. The h e m a t o m a was evacuated by burr holes or craniotomy in all cases. Results During the follow-up period, 104 patients died and 45 survived; 48 patients died within the first 3 days after operation, 66 patients died within 1 month, and 81 within 1 year. Ninety patients died as a result of their h e m a t o m a , and the mortality statistics are based on these 90 patients. The remaining 14 died of unrelated causes (five of malignant disease, four of cardiac disease, and five of other causes). In all, 73% of patients with acute subdural h e m a t o m a s and 27% with subacute subdural h e m a t o m a s died. The mortality is shown in Table 2; 55% of the men and 76% of the women died, but the average age at death was higher in females and the acute h e m a t o m a s constituted 85% of the female group. The mortality increased with increasing age in spite of a preponderance of subacute h e m a t o m a s in the oldest age groups. The mortality rate was low in patients who were awake or slightly somnolent, and low when the pupillary conditions were normal or the pupils showed reaction on light stimulation (Table 2). Only one boy who had dilated non-reacting pupils at the time of operation 346
Subacute Subdural Hematomas Males Females -20 11 31
-6 -6
Total No. of Cases 7 104 38 149
survived, and he was in good condition. We found that the prognosis was best when the systolic blood pressure was between 120 and 150 m m H g measured with a brachial cuff, and the pulse rate was between 60 and 90/min. Patients with low blood pressure had a fatal outcome. Only 12 patients showed signs of the typical Cushing response. With the onset of brain-stem attacks the mortality was 86%. A total of 122 arteriograms were reviewed. In most cases the angiograms showed a midline shift, and in 117 cases this was associated with a crescent-shaped avascular zone. In five patients, of whom four had a subacute and one an acute h e m a t o m a , the avascular zone was lens-shaped. In 34 of the 117 patients with a crescentshaped avascular zone on the arteriogram, we found a midline dislocation and elevation of the middle cerebral artery, but no difference in mortality was found between these two groups. N o cases of bilateral h e m a t o m a s were observed. The h e m a t o m a s were evacuated by burrhole drainage in 106 and by craniotomy in 43 patients. N o difference in mortality between these groups could be shown, neither in the acute nor the subacute group. Steroid therapy with d e x a m e t h a s o n e in standard dose was given to 64 patients, but the mortality rate was the same in the treated as in the untreated group. The cumulative survival rates calculated in a c c o r d a n c e with the life table method are shown in Fig. 1. The much better prognosis of patients with subacute subdural h e m a t o m a is seen, with a highly significant difference (p < 0.001). 2 At follow-up study in the spring of 1976, 45 patients had survived; their neurological, J. Neurosurg. / Volume 48 / March, 1978
Prognosis in acute and subaeute subdural hematomas TABLE 2
Mortality (7o) in patients with acute and subacute subdural hematomas in relation to sex, age, and different clinical conditions Acute Subdural Hematomas
Factor
Subacute Subdural Hematomas
Total No.
Deaths
(%)
No. of Cases
Deaths (~o)
No. of Cases
Deaths (7o)
77 35
69 85
31 6
19 33
108 41
55 76
age (years) < 15 15-64 > 64
7 78 27
57 71 85
-26 11
-23 18
7 104 38
57 59 66
level of consciousness awake or slightly somnolent stuporous or comatose
22 90
36 82
28 9
11 56
50 99
22 78
pupillary conditions normal unequal but reacting to light one dilated & fixed both dilated & fixed unknown
20 13 34 40 5
50 46 74 98 40
21 7 2 -7
24 29 50 -0
41 20 36 40 12
37 40 72 98 17
HEMATOMAS
N=37
sex
males females
CUMULATIVE
100-
A SUBACUTE SUBDURAL
9 ACUTE SUBDURAL HEMATOMAS
SURVIVAL RATES
80
N =112
~ZX
60
40
T ""------ O--..-.-.-_._I ...____._._O
20
!
3
days
I
1
month
I
1
year
I
2
I
3
I
1,
I
5
I
6
I~
years TIME OF OBSERVATION
FIG. 1. C u m u l a t i v e survival g r a p h d e m o n s t r a t i n g the difference in survival between patients with acute and subacute subdural h e m a t o m a s .
