Documente Academic
Documente Profesional
Documente Cultură
Faculty of Medicine
Postgraduate Medical Studies Board
By
Dr. Faiz A.S Kadhim
M.B. Ch.B. (University of Al Mustansiriyah, Iraq)
Supervisor
Dr. Hago Mustafa Ali
Consultant Radiologist (MD)
Co-supervisor
Prof. Mohammed Abdel Rahman Arbab
Consultant Neurosurgeon
Faculty of Medicine
University of Khartoum
1
) (
- )(269
Faiz
encouragement
and
much
valuable
advice
am
greatly
indebted
to
my
co-supervisor
Prof.
working
staff
in
Emergency
Department
of
ABBREVIATIONS
SDH
Subdural hematoma
ASDH
SDHs
Subdural hematomas
CSDH
ATSDH
PCA
CBF
CSF
Cerebrospinal fluid
GCS
TIA
CT
Computed Tomography
ICP
Intracranial Pressure
MRI
RBCs
T1 -WIs
T1 weighted images
T2 -WIs
T2 weighted images
3D
Three dimension
IHD
ABSTRACT
This prospective study was conducted between
January 2003 to January 2004 in National Center of
Neurological Sciences (Al Shaab Teaching Hospital), to deal
with postoperative immediate outcome of patients with
subdural hematoma in correlation with CT scan findings
and clinical presentation. One hundred randomly selected
patients with 116 subdural hematomas were operated on
depending upon CT scan findings.
The age range for the study group was 37-90 years
with a mean of 65 years.
Of the total (100 patients), male to female ratio was
9:1 (90:10). Thirty-six patients (36%) did not have any
history of trauma, 44 (44%) patients with history of a minor
trauma and 20 (20%) patients were sustained with a
relatively severe trauma.
Eighty-five (85%) patients had CT scan finding of
brain atrophy. Seventy-eight patients (78%) had unilateral
SDHs and 22 (22%) patients with bilateral SDHs.
correlation
is
present
with
the
clinical
2003 2004
) (
) (
.
100 116
: 65
%36 1:9 %44
%20 .
%85 :
%78 %20 %15.5
) 18( 64) %55.2 ( 34) %29.3(
.
.
.%6
.
LIST OF FIGURES
Page No.
Fig. (1) Distribution of study population according to age
32
33
34
35
36
37
38
10
LIST OF TABLES
Page No.
Table (1) Distribution of study populations according
to the mean age
39
Table (4)
40
41
43
42
44
45
Table (9)
46
47
11
CONTENTS
Page
Dedication .....................................................................................I
Acknowledgment............................................................................. II
Abbreviations............................................................................III
Abstract..............................................................................IV
Abstract (Arabic) .............................................................................VI
List of figures .........................................VII
List of tables..................................................................VIII
CHAPTER ONE
INTRODUCTION AND LITERATURE REVIEW .....................1
OBJECTIVES...........................................................................24
CHAPTER TWO
PATIENTS & METHODS .................................................25
CHAPTER THREE
RESULTS .............................................................27
CHAPTER FOUR
DISCUSSION...........................................................................48
CONCLUSION ...........................................................56
RECOMMENDATIONS ....................................57
REFERENCES...........................................................58
APPENDIX (Questionnaire)
12
1.1. Definition:
Subdural haematoma (SDH) is abnormal blood
collection or its breakdown between the inner layer of dura
and arachnoid membrane.(1)
The hyperacute phase of an SDH is within the first
day after injury.(1)
Acute SDHs are less than 3 days old. Subacute
SDHs are 3-20 days old. Chronic SDHs are older than 3
weeks.(2)
Clinically, SDHs behave as acute haematomas when
less than 1 week old and as chronic hematomas when they
are older than one week old.(3)
margin;
and
the
straight
sinus
runs
along
its
14
1.3. Pathophysiology:
ASDH usually develops by one of three mechanisms:
surrounding
the
hematoma
can
bleed
begins
to
decrease;
small
increase
in
pressure,
leading
to
decreased
cerebral
which
was
caused
by
increased
intracranial pressure.(6)
The trauma is often less significant than that
required to produce an extradural hematoma. Fractures are
infrequently seen, and the bleeding may be venous and at a
lower pressure. Arterial bleeding, in severe trauma may
however, also produce a subdural collection.(7)
1.4. Incidence:
-
19
20
included:
subarachnoid
dementia,
hemorrhage,
stroke,
meningitis
TIA,
and
initial
neurologic
examination
provides
an
score,
it
also
provides
important
prognostic
information.(6)
Signs of external trauma alert the physician to the
expected location of coup or countercoup injuries on CT
scan.(2)
GCS score less than 15 after blunt head trauma, in
patient with no intoxicating substance used for impaired
mental status baseline), warrant consideration of an urgent
CT scan.(2)
21
trauma
is
ominous
and
requires
an
emergent
explanation.(2)
1.6. Work-up:
1.6.1 Lab studies:
Coagulation profile.
