A pediatric chronic subdural hematoma: Case Report and Literature Review

Abstract

Chronic SDH is one of the most frequent pathologies in neurosurgery.  Its etiopathogenesis and adequate treatment remain poorly known despite actual investigation. The origin of CSDH is usually a sub dural hygroma (SDG), although a few cases are caused by acute subdural haematomas (ASDH). Since the ASDH is usually absorbed within a few weeks, only  some cases of an acute sub dural heamatoma become CSDHs, when there is a sufficient potential subdural space. We report a  rare case of a chronic subdural hematoma developed from an acute subdural hematoma treated surgically with a good outcome.

Key words : Pathogenesis of CSDH, Origin of CSDH, Relation among  sub dural lesions

Introduction

Chronic sub dural hematoma is one of the most frequent pathologies in neurosurgery. Its etiopathogenesis and adequate treatment remain poorly known despite  actual  investigation.

Cases of chronic subdural hematoma developed from an acute subdural hematoma with rapid onset of clinical symptoms have been rarely reported in the literature.

Case report

73-year-old patient with history  of chronic alcoholism and Alzheimer's disease, presented to emergency with headache, which was worsening over the last month before his admission to the hospital. There was no history of head trauma and physical examination was unremarkable for neurological deficits. Brain computed tomography (CT) scan demonstrated a spontaneously  left hyperdense hemispheric subdural hematic collection measuring  8mm in thickness ,  without mass effect.

A patient underwent conservative medical treatment, including rehydration and corticosteroids, for one week. After two weeks, he was readmitted to the emergency with left unilateral mydriasis and right hemiparesis. A CT scan showed a 13mm thick hypo dense left hemispheric subdural hematic collection, with signs of recent bleeding. An emergency surgery was performed, and the hematoma was evacuated through a burr hole. The patient showed good neurological recovery after the surgery, and a control cerebral CT scan showed total regression of the hematoma one month later.

FIG.1  (a, b) :  Brain CT scan showed a left hemispheric sub dural collection which apparead hyperdense to CSF (black arrow)

FIG.2  (c, d) : Brain CT scan demonstrated a left hemispheric large sub dural collection which apparead hypordense to CSF (red arrow) with recent Signs of recent rebleeding  within the hematoma.

FIG.3  (e, f) :    Brain CT scan demonstrated total regression of CSDH after evacuation and drainage

Discussion

Chronic SDH is one of the most frequent pathologies in neurosurgery.  Its etiopathogenesis and adequate treatment remain poorly unclear.

The origin of CSDH is usually a sub dural hygroma (SDG), although  few cases are caused by an acute subdural haematomas (ASDH). 

ASDH is usually absorbed by redistribution of blood to other sites within a few weeks. However,  some  cases  become chronic , when there is a sufficient potential subdural space.

In a retrospectively analyzed series of 177 patients, Lee and colleagues (2) compared 16 patients (9%) in whom no operatively managed ASDH progressed to CSDH requiring surgical evacuation with 161 patients in whom ASDH resolved with conservative management. In this study, he  found that older age and larger hematoma size were associated with progression of ASDH to symptomatic CSDH. They did not find a correlation with use of anticoagulant or antiplatelet agents.

K S Lee et al (3),  tried to find a certain relationship among  three subdural lesions, sub dural hygroma, acute and chronic sub dural heamatoma in 436 consecutive patients. He concluded that a half of CSDHs may originate from ASDHs.

The exact cause of acute SDH and the origin of the bleeding are unclear in our reported  case; it  would probably be related to vascular fragility due to chronic alcoholism and the patient's age. However, its transformation to CSDH is probably related to microvascular proliferation within the hematoma.

The development of microvascular proliferation within the clots of acute SDH can leads to its rapid expansion and then its transformation into an organized chronic subdural heamatoma. In addition, the period of transformation of acute sub dural hematoma into symptomatic chronic HSD is faster than the development time of the novo chronic sub dural hematoma ranging from 4 to 6 weeks. So, surgically evacuation and drainage is mandatory.

Conclusion

Chronic sub dural heamatoma developed from an acute sub dural heamatoma is very rare entity. Only few cases are reported in the literature.

Surgical evacuation through an enlarged burr hole  is the appropriate method.

References

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   Origin of chronic subdural haematoma and relation to traumatic subdural lesions. Brain Inj. 12:901–10.

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   Relations among traumatic subdural lesions. J Korean Med Sci ;11(1):55-

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