J. Neurosurg. / Volume 48 / March, 1978
347
j. RosenFrn and F. Gjerris TABLE 3 Social, mental, and neurological conditions in 45 patients with acute and subacute subdural hematomas surviving 2 to 12 years after operation
Social Status workingor in school disability pension or in nursing home total
Mental State
Good
Fair Poor
Total
Cases
Fair Poor
19
5
0
20
4
0
24
0
14
7
4
10
7
21
19
19
7
24
14
7
45
mental, and social status is shown in Table 3. Of these patients, 24 are back at work or in school, and 21 receive disability pension or are institutionalized. O f the 24 patients who are at work, 12 had an acute and 12 a subacute subdural hematoma, so that in all, 11% of the patients with an acute subdural hematoma went back to work, as against 32% of the patients with subacute hematomas. Of the total series, only 16% went back to work or school, and only 11% were without any sequelae. The 24 patients who went back to work were on the average unfit for work for a period of 15 weeks after operation: 18 weeks in patients with an acute hematoma, and 12 weeks in patients with a subacute hematoma, respectively. Discussion
Our experience in this study of patients with traumatic subdural hematomas is in agreement with what has been reported during the last 20 years by many authors? ,3,6a~176 All patients with lacerations of the brain, hematomas of a site other than the subdural space, and subdural hygromas 4,~8,23 were excluded from our study. We have confirmed that the prognosis in patients with acute subdural hematomas is poor, with many deaths in the acute stage and within the first m o n t h after head inj u r y ? ,5,6,'5,~7 Only 35% of our patients with acute subdural hematomas were alive after 1 year, and some of these patients died within the next 5 years due to brain contusion or brain compression from the hematoma. None of the patients with a subacute subdural hematoma died as a result of their head injury more than 2 years after the operation, but several died of extracranial diseases in the 348
Neurological State
Good
older age groups. Only 30% of the patients with acute subdural hematomas are alive 5 years after the operation, as against 80% of the patients with subacute subdural hematomas.14, 22 The prognosis is also dependent on the age of the patient at the time of head trauma, 8 and the following signs gave a poor prognosis in our series: unconsciousness, one or two dilated and fixed pupils, low and high systolic blood pressure, and onset of decerebrate rigidity? ,8,8,x~ Dexamethasone in doses of 24 m g / d a y had no effect in these patients. The difference in treatment and mortality has been discussed. Some advocate only burr-hole drainage, others burr-hole drainage followed by craniotomy. Extensive craniotomies have also been tried, e,~a,~~ We have found no difference in mortality or in the quality of life of the survivors between the group treated with burr-hole drainage or the group treated with craniotomy. Very few patients in our series received hyperventilation, diuretics, or massive doses of steroids. It is to be hoped that such treatment may alter the poor prognosis in patients suffering from traumatic acute subdural hematomas. We are in agreement with the pessimistic attitude of many authors regardlng patients with acute subdural hematomas, possibly with the exception of children and younger persons. From our results we can anticipate for future patients with subdural hematomas, selected by the criteria used in the present series, a 5-year survival rate between 10% and 46% in patients with acute subdural h e m a t o m a s , but a 5-year survival rate between 61% and 91% in patients with subacute subdural hematomas. J. Neurosurg. / Volume 48 / March, 1978
Prognosis in acute and subacute subdural hematomas References I. Albert HH, Jammal A, Lanksch W: Erkennung und Prognose der akuten posttraumatischen intrakraniellen H/imatome. Munch Med Wochenschr 111:1145-1151, 1969 2. Andersen B, Bonnevie O: Principper i medicinsk statistik. XI. Sammenligning mellem overlevelsekurver. Nord Med 86: 1388-1391, 1971 3. Bisgaard-Frantzen CF, Dalby M: Acute subdural hematoma. Acta Psychiatr Neurol Scand 32:117-124, 1957 4. Blaauw G: Subdural effusions in infancy and childhood, in Vinken P J, Bruyn GW (eds): Handbook of Clinical Neurology, Vol 24: Injuries of the Brain and Skull, Part II. Amsterdam/NY: North Holland, 1976, pp 329-341 5. Bromowicz J, Mert B: Acute subdural hematoma. Pol Med J 11:1699-1705, 1972 6. Fell DA, Fitzgerald S, Moiel RH, et al: Acute subdural hematomas. Review of 144 cases. J