Elsevier

World Neurosurgery

Volume 96, December 2016, Pages 66-71
World Neurosurgery

Literature Review
Case Report and Review of Literature of Delayed Acute Subdural Hematoma

https://doi.org/10.1016/j.wneu.2016.08.075Get rights and content

Background

The authors present a case of delayed acute subdural hematoma and review all reported cases in the literature. The focus of this paper is to identify the subset of the population who are at risk, and determine whether they should be admitted for observation in the setting of mild traumatic brain injury.

Case Description

A 75-year-old woman taking daily aspirin (81 mg) had a fall with loss of consciousness. Her Glasgow Coma Scale (GCS) score was 15 at the time of presentation to the emergency department. However, because of her postconcussive symptoms, computed tomography (CT) of the head was obtained, and the results were negative for any intracranial hemorrhage or fractures. She was admitted for workup. The next day, she neurologically deteriorated to a GCS score of 6. CT of the head was reobtained and showed acute, left-sided subdural hematoma with shift and herniation. She was taken to operating room for emergent decompressive craniotomy. Postoperatively, she developed left-sided temporal and occipital intraparenchymal hemorrhage. She died after being placed on comfort care.

Conclusion

Delayed acute subdural hematoma occurs mainly in the middle-aged or older population who are taking anticoagulation or antiplatelet therapy. Most patients have a GCS score of 15 with no loss of consciousness. Neurological deterioration occurs within the first 24 hours for 70% of the patients. Therefore, we recommend admission and observation of these selected group of patients. Due to small reported population of patients, we could not determine whether the patients taking anticoagulant, antiplatelet, or both anticoagulant and antiplatelet medication are at higher risk. In addition, the role of delayed CT of the head without change in the examination result needs to be explored further.

Introduction

Traumatic acute subdural hematoma is one of the most lethal causes of head injuries. A critical factor in survival has been the timing of intervention for evacuation of hematoma. The mortality rate can be as high as 14% for adult patients with acute subdural hematoma.1 However, delayed acute subdural hematoma (DASH) is an entity that is rarely reported in the literature. We are reporting a case of DASH and reviewing the literature.

Section snippets

Case Report

A 75-year-old woman with a medical history of hypertension, hypothyroidism, hyperlipidemia, osteopenia, and daily use of aspirin (81 mg) for good health presented to the emergency department (ED) at approximately 1:00 AM after she was found by her family in the kitchen on the floor and minimally responsive. At the ED, her Glasgow Coma Scale (GCS) score was 15 but amnestic to the events. Computed tomography (CT) of the head (Figure 1) was obtained and was negative for any intracranial

Results

In United States and Canada, approximately 1 million patients experience blunt traumatic brain injury (TBI); 66%–75% of these injuries are considered minor.2 Prospective studies have found that 3%–13% of patients with mild TBI and a GCS score of 15 had intracranial findings on CT of the head.2 In the literature, there has been great discussion regarding delayed intracerebral hemorrhage, delayed epidural hematoma, and delayed chronic SDH; however, there are limited data regarding DASH.3 In our

Discussion

Mild TBI (mTBI) is defined as a head injury for which the GCS score is 13–15. The majority of patients with mTBI have uneventful recovery; however, misdiagnosis can result in death, prolonged vegetative states, or significant disability.4 The acute phase of mTBI is characterized by approximately 10% risk for intracranial abnormalities such as contusion, subdural or epidural hematoma, brain swelling, subarachnoid hemorrhage, or pneumocephalus.5 There is an approximately 1% risk of

Conclusion

According to our review of the literature, DASH mainly occurs in middle-aged to older patients who are taking anticoagulation or antiplatelet therapy. It has been postulated that the rupture of bridging veins or small perisylvian arteries,7, 8, 9 in the presence of hypotension followed by fluid resuscitation, might be the mechanism for the delayed development of acute SDH. However, the exact mechanism has not been determined. In about 70% of patients, neurological deterioration due to DASH

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding: Department of Neurological Surgery at Medical College of Wisconsin.

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