Electrolytes.(2)
1.6.2 Imaging studies:
1.6.2.1 Plain radiographs:
A
chronic
extracerebral
hematoma
may
be
show
focal
expansion,
often
bilateral
and
the
injury
has
occurred
early in
life,
and
of
old
trauma,
fractures,
burr
holes...etc
are
making
management
diagnosis
purposes.(1)
and
suffice
Modern
CTs
for
immediate
can
produce
2.
3.
Disseminated
intravascular
coagulopathy.(13)
24
4.
Tears
in
the
arachnoid
membrane,
hyperacute
phase:
comprises
primarily
gray
matter
on
T1-weighted
images
and
reason
for
this
include
active
bleeding
with
subacute
phase:
During
this
time
hematoma
differs
in
appearance
on
MRI.
ferritin
and
hemosiderin
deposition
in
differs
from
that
seen
in
chronic
intra-axial
1.7. Treatment:
The clinical status of the patient determines the type
of management. Small acute SDH less than 5 mm thick on
axial CT images, without sufficient mass effect to cause
midline
shift
or
neurological
signs,
can
be
followed
clinically.(3)
Emergent medical treatment of an acute SDH, that
causes impending transtentorial herniation, is the bolus
administration of mannitol therapy. Surgical evacuation of
the lesion is the definitive treatment and should not be
delayed.(3)
Chronic SDH without mass effect on imaging studies
and no neurological symptoms or signs except mild
headache, can be followed with serial scans and may
resolve. No medical therapy has been shown to be effective
in expediting rapid resolution of chronic SDHs.(3)
A thin layer under 1 cm may be reasonably tolerated
by the patient, but when the hematoma exceeds 1 cm it is
30
has
been
advocated
when
SDH
1.8. Complications:
1.8.1. Postoperative complications:
Elevated ICP.
Brain edema.
Infection.
Seizures.(2)
1.10. Prognosis:
department
evaluation.
Ultimate
31
is
injury
pupillary
and
pupillary
reaction
to
light
inequality.
also
Age
correlate
and
with
pressure
factors
monitoring
(elevated
ICP
are
important
postoperatively
No
method
of
assessing
prognosis
is
100%
accurate.(6)
CT
is
an
x-ray
examination
characteristics.(15)
32
with
unique
No superimposition of tissues.
1.10.3 CT number:
33
e.g.
Material
water
CT valve
0
Air
- 1000
Bone
~ 1000(16)
1.11. Scales:
1.11.1 Glasgow Coma Scale (GCS):(19)
Assessment of neurologic function based in these
determinants.
Response category
point value
6
34
Localizes stimuli
Abnormal flexion
Extensor response
None
Verbal response :
Oriented
Confused conversation
Inappropriate words
Incomprehensible sounds
None
Eye opening:
Spontaneous
To speech
To noxious stimulation
None
(20)
Meaning
35
OBJECTIVES
2.