Neurosurg 42:37-42, 1975 7. Gurdjian ES, Thomas LM: Operative Neurosurgery, ed 3. Baltimore: Williams and Wilkins, 1970 8. Hooper R: Patterns of Acute Head Injury. London: Edward Arnold, 1969 9. Jamieson KG: Surgical lesions in head injuries: their relative incidence, mortality rates and trends. Aost NZ J Surg 44:241-250, 1974 10. Jamieson KG, Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37:137-149, 1972 11. Kristiansen K, Tandon P: Diagnosis and surgical treatment of severe craniocerebral injuries. J Oslo City Hosp 10:105-213, 1960 12. Lewin W: The Management of Head Injuries. London: Bailli6re, Tindall and Cassell, 1966 13. Loew F, Wfistner S: Diagnose, Behandlung und Prognose der traumatischen H/imatome des Sch/idelinneren. Acta Neurochir (Suppl V11I):1-158, 1960
J. Neurosurg. / Volume 48 / March, 1978
14. McKissock W, Richardson A, Bloom WH: Subdural haematoma. A review of 389 cases. Lancet 1:1365-1369, 1960 15. McLaurin RL, Tutor FT: Acute subdural hematoma. Review of ninety cases. J Neurosurg 18:61-67, 1961 16. Oka H, Motomochi M, Suzuki Y, et al: Subdural hygroma after head injury. A review of 26 cases. Acta Neurochir 26:265-273, 1972 17. Phillips DG, Azariah RGS: Acute intracranial haematoma from head injury: a study in prognosis. Br J Surg 52:218-222, 1965 18. Ramamurthi B: Acute subdural haematoma, in Vinken P J, Bruyn GW (eds): Handbook of Clinical Neurology, Vol 24: Injuries of the Brain and Skull, Part II. Amsterdam/NY: North Holland, 1976, pp 275-296 19. Ransohoff J, Benjamin MV, Gage EL Jr, et al: Hemicraniectomy in the management of acute subdural hematoma. J Neurosurg 34:70-76, 1971 20. Richards T, Hoff J: Factors affecting survival from acute subdural hematoma. Surgery 75:253-258, 1974 21. Rosenbluth PR, Arias B, Quartetti EV, et al: Current management of subdural hematoma. Analysis of 100 consecutive cases. J A M A 179:759-762, 1962 22. Rowbotham GF: Acute Injuries of the Head. Diagnosis, Treatment, Complications and Sequels, ed 4. Edinburgh/London: E and S Livingstone, 1964 23. Winestock DP, Spetzler RF, Hoff JT: Acute, post-traumatic subdural hygroma. Natural course with angiographic documentation. Radiology 115:373-375, 1975
Address reprint request to: Flemming Gjerris, M.D., University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
349
Long-term follow-up review of patients with acute and subacute subdural hematomas JARL ROSEN~RN, M . D . , AND FLEMMING GJERRIS, M.D.
Department of Neurosurgery, Bispebjerg Hospital, Copenhagen, Denmark o,' The authors present 149 patients suffering from acute (112) and subacute (37) subdural hematomas admitted during the 10-year period 1965 to 1974, with a follow-up period of 2 to 12 years. During the time of observation, 104 patients died and 45 survived; 73% of the patients with acute and 27% with subacute subdural hematomas died. Of the patients with an acute subdural hematoma, 11% went back to work, as against 32% of those with subacute subdural hematomas. The 5-year survival rate was 28% in patients with acute and 76% in patients with subacute subdural hematomas. KEY WORDS
9 subdural h e m a t o m a
S
UBDURAL hematomas are arbitrarily grouped as acute, subacute, or chronic. This distinction is of value in determining the prognosis, and is based on the interval from t r a u m a to development of symptoms from the h e m a t o m a s . 7,13,14,21,22 The overall mortality of patients with acute and subacute subdural hematomas has always been high, ~8 and this is still the most common finding in reports from the last decade, in spite of the introduction of steroids, diuretics, hyperventilation, and decompression to treat edema? ,6'9,11,~5 The mortality reported is about 50% to 70% in patients with acute and 25% to 35% in patients with subacute subdural hematomas, but in most reports the follow-up study is very short and includes less than 100% of the series. The main purpose of the present investigation was to study the symptoms and treatment of a consecutive series of patients with acute and subacute subdural hematomas, and to evaluate the quality of survival and the long-term prognosis resulting from a 100% study. J. Neurosurg. / Volume 48 / March, 1978
9 prognosis
9 survival rate
Clinical Material and M e t h o d s
