Hematoma subdural crónico / Chronic subdural hematoma

El hematoma subdural crónico (HSC) es una patología neuroquirúrgica frecuente, que se reconoce como consecuencia de traumatismos craneoencefálicos de poca magnitud que habitualmente se diagnostican en pacientes seniles, aunque puede presentarse en pacientes jóvenes y sin antecedentes de traumas.El objetivo que persigue este trabajo es la presentación de una paciente con un HSC bilateral, con características poco usuales.Caso clínico: se presenta una paciente del sexo femenino, de 46 años de edad, sin antecedente de traumatismo craneal ni de otra patología concomitante, que consulta por una cefalea de 15 días de evolución. El examen físico constató midriasis, pupila de Hutchinson, papiledema bilateral y exoforia del ojo derecho, parálisis del tercer par craneal y ataxia de tronco, fue catalogada con Glasgow 13. Se realizó tratamiento anti edema cerebral temprano y las manifestaciones desaparecieron en gran medida. En la Tomografía axial computarizada se diagnosticó un hematoma subdural frontotemporal bilateral con desplazamiento de las estructuras de la línea media a la izquierda. Fue operada de urgencia y dada de alta completamente recuperada tres días después.Conclusión: el HSC puede presentarse con distintas formas clínicas, simulando procesos expansivos tumorales, ataques cerebrovasculares, demencias o entidades neurológicas de otra índole. El manejo del caso por clínicos y neurocirujanos fue rápido y efectivo, lo que explica que la paciente tuvo una recuperación temprana y total. En estos casos la actuación médica es decisiva en el éxito del tratamiento.

Chronic subdural hematoma (CSH) is a common neurosurgical pathology that is recognized as a consequence of minor head injuries that are usually diagnosed in senile patients, although it can occur in young patients without a history of trauma.The objective of this work is the presentation of a patient with a bilateral CSH, with unusual characteristics.Clinical case: a 46-year-old female patient with no history of head trauma or other concomitant pathology is presented, who consulted for a 15-day-old headache. Physical examination confirmed mydriasis, Hutchinson's pupil, bilateral papilledema and exophoria of the right eye, third cranial nerve palsy, and trunk ataxia. She was cataloged with Glasgow 13. Early anti-cerebral edema treatment was performed and the manifestations largely disappeared. A computed tomography scan diagnosed a bilateral fronto temporal subdural hematoma with displacement of the midline structures to the left. She underwent emergency surgery and was discharged completely recovered three days later. Conclusion: HSC can present with different clinical forms, simulating expansive tumor processes, cerebrovascular attacks, dementias or neurological entities of another nature. The case management by clinicians and neurosurgeons was quick and effective, which explains that the patient had an early and complete recovery. In these cases, medical action is decisive in the success of the treatment.

Analysis of predisposing factors for chronic subdural hematoma recurrence

SUMMARY OBJECTIVES: To identify recurrence and its potential predisposing factors in a series of 595 patients with an initial diagnosis of Chronic Subdural Hematoma (CSDH) who underwent surgical treatment at a Reference Hospital of São Paulo. METHODS: A retrospective descriptive study, in which the medical records of all patients with a CSDH diagnosis submitted to surgical treatment from 2000 to 2014 were analyzed. RESULTS: The final study population consisted of 500 patients with a diagnosis of CSDH (95 patients with a diagnosis of Cystic Hygroma were excluded), of which 27 patients presented recurrence of the disease (5.4%). There were no statistically significant differences in relapses when cases were stratified by gender, laterality of the first episode or surgical procedure performed in the first episode (trepanning vs. craniotomy). It was possible to demonstrate an age-related protective factor, analyzed as a continuous variable, regarding the recurrence of the CSDH, with a lower rate of recurrence the higher the age. CONCLUSIONS: The results indicate that, among possible factors associated with recurrence, only age presented a protective factor with statistical significance. The fact that no significant difference between the patients submitted to trepanning or craniotomy was found favors the preferential use of burr-hole surgery as a procedure of choice due to its fast and less complex execution.

