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African Journal of Neurological Sciences
Pan African Association of Neurological Sciences
ISSN: 1015-8618
Vol. 14, Num. 2, 1995
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The African Journal of Neurological Sciences
Vol 14 No.2, 1995
ACUTE SUBDURAL HAEMATOMA OF ARTERIAL ORIGIN: A CASE OF SUCCESSFUL
SURGICAL TREATMENT.
A. Adeloye: Blantire - Malawi
N. Kuoka: Fahaheel - Kuwait
Code Number: NS95007
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Text: 12K
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SUMMARY
A Kuwaiti woman of 47 years came to hospital after being involved in a
road traffic accident fully conscious but complaining of headache. She had
no obvious head injury. Clinically there was no neurological deficits,
skull radiography was normal and hence was discharged home after a period
of observation. Twenty four hours later she was admitted to hospital with
impaired consciousness, dilated right pupil and right spastic hemiparesis.
CT scan of the brain showed right fronto-parietotemporal mass with shift of
the brain to the opposite side. At emergency craniotomy extensive subdural
haematoma was found and evacuated and a bleeding cortical artery in the
sylvian fissure coagulated. She made a rapid, uneventful recovery after
craniotomy, and she remained neurologically normal during follow-up.
RESUME
Une femme Koweitienne de 47 ans a ete hospitalisee apres un accident de
la voie publique. Elle n'a pas eu de perte de canescence mais se plaignait
de cephalees. Elle ne presentait pas de blessure evidente a la tete.
Cliniquiment, il n'y avait pas de deficit neurologique. La radio du crane
etait normale, elle rentra donc chez elle apres une periode d'observation;
24 beures apres, elle etait hospitalisee avec une dimunution de la
conscience, une mydriase droite et une hemiparesie droite spastique. Le
scanner cerebral a montre une masse fronto-parietotemporale droite avec
deplacement du cerveau du cote oppose. Une trepanation faite en urgence a
permis d'evacuer un hematome sous-dural etendu et de coaguler une artere
corticale sylvienne qui saignait. Le retablissement de la patiente a ete
rapide apres la trepanation, et l'examen neurologique normal pendant toute
la duree du suivi.
Key Words: Subdural haematoma - Arterial origin
INTRODUCTION
Although subdural haematoma is usually of venous origin, it is known
that it can sometimes result from arterial rupture occurring in association
with an aneurysmal or arteriovenous malformation (1,6), neoplastic lesions
on the dura (8), infection, vitamin C deficiency, alcohol abuse and
coagulopathy (3). Rarely, the arterial rupture may be spontaneous when it
occurs in the absence of obvious head trauma and of the above predisposing
and risk factors.
Whatever the aetiology, the literature review of acute subdural haematoma
(ASH) of arterial origin has shown it to be attended by an unusually high
mortality of about 50 per cent (12) due to delay in diagnosis and
institution of appropriate surgical treatment. We present a case in this
paper in which early diagnosis and prompt correct neurosurgical
intervention led to a successful outcome.
CASE REPORT
S.F., a 47 year old Kuwaiti woman, the mother of seven children, was
involved in a road traffic accident on January 31, 1990. The car she was
driving overturned over after bursting a tyre and she was thrown against
the steering wheel. She did not lose consciousness. She come to the
Casualty Department of Al-Adan Hospital, Kuwait complaining of headache. On
physical examination, she was correctly oriented and cooperative; there was
no head wound and the neurological system was clinically normal. Skull and
chest radiograms obtained were normal. She was kept under observation in
the Casualty Department for four hours after which she was allowed to go
home because she remained clinically stable.
On February 1, 1990, about 24 hours after discharge, an ambulance brought
her back to the Medical Section of the Casualty Department of Al-Adan
Hospital on the suspicion that she had suffered a stroke because she was
drowsy. After leaving hospital on January 31, 1990, her headache had
worsened especially on the right side, accompanied by vomiting,
unsteadiness of gait and slurring of her speech. On examination by the
receiving physician, She was described as drowsy with a Glasgow coma score
of 10, right facial palsy of upper motor neurone type and right spastic
hemiparesis. The scalp was normal, her pulse rate was 56 per minute and the
blood pressure 160/110 mm Hg. She was admitted to the Medical Ward of the
hospital with the diagnosis of cerebrovascular accident, with the
differential diagnosis of subdural haematoma.