The case material comprises 149 patients with traumatic acute or subacute subdural hematomas admitted to our department during the 10-year period from April, 1965, to March, 1974. This study is partly retrospective and partly prospective, inasmuch as each of these patients was seen by one of the authors within the last 3 years of the study period. All patients have been followed up either to their death or to the spring of 1976, 2 to 12 years after operation. All hematomas were more than 10 mm thick. N o patients with more extensive lacerations of the brain, with an epidural or intracerebral hematoma, or with an acute subdural hygroma were included in this material. Based on the distinction generally accepted, namely, that a subdural h e m a t o m a is acute if the symptoms caused by it develop within 3 days of trauma, and subacute if the symptoms develop within 3 days to 3 weeks of trauma, 112 of our patients (75%) had an acute subdural hematoma, and 37 had a sub345
j. RosenCrn and F. Gjerris TABLE 1 Distribution of age and sex in 149 patients with acute and subacute subdural hematomas
Age (years) 64 total
Acute Subdural Hematomas Males Females 5 57 15 77
2 21 12 35
acute subdural h e m a t o m a . 14,~a Only a few of our patients with subacute subdural h e m a t o m a s had s y m p t o m s lasting more than 10 days? 3 There were 108 men and 41 women, with ages ranging from 8 months to 88 years (Table 1). The average age at the time of operation was 52 years (50 years for men and 55 for women). In 122 patients the h e m a t o m a was demonstrated by carotid angiography and in 27 by operation alone. The h e m a t o m a was evacuated by burr holes or craniotomy in all cases. Results During the follow-up period, 104 patients died and 45 survived; 48 patients died within the first 3 days after operation, 66 patients died within 1 month, and 81 within 1 year. Ninety patients died as a result of their h e m a t o m a , and the mortality statistics are based on these 90 patients. The remaining 14 died of unrelated causes (five of malignant disease, four of cardiac disease, and five of other causes). In all, 73% of patients with acute subdural h e m a t o m a s and 27% with subacute subdural h e m a t o m a s died. The mortality is shown in Table 2; 55% of the men and 76% of the women died, but the average age at death was higher in females and the acute h e m a t o m a s constituted 85% of the female group. The mortality increased with increasing age in spite of a preponderance of subacute h e m a t o m a s in the oldest age groups. The mortality rate was low in patients who were awake or slightly somnolent, and low when the pupillary conditions were normal or the pupils showed reaction on light stimulation (Table 2). Only one boy who had dilated non-reacting pupils at the time of operation 346
Subacute Subdural Hematomas Males Females -20 11 31
-6 -6
Total No. of Cases 7 104 38 149
survived, and he was in good condition. We found that the prognosis was best when the systolic blood pressure was between 120 and 150 m m H g measured with a brachial cuff, and the pulse rate was between 60 and 90/min. Patients with low blood pressure had a fatal outcome. Only 12 patients showed signs of the typical Cushing response. With the onset of brain-stem attacks the mortality was 86%. A total of 122 arteriograms were reviewed. In most cases the angiograms showed a midline shift, and in 117 cases this was associated with a crescent-shaped avascular zone. In five patients, of whom four had a subacute and one an acute h e m a t o m a , the avascular zone was lens-shaped. In 34 of the 117 patients with a crescentshaped avascular zone on the arteriogram, we found a midline dislocation and elevation of the middle cerebral artery, but no difference in mortality was found between these two groups. N o cases of bilateral h e m a t o m a s were observed. The h e m a t o m a s were evacuated by burrhole drainage in 106 and by craniotomy in 43 patients. N o difference in mortality between these groups could be shown, neither in the acute nor the subacute group. Steroid therapy with d e x a m e t h a s o n e in standard dose was given to 64 patients, but the mortality rate was the same in the treated as in the untreated group. The cumulative survival rates calculated in a c c o r d a n c e with the life table method are shown in Fig. 1. The much better prognosis of patients with subacute subdural h e m a t o m a is seen, with a highly significant difference (p < 0.001). 2 At follow-up study in the spring of 1976, 45 patients had survived; their neurological, J. Neurosurg. / Volume 48 / March, 1978
Prognosis in acute and subaeute subdural hematomas TABLE 2
Mortality (7o) in patients with acute and subacute subdural hematomas in relation to sex, age, and different clinical conditions Acute Subdural Hematomas
Factor
Subacute Subdural Hematomas
Total No.