RESUMO OBJETIVOS: Identificar a taxa de recidiva e seus potenciais fatores predisponentes em série de 595 pacientes consecutivos com diagnóstico inicial de hematoma subdural crônico (HSDCr) submetidos a tratamento cirúrgico em hospital terciário de São Paulo nos últimos 14 anos. MÉTODOS: Estudo retrospectivo descritivo, no qual foram analisados os prontuários de todos os pacientes com diagnóstico de HSDCr submetidos a tratamento cirúrgico, no período de 2000 a 2014. RESULTADOS: A amostra final consistiu em 500 pacientes com diagnóstico de HSDCr — foram excluídos 95 pacientes com diagnóstico de higroma cístico —, dos quais 27 sujeitos apresentaram recidiva do quadro (5,4%). Não foram observadas diferenças estatisticamente significativas nas recidivas quando os casos foram estratificados por gênero, lateralidade do primeiro episódio ou procedimento cirúrgico executado no primeiro episódio (trepanação vs. craniotomia). Foi possível demonstrar um fator protetor relacionado à idade, analisado como variável contínua, no que diz respeito à recidiva do HSDCr, com menor taxa de recidiva com o avançar desta CONCLUSÕES: Os resultados indicam que, dentre os fatores possivelmente associados à recidiva, apenas a idade se apresentou como fator protetor com significância estatística. O fato de não ser demonstrada diferença significativa entre os pacientes submetidos a tratamentos cirúrgicos por trepanação ou por craniotomia favorece o uso preferencial da trepanação como procedimento de escolha, em virtude de apresentar execução rápida e menos complexa.

Hematoma subdural crônico em adultos jovens / Subdural Hematoma Chronic in Young Adults

Objetivo O hematoma subdural crônico em adultos jovens é relativamente frequente, sendo tipicamente encontrado em idosos. Os principais fatores relacionados ao hematoma subdural crônico em adultos jovens são: derivação ventriculoperitoneal, cisto aracnóideo, uso de droga anticoagulante, coagulopatias e esportes vigorosos. O prognóstico depende da idade do paciente, do estado neurológico na admissão, das doenças sistêmicas associadas, assim como do diagnóstico preciso e tratamento adequado. Métodos Foram incluídos pacientes de ambos os gêneros, da faixa etária de 20 a 45 anos de idade, com diagnóstico confirmado de hematoma subdural crônico. Resultados Foram analisados 34 pacientes no período de janeiro de 2005 a dezembro de 2013. O gênero masculino teve 25 e o feminino 9 casos. As causas foram: traumatismo cranioencefálico (20 pacientes), etilismo (7), crises convulsivas (3) e raquianestesia (2); as causas permaneceram desconhecidas em 2 pacientes. A tomografia computadorizada foi realizada em todos os pacientes e a ressonância magnética em 2 deles. Localização unilateral em 30 e bilateral em 4. Foram tratados cirurgicamente 28 pacientes e 6 receberam tratamento conservador. Tiveram boa evolução 27 pacientes, 4 apresentaram déficit neurológico focal, 2 apresentaram crise convulsiva e houve um óbito. Conclusões O hematoma subdural crônico é frequente em adultos jovens. O traumatismo cranioencefálico e etilismo crônico foram as principais causas de hematoma subdural crônico em jovens. Acomete mais o gênero masculino. O tratamento de escolha é cirúrgico. O prognóstico é bom.