3.
4.
36
hundred
signs
hematomas
randomly
and
(SDHs)
symptoms
were
selected
patients
suggesting
admitted
to
the
with
subdural
Emergency
Department of Neurosurgery.
CT
was
introduced
as
an
integral
part
of
admitted
to
the
Neurosurgery
Emergency
Department.
Clinical data was classified as headache, side
weakness, headache and side weaknesses, and headache
with or without side weakness plus other neurologic signs.
CT findings like the number, site, size and age of
haematoma, through its density as well as its mass effects,
like midline shift, ventricular compression, displacement
and effaced sulci or cisterns are noted, as well as any
associated intracranial lesions.
Finally the surgical outcome was assessed at the
time of leaving hospital and was classified according to their
clinical improvement or not, the improvement with or
without neurologic deficit or the patient died.
RESULTS
of
brain
atrophy,
clearly
identifiable
in
supraventricular CT slices.
Fig. 6 demonstrates that 78% of patients (n = 78)
had an unilateral SDH and 22% (n= 22) with bilateral SDH
of different sizes.
Fig. 7 shows that 15.5% (n= 18) of SD collections
were purely hyperdense, 64 SD collections (55.2%) with
mixed density, isodensity or with layering and 29.3%
(n= 34) were purely hypodense.
40
discharged
with
immediate
good
outcome
(n= 4) with GCS (9-12) and one case with GCS (< 8) and
they showed good or partial improvement at the time of
discharge from the hospital.
Table 7 in this table, the patients were classified into
4 subdivision groups of clinical presentation.
The first subdivision had headache only (n = 5; 5%).
The second one had hemiparesis only (n = 17; 17%). The
aforementioned groups showed good or partial immediate
improvement with no dead cases. The third groups included
patients with headache and hemiparesis. The last group had
neurologic
deficit
and
deterioration
in
the
level
of
ii.
The
remaining
dead
cases
43
%
%
%
44
45
Femal
%
Male
%
%
%
Severe trauma
Minor trauma
NO trauma
47
35
%
%
30
%
25
%
20
%
%
%
15
%
10
%
3 Months
Months
48
Month
NO brain atrophy
15%
Brain atrophy
85%
49
Bilateral
22%
Unilateral
78%
50
60.00
%
.%
50.00
%
40.00
%
.%
30.00
%
20.00
%
.%
10.00
%
0.00
%
Hypodensity
Mixed density
Hyperdensity
51
Mi
Maximum
Mean
STD
90
65
11.5
nimum
100
37
52
Table (2) Relation between the midline shift and mass effects on
lateral ventricle and /or sulci
CT
Midline shift
Total
Findings
Unilateral
<5mm
SDH
15
12
31
1 cm
36
38
>1cm
Bilateral
No shift
SDHs
<5 mm
65
100
1 cm
> 1cm
Total
53
26
Unilateral
1 cm
SDH
1.5 cm
10
33
38
2.5 cm
3.0 cm
10
12
22
10
25
65
100
2.0 cm
Bilateral
SDHs
Total
54
Improved
Partially improved
Died
Total
Hyperdensity
11 (11%)
3 (3%)
1 (1%)
15 (15%)
Mixed density
44 (44%)
12 (12%)
3 (3%)
59 (59%)
Hypodensity
18 (18%)
6 (6%)
2 (2%)
26 (26%)
73 (73%)
21 (21%)
6 (6%)
100 (100%)
Total
P. 0.05
55
Partially
Deteriorated
Total
ied
Improvement
SDH
Unilateral
60 (60%)
15 (15%)
3 (3%)
78 (78%)
Bilateral
13 (13%)
6 (6%)
3 (3%)
22 (22%)
Total
73 (73%)
21 (21%)
6 (6%)
100 (100%)
P= 0.13
X2 = 4.0
df. = 2 (insignificant)
56
53
10
53%
10%
GCS :9 - 12
4%
GCS :<8
1%
1%
Not done
15
10
15%
9%
73
21
73%
21%
P= 0.49
X2 = 2.3
64
1%
64%
2%
6%
2
2%
df. = 3 (insignificant)
57
Total
ied
Total
Deteriorated
Improvement
Moderate
Severe
Partially
28
3%
28%
100
6%
58
Month
2 Months
3 Months
or more
Total
P= 0.021
Partially
Deteriorated
ied
Improvement
22
22%
6%
24
24%
4%
15
15%
5%
12
12%
6%
73
21
73%
21%
X2 = 9.6
31
3%
31%
30
2%
30%
21
1%
21%
18
18%
df. = 3 (significant)
59
Total
100
6%
100%
DISCUSSION
60
of the cases were above age of 50 (n= 89: 89%) and 77% of
patients (n=77) were above the age of 60 years (Table 1),
indicating that SDHs is mostly a disease of the aged
patients regardless the relation with other parameters.