An electrocardiogram showed sinus bradycardia and an emergency CT scan of
the brain revealed a large right fronto-parieto-temporal mass with marked
shift of the brain to the left side. Neurosurgical consultation was
immediately sought.
Within one hour of admission, she rapidly passed from a drowsy state into
coma with the right pupil dilated but slowly reacting to light. She was
intubated and put on controlled ventilation in preparation for emergency
neurosurgical operation.
At operation, no scalp wound was found. A right parietal burr hole showed
no extradural haematoma but a blue bulging non-pulsatile dura indicating
subdural haematoma. A fronto-parieto-temporal craniotomy was performed.
When the dura was opened. an extensive fronto-parieto-temporal subdural
haematoma which had partially clotted was revealed; it was peeled off and
removed completely to show normal looking brain. At the bottom of the
wound, close to the skull base, a slowly bleeding cortical artery was
found; the vessel was easily coagulated and the bleeding arrested.
The patient made a remarkable good and uneventful postoperative recovery.
She come off the ventilator on February 3 and soon regained full
consciousness. She moved all her limbs satisfactorily and the right pupil
became normal. She was transferred from the Intensive Care Unit to the
Surgical Female Ward on February 4 and discharged from hospital on February
11, 1990. She complained of dizziness and had elevated blood pressure which
necessitated treatment with methyldopa. She had been known to have arterial
hypertension for about a year before her accident but had been on irregular
treatment.
She was last seen in Neurosurgery Clinic on June 19, 1990, doing well and
neurologically normal. She was booked to attend the Clinic again by the
middle of August 1990. She could not keep that appointment with the Iraqi
invasion in Kuwait on August 2, 1990.
DISCUSSION
Acute subdural haematoma (ASH) of arterial origin is probably not as
rare as formerly thought (3, 14) and the features appear uniform enough to
make it a distinctive entity of its own. The patients are middle-aged to
elderly. The bleeding artery is seen at operation close to the base of the
skull in the region of the Sylvian fissure and the brain is grossly normal.
CT scan shows that the brain shift is often considerable such that it
produces ipsilateral hemiparesis, the Kernohan's phenomenon (5).
All these features were present in our patient. The Kernohan's phenomenon
was common in the cases reported by Tokoro et al (14). Indeed, Talalla and
McKissock (13) had suggested that the phenomenon is a sign of ASH of
arterial origin; unrelieved the shift caused by the rapid increase in the
size of the haematoma can precipitate quick deterioration in the level of
consciousness and even death.
ASH of arterial origin can easily be confused with cerebrovascular
accident, as was our case and those reported in the literature (12, 13)
Tokoro et al (14) labelled it an unusual form of cerebrovascular accident.
This seems appropriate since the bleeding in the cases reported came from
the cortical branches of the middle cerebral artery. This is an anatomical
territory of arterial junction where strains and stresses, which can be
precipitated by mild or unobserved head trauma can cause arterial rupture
and bleeding.
Two factors which predispose to arterial bleeding into the subdural space
in our case are head injury and arterial hypertension. Although she had no
obvious head wound and skull radiography was normal, head trauma cannot be
totally excluded in our case. Drake (2) had postulated that in the so
called spontaneous variety of ASH of arterial origin, head trauma is
involved but it may be minor and mild and pass unnoticed. Shenkin (11)
found arterial bleeding in over 60 percent of his 39 patients with
traumatic subdural haematoma.
Arterial hypertension was present in about 45 per cent of cases of ASH of
arterial origin described in the literature (7,14). Subdural haematoma has
been observed to be commoner in hypertensives than in normotensive
individuals (9).
Delay in instituting neurosurgical treatment can be fatal as shown by case
3 of Stephenson and Gibson (12) and accounts for the high mortality
associated with this disease. On the other hand, prompt neurosurgical
evacuation of the haematoma is very rewarding with the survivor gaining a
life with little or no neurological deficits (3).
Simple burr hole is not enough to remove the subdural clotted blood and
control the arterial bleeding. Jamieson and Yelland (4) advised that once
the subdural haematoma had been detected through a burr hole, the latter
should be converted to a craniotomy, as we did in our case. A craniotomy is
essential not only to completely evacuate the large thick and extensive
haematoma but also to facilitate the arrest of the arterial bleeding. The
procedure makes for adequate intracranial decompression and a good early
post operative recovery.
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1
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Copyright 1995 Pan African Association of Neurological Sciences
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