Objective Chronic subdural hematoma in young adults is relatively common, typically found in the elderly. The main factors related to chronic subdural hematoma in young adults are: ventriculoperitoneal shunt, arachnoid cyst, anticoagulant drug, coagulopathies and vigorous sports. The prognosis depends on the patient's age, neurological status on admission, associated systemic diseases, as well as the accurate diagnosis and proper treatment. Methods Patients of both sexes were included with 20-45 years of age with a confirmed diagnosis of chronic subdural hematoma. Results 34 patients were analyzed from January 2005 to December 2013. Males reported 25 cases and 9 female. The causes were 20 traumatic brain injury, alcoholism 7, 3 seizures, spinal anesthesia 2 and unknown 2 patients. Computed tomography was performed in all patients and magnetic resonance imaging in 2 cases. Location unilateral in 30 and bilateral in 4. Surgically and 28 patients were treated conservative 6. Twenty-seven patients improved, four had focal neurological deficits, seizures two and one case died. Conclusions The chronic subdural hematoma is common in young adults. The craniocerebral trauma and chronic alcohol consumption were the main causes of chronic subdural hematoma in young. It affects more males. The treatment of choice is surgery. The prognosis is good.

Paralisia do nervo oculomotor como manifestação inicial de hematoma subdural crônico ? Relato de caso / Oculomotor nerve palsy as initial manifestation of chronic subdural hematoma ? Case report

A presença de paralisia do nervo oculomotor (NOM) sem outro déficit neurológico é considerada rara como forma de apresentação em hematoma subdural crônico (HSDC). Geralmente apresenta sintomas de déficit neurológico focal, cefaleia e alterações do nível de consciência, havendo múltiplos diagnósticos diferenciais. RTA, 79 anos, masculino. Paciente com demência senil, hipertensão arterial sistêmica e diabetes mellitus. Estado geral: moderado. Exame físico: sonolento, eupneico. Exame neurológico: disfásico e anisocoria esquerda. Tomografia computadorizada (TC) de crânio sem contraste revelou lesão com densidade heterogênea na região frontoparietotemporal esquerda com efeito de massa e hipodensa na região frontoparietal direita. Submetido a trépano-punção frontal anterior e parietal posterior esquerda e drenagem do hematoma. Evoluiu com melhora da paralisia do NOM à esquerda. Em caso de HSDC volumoso, pode-se comprimir o mesencéfalo e apresentar-se herniação do uncus do hipocampo, podendo causar paralisia do NOM. Seu diagnóstico precoce e tratamento correto apresentam bons resultados...

The presence of complete paralysis of the oculomotor nerve (OMN) with no other neurological deficit is rare as the presentation of chronic subdural hematoma (CSDH). Usually there are symptoms of focal neurologic deficit, headache and changing consciousness level, so there are multiple differential diagnoses. RTA, 79-year-old man. Patient who has senile dementia, hypertension and diabetes mellitus. General condition: moderate. Physical examination: sleepy, eupneic. Neurological examination: dysphasia and anisocoria left eye. Computed tomography (CT) scan without contrast revealed a lesion with heterogeneous density in the left frontoparietotemporal region, with mass effect and hipodense region right parietofrontal. The patient was submited to trepano-punction at left anterior frontal and posterior parietal and drainage of the hematoma. He evolved with neurological improvement of the paralysis of OMN on the left eye. The CSDH when it was large, can compress the midbrain and provide herniation of hippocampus? uncus may cause paralysis of the OMN. Early diagnosis and correct treatment has shown good results...

Hematoma subdural crónico: análisis de 95 casos / Chronic subdural hematoma: analysis of 95 cases

El Hematoma Subdural crónico es una patología relativamente frecuente que predomina en adultos mayores. Es de inicio insidioso, su diagnóstico se basa en el cuadro clínico y estudios radiológicos como la tomografía computarizada (TAC), el manejo es predominante quirúrgico y su pronóstico es bueno. Se analiza en el presente estudio, una muestra de 95 expedientes clínicos de pacientes con dicho diagnóstico, síntomas iniciales, TAC pre y post diagnóstico, tratamiento y evolución...