Deaths
(%)
No. of Cases
Deaths (~o)
No. of Cases
Deaths (7o)
77 35
69 85
31 6
19 33
108 41
55 76
age (years) < 15 15-64 > 64
7 78 27
57 71 85
-26 11
-23 18
7 104 38
57 59 66
level of consciousness awake or slightly somnolent stuporous or comatose
22 90
36 82
28 9
11 56
50 99
22 78
pupillary conditions normal unequal but reacting to light one dilated & fixed both dilated & fixed unknown
20 13 34 40 5
50 46 74 98 40
21 7 2 -7
24 29 50 -0
41 20 36 40 12
37 40 72 98 17
HEMATOMAS
N=37
sex
males females
CUMULATIVE
100-
A SUBACUTE SUBDURAL
9 ACUTE SUBDURAL HEMATOMAS
SURVIVAL RATES
80
N =112
~ZX
60
40
T ""------ O--..-.-.-_._I ...____._._O
20
!
3
days
I
1
month
I
1
year
I
2
I
3
I
1,
I
5
I
6
I~
years TIME OF OBSERVATION
FIG. 1. C u m u l a t i v e survival g r a p h d e m o n s t r a t i n g the difference in survival between patients with acute and subacute subdural h e m a t o m a s .
J. Neurosurg. / Volume 48 / March, 1978
347
j. RosenFrn and F. Gjerris TABLE 3 Social, mental, and neurological conditions in 45 patients with acute and subacute subdural hematomas surviving 2 to 12 years after operation
Social Status workingor in school disability pension or in nursing home total
Mental State
Good
Fair Poor
Total
Cases
Fair Poor
19
5
0
20
4
0
24
0
14
7
4
10
7
21
19
19
7
24
14
7
45
mental, and social status is shown in Table 3. Of these patients, 24 are back at work or in school, and 21 receive disability pension or are institutionalized. O f the 24 patients who are at work, 12 had an acute and 12 a subacute subdural hematoma, so that in all, 11% of the patients with an acute subdural hematoma went back to work, as against 32% of the patients with subacute hematomas. Of the total series, only 16% went back to work or school, and only 11% were without any sequelae. The 24 patients who went back to work were on the average unfit for work for a period of 15 weeks after operation: 18 weeks in patients with an acute hematoma, and 12 weeks in patients with a subacute hematoma, respectively. Discussion
Our experience in this study of patients with traumatic subdural hematomas is in agreement with what has been reported during the last 20 years by many authors? ,3,6a~176 All patients with lacerations of the brain, hematomas of a site other than the subdural space, and subdural hygromas 4,~8,23 were excluded from our study. We have confirmed that the prognosis in patients with acute subdural hematomas is poor, with many deaths in the acute stage and within the first m o n t h after head inj u r y ? ,5,6,'5,~7 Only 35% of our patients with acute subdural hematomas were alive after 1 year, and some of these patients died within the next 5 years due to brain contusion or brain compression from the hematoma. None of the patients with a subacute subdural hematoma died as a result of their head injury more than 2 years after the operation, but several died of extracranial diseases in the 348
Neurological State
Good
older age groups. Only 30% of the patients with acute subdural hematomas are alive 5 years after the operation, as against 80% of the patients with subacute subdural hematomas.14, 22 The prognosis is also dependent on the age of the patient at the time of head trauma, 8 and the following signs gave a poor prognosis in our series: unconsciousness, one or two dilated and fixed pupils, low and high systolic blood pressure, and onset of decerebrate rigidity? ,8,8,x~ Dexamethasone in doses of 24 m g / d a y had no effect in these patients. The difference in treatment and mortality has been discussed. Some advocate only burr-hole drainage, others burr-hole drainage followed by craniotomy. Extensive craniotomies have also been tried, e,~a,~~ We have found no difference in mortality or in the quality of life of the survivors between the group treated with burr-hole drainage or the group treated with craniotomy. Very few patients in our series