In this study the overall male to female ratio was 9:1
(90:10)
indicating
that
males
outnumbered
females
depending
intensities
of
upon
its
blood
ability
from
to
visualize
signal
oxyhaemoglobin,
for
surgical
management
based
on
CT
findings.(4,6).
In cases with bilateral SDHs, some of them (n=9)
showed a midline shift probably related to the asymmetry in
the sizes of SDH, causing a mass effect on ipsilateral lateral
ventricle (Table 2).
In this study, the mass effect on lateral ventricles
was strongly related to the thickness of an SDH, as there
were only 3 cases with a midline shift of 1 cm and showed
no effect on lateral ventricle. Only one case of 78 cases, with
thickness more than 1 cm, showed no midline shift. The
thickness rather than the size of an SDH has mass effect,
this depends on the anatomical fact that an SDH, unlike
epidural haematoma, is not limited by sutures,(4) so an
increase in thickness of SDH means that it is the last event
in the pathogenesis of SDH after complete expansion in all
directions. So any little increase in the thickness would lead
to more mass effect on the adjacent structures and results
in midline shift.
65
or
partial
improvement
had
no
relation
with
start
of
complaint,
CT
diagnosis
and
surgical
for
a small SDH
CONCLUSION
68
RECOMMENDATION
69
REFERENCES
70
1-
2-
P. 1351-52.
http://www.
Grant
eMedicine
P.
Sinson,
Journal
et
al.
2002;
Subdural
3(1).
haematoma,
Available
from
5-
6-
71
7-
8-
Grainger
and
Ellison.
Extra
axial
collection.
In:
10-
1056-
1057.
11-
72
13-
scan.org.
18-
Mark
S.
Greenberg.
Glasgow
outcome
scale.
In:
73
20-
Neurosurgery,
2nd
ed.
New
York:
McGraw-Hill
74
Health
26-
75
University of Khartoum
Faculty of Medicine
Postgraduate Medical Studies Board
Questionnaire:
Correlation between computerised tomography (CT) findings,
clinical presentation and immediate postoperative results in
subdural haematoma
Name:.......................................Age:..........................Sex:.............
.....
Residence:.......................................
...
Date of trauma:.............
Type of trauma: No
Date
of
Minor
CT
Severe
scan:........................
Rad.
center:..................................
Date
of
operation:.......................
Recurrence:..................................
Smoking
Yes
No
- Bleeding disorder
- Alcoholism
-
Diabetes mellitus
Hypertension
Others
CT findings: ..
- Brain atrophy:
Yes
- Number of SDH:
Unilateral
No
Bilateral
- Site of SDH: .
76
Size
of
SDH:
.
- CT number of SDH or density: ..
- Mass effect: Obliterated
LV
Effaced sulci
Any
< 5 mm
associated
1 cm
intracranial
Patient's outcome:
Improvement with no neurologic deficit
- Improvement with neurologic deficit
- Deteriorated
Died
77
>1 cm
lesion:
78