Apresentaçao clínica e prognóstico dos pacientes com hematoma subdural crônico / Relation between clinical presentation and prognosis in chronic subdural hematoma patients

Introdução: O hematoma subdural crônico é considerado uma das lesões neurocirúrgicas que apresenta bom prognóstico. Os autores apresentam sua experiência sobre apresentação clínica e prognóstico. Pacientes e métodos: Foram analisados, retrospectivamente, 60 casos de hematoma subdural crônico entre janeiro de 2002 e junho de 2008. Os dados analisados foram características demográficas, quadro clínico, tratamento, complicações e prognóstico. Resultados: A idade variou entre 38 e 82 anos, com média de 58 anos. Houve predomínio do sexo masculino com relação masculino:feminino de 2,53:1. A localização foi unilateral em 49 casos e bilateral em 11 casos. Fatores predisponentes: traumatismo craniano (30), alcoolismo crônico (14), uso de anticoagulante oral (6), outras causas (6) e desconhecido (4). Apresentações clínicas foram: acidente vascular cerebral (16), hipertensão intracraniana (12), distúrbios psiquiátricos (11), síndrome piramidal (8), crises convulsivas (8), sintoma extrapiramidal (4) e hemorragia subaracnóidea (2). Tratamento cirúrgico foi realizado em 58 casos. Os casos de alcoolismo crônico associados à apresentação psiquiátrica tiveram péssimo prognóstico, seguidos dos casos de uso de anticoagulantes orais associados a hipertensão intracraniana. Os resultados foram ótimos em casos de hematoma subdural crônico associados a hipertensão intracraniana e nos casos com clínica piramidal e extrapiramidal. Cinco pacientes foram a óbito (dois por intercorrências cirúrgicas, dois por doenças sistêmicas e um por infecção hospitalar). Conclusão: O hematoma subdural crônico manifesta-se por formas clínicas variadas, seu prognóstico encontra-se diretamente relacionado à causa básica, apresentação clínica e tratamento.

Management and outcome of chronic subdural haematoma

To analyze overall outcome in chronic subdural haematoma and study the results of different surgical methods employed to treat this condition. This prospective, descriptive observational study was carried in the Department of Neurosurgery, Nishtar Medical College and Hospital, Multan from October 2007 to April 2008. A total of 60 patients were included in the study. Out of 60 patients, 44 [73%] were male and 16 [27%] were female. 60% patients presented with history of minor trauma to he head in road traffic accidents, falls and slips in bath rooms of different durations, usually more than 2 weeks. The chronic subdural haematoma is a surgical lesion. The burr-holes aspiration under local anesthesia is the perfect surgical method in most of the cases

Development of chronic subdural haematoma: a reminder to its pathogenesiss

A patient of road traffic accident was noted to have contusions, which in due course of time resolved and he improved, but never became fully all right. He was treated conservatively. Two months later, he presented with a short history of progressive hemiparesis and difficulty in walking. He was detected to have a large chronic subdural haematoma. He was treated with burr hole evacuation with which he improved. The case is discussed and hypothesis about its evolution and progression are discussed highlighting the unpredictabillty in its development. A high index of suspicion is the only key to anticipate and diagnose this neurological chameleon

The fate of traumatic subdural hygroma in serial computed tomographic scans

We reviewed serial computed tomographic (CT) scans of 58 patients with traumatic subdural hygroma (SDG) to investigate its natural history. All were re-evaluated with a special reference to the size and density of SDG. Thirty-four patients (58.6%) were managed conservatively and 24 patients (41.4%) underwent surgery. The lesion was described as remained, reduced, resolved, enlarged and changed. Means of interval from injury to diagnosis and any changes in CT were calculated. SDGs were resolved in 12 (20.7%), reduced in 15 (25.9%), remained in 10 (17.2%), enlarged in 2 (3.4%), and changed into chronic subdural hematoma (CSDH) in 19 patients (32.8%). SDG was diagnosed at 11.6 days after the injury. It was enlarged at 25.5 days, remained at 46.0 days, reduced at 59.3 days, resolved at 107.5 days, and changed into CSDH at 101.5 days in average. SDGs were developed as delayed lesions, and changed sequentially. They enlarged for a while, then reduced in size. The final path of a SDG was either resolution or CSDH formation. Nearly half of SDGs was resolved or reduced within three months, however, 61.3% of unresolved or unreduced SDG became iso- or hyperdense CSDH. These results suggest that the unresolved SDG is the precursor of CSDH.