received hyperventilation, diuretics, or massive doses of steroids. It is to be hoped that such treatment may alter the poor prognosis in patients suffering from traumatic acute subdural hematomas. We are in agreement with the pessimistic attitude of many authors regardlng patients with acute subdural hematomas, possibly with the exception of children and younger persons. From our results we can anticipate for future patients with subdural hematomas, selected by the criteria used in the present series, a 5-year survival rate between 10% and 46% in patients with acute subdural h e m a t o m a s , but a 5-year survival rate between 61% and 91% in patients with subacute subdural hematomas. J. Neurosurg. / Volume 48 / March, 1978
Prognosis in acute and subacute subdural hematomas References I. Albert HH, Jammal A, Lanksch W: Erkennung und Prognose der akuten posttraumatischen intrakraniellen H/imatome. Munch Med Wochenschr 111:1145-1151, 1969 2. Andersen B, Bonnevie O: Principper i medicinsk statistik. XI. Sammenligning mellem overlevelsekurver. Nord Med 86: 1388-1391, 1971 3. Bisgaard-Frantzen CF, Dalby M: Acute subdural hematoma. Acta Psychiatr Neurol Scand 32:117-124, 1957 4. Blaauw G: Subdural effusions in infancy and childhood, in Vinken P J, Bruyn GW (eds): Handbook of Clinical Neurology, Vol 24: Injuries of the Brain and Skull, Part II. Amsterdam/NY: North Holland, 1976, pp 329-341 5. Bromowicz J, Mert B: Acute subdural hematoma. Pol Med J 11:1699-1705, 1972 6. Fell DA, Fitzgerald S, Moiel RH, et al: Acute subdural hematomas. Review of 144 cases. J Neurosurg 42:37-42, 1975 7. Gurdjian ES, Thomas LM: Operative Neurosurgery, ed 3. Baltimore: Williams and Wilkins, 1970 8. Hooper R: Patterns of Acute Head Injury. London: Edward Arnold, 1969 9. Jamieson KG: Surgical lesions in head injuries: their relative incidence, mortality rates and trends. Aost NZ J Surg 44:241-250, 1974 10. Jamieson KG, Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37:137-149, 1972 11. Kristiansen K, Tandon P: Diagnosis and surgical treatment of severe craniocerebral injuries. J Oslo City Hosp 10:105-213, 1960 12. Lewin W: The Management of Head Injuries. London: Bailli6re, Tindall and Cassell, 1966 13. Loew F, Wfistner S: Diagnose, Behandlung und Prognose der traumatischen H/imatome des Sch/idelinneren. Acta Neurochir (Suppl V11I):1-158, 1960
J. Neurosurg. / Volume 48 / March, 1978
14. McKissock W, Richardson A, Bloom WH: Subdural haematoma. A review of 389 cases. Lancet 1:1365-1369, 1960 15. McLaurin RL, Tutor FT: Acute subdural hematoma. Review of ninety cases. J Neurosurg 18:61-67, 1961 16. Oka H, Motomochi M, Suzuki Y, et al: Subdural hygroma after head injury. A review of 26 cases. Acta Neurochir 26:265-273, 1972 17. Phillips DG, Azariah RGS: Acute intracranial haematoma from head injury: a study in prognosis. Br J Surg 52:218-222, 1965 18. Ramamurthi B: Acute subdural haematoma, in Vinken P J, Bruyn GW (eds): Handbook of Clinical Neurology, Vol 24: Injuries of the Brain and Skull, Part II. Amsterdam/NY: North Holland, 1976, pp 275-296 19. Ransohoff J, Benjamin MV, Gage EL Jr, et al: Hemicraniectomy in the management of acute subdural hematoma. J Neurosurg 34:70-76, 1971 20. Richards T, Hoff J: Factors affecting survival from acute subdural hematoma. Surgery 75:253-258, 1974 21. Rosenbluth PR, Arias B, Quartetti EV, et al: Current management of subdural hematoma. Analysis of 100 consecutive cases. J A M A 179:759-762, 1962 22. Rowbotham GF: Acute Injuries of the Head. Diagnosis, Treatment, Complications and Sequels, ed 4. Edinburgh/London: E and S Livingstone, 1964 23. Winestock DP, Spetzler RF, Hoff JT: Acute, post-traumatic subdural hygroma. Natural course with angiographic documentation. Radiology 115:373-375, 1975
Address reprint request to: Flemming Gjerris, M.D., University Clinic of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
349
