Rapid Resolution of Acute Subdural Hematoma in a Coagulopathic Patient

Abstract

Acute subdural hematoma (aSDH) is associated with a 60-80% mortality rate and is considered a neurosurgical emergency. Although it is most often treated with emergent surgical decompression, patients may be managed conservatively when they are neurologically intact or the hematoma is small. Typical progression of aSDH resolution occurs over weeks, and is characterized by corresponding changes on radiographic imaging where bright aSDH becomes first isointense at about two weeks and then hypointense on noncontrast computed tomogram (CT) head imaging. If there is continued bleeding acutely, however, the SDH may increase in size leading to transtentorial herniation and subsequent clinical deterioration of the patient.Interestingly, there are a number of case reports in the literature describing the event of spontaneous aSDH resolution. Several hypotheses have been put forward to explain this phenomenon including redistribution of subdural blood and dilution by cerebral spinal fluid (CSF) 1 . Cerebral atrophy, as well as cerebral swelling were both identified to facilitate aSDH resolution 2,3 . Here we describe a patient with an unexpected resolution of an acute SDH in the setting of a bleeding diathesis, and propose that in this patient, coagulopathy contributed to the spontaneous resolution of the hematoma. CASE PRESENTATIONOur patient is a 73-year-old gentleman who had acute onset of left-sided weakness. His strength was 4-/5 in the left upper and lower extremities. He was alert and oriented, with stable vital signs. His past medical history was significant for myelodysplastic syndrome with chronic pancytopenia, and atrial fibrillation on warfarin therapy.On admission, significant findings on bloodwork included platelet count of 17 x 10 9 /L and an international normalized ratio (INR) of 1.6. Non-contrast CT head scan performed at the initial evaluation demonstrated a moderate-sized acute subdural hemorrhage over the right convexity ( Figure 1A). He received vitamin K and platelets, and was admitted for observation. Five hours later, his level of consciousness decreased, and he required intubation. A follow-up non-contrast CT head demonstrated dramatic enlargement of the acute SDH with uncal herniation ( Figure 1B). He received a platelet transfusion and the prothrombin complex concentrate on formulary, Octaplex, in anticipation of emergent surgical evacuation. However, the patient's family instead opted for comfort measures.Over

Rapid spontaneous resolution of the acute subdural hematoma: Case series and review of literature

“…[ 20 24 ] The possible explanation could be, coagulopathy prevents formation of well-organized clot, making it susceptible to redistribution by CSF dilution. [ 24 ] The possible association of middle cranial fossa arachnoid cyst and posterior fossa cyst in dandy walker malformation has been mentioned in the literature. Arachnoid tear in cyst wall with mixing of CSF and hematoma has been postulated for the resolution of ASDH in such cases.…”

“…In some cases, neurological condition remained stable[ 8 10 17 21 28 33 ] or improved gradually[ 12 15 16 18 19 24 29 35 ] The death of one such patient reported by Balik et al . had been correlated with hemodynamic instability and sudden cardiac arrest due to sympathetic hyperactivity.…”

Rapid Spontaneous Resolution of Acute Subdural Hematoma in a Patient with Liver Cirrhosis

“…To date, only one case of similar phenomenon has been reported. Chaudhary et al 4) described a similar case of resolution of large SDH in a 73-year-old male with myelodysplastic syndrome. Healthy individuals possess adequate amounts of clotting factors, regulatory proteins, and platelets to achieve optimal clot formation, clot limitation, and dissolution.…”

Rapid Spontaneous Resolution of Large Acute Subdural Hematoma

“…So called “low-density band” between ASDH and skull seen in CT scan suggests such CSF collection. 2 3 4 5 6 7 8 9 10 11 12 13 16 17 19 20) 2) Redistribution of hematoma to another space; contralateral intracranial space, intradiploic space and/or subgaleal space through the skull fracture, spinal subdural space, by raised pressure caused by brain swelling, other intracranial hemorrhages, and/or subdural hematoma itself. 1 3 4 5 6 7 8 9 10 11 12 13 14 16 17 19 20) It has been claimed also that brain atrophy leads to widening of subarachnoid space, which facilitates the removal of ASDH by aiding the redistribution of the hematoma.…”

“… 2 3 4 5 6 7 8 9 10 11 12 13 16 17 19 20) 2) Redistribution of hematoma to another space; contralateral intracranial space, intradiploic space and/or subgaleal space through the skull fracture, spinal subdural space, by raised pressure caused by brain swelling, other intracranial hemorrhages, and/or subdural hematoma itself. 1 3 4 5 6 7 8 9 10 11 12 13 14 16 17 19 20) It has been claimed also that brain atrophy leads to widening of subarachnoid space, which facilitates the removal of ASDH by aiding the redistribution of the hematoma. 1 5 8 12 13 19) Lee et al 12) suggest that the expanded subarachnoid space due to brain atrophy can be a favorable factor which could affect the dilution and redistribution of the hematoma.…”