Chronic subdural hematoma presenting as transient neurologic deficits

Pathophysiology of transient neurological deficit in patients with chronic subdural hematoma: A systematic review

Patients with chronic subdural hematoma (CSDH) can have transient neurological deficits deficit (TND) mimicking transient ischemic attacks. The prevalence of TNDs in CSDH varies between 1%-24%, depending on TND definition. Despite this high prevalence the pathophysiology of TND in CSDH is not clear in many cases. In this systematic review, we aim to unravel the responsible mechanism. Pubmed and Embase were searched for all articles concerning the pathophysiology of TND as a presenting symptom in patients with CSDH. There were no publication date restrictions for the articles in the search. Two reviewers independently selected studies for inclusion and subsequently extracted the necessary data. Out of 316 identified references, 15 met the inclusion criteria. Several articles mentioned multiple pathophysiological mechanisms. One of the proposed etiologies of TND was epileptic activity, stated by three articles. In contrast, three different studies stated that seizures are unlikely to cause TND. Five papers suggested that obstruction of blood flow, caused by the hematoma or subsequent swelling, might be the cause. Six articles made no definite statement on the responsible pathophysiological mechanism of TND. Different mechanisms have been proposed to be the cause of TNDs in patients with CSDH. Based on this review, the exact pathophysiology of TND remains unclear. We suggest that future studies on this topic should incorporate MRI of the brain (with diffusion-weighted imaging) and EEG, to provide better insight into TND pathophysiology. The knowledge resulting from future studies might contribute to better understanding of TND and optimal treatment in CSDH.

Transient neurological deficit in patients with chronic subdural hematoma: a retrospective cohort analysis

RATIONALE

Symptoms of chronic subdural hematoma (CSDH) vary widely, including transient neurological deficit(s) (TND). The precise prevalence and the clinical aspects of TND are yet to be determined. Most TNDs are regarded and treated as symptomatic seizures, but the rationale for this decision is not always clear.

METHODS

Patients with temporary symptoms were selected from a retrospective cohort of CSDH patients. We analyzed the association of TND characteristics with patients being classified as having a symptomatic seizure and with functional outcome using logistic regression analysis.

RESULTS

Of the included 1307 CSDH patients, 113 (8.6%) had at least one episode of TND. Most common TNDs were aphasia/dysphasia, impaired awareness or clonic movements. Of these 113 patients, 50 (44%) were diagnosed with symptomatic seizure(s) by their treating physician. Impaired awareness, clonic movements and the presence of 'positive symptoms' showed the strongest association with the diagnosis symptomatic seizure (OR 36, 95% CI 7.8-163; OR 24, 95% CI 6.4-85; and OR 3.1, 95% CI 1.3-7.2). Aphasia/dysphasia lowered the chance of TND being classified as symptomatic seizure together with a longer TND duration (OR 0.2, 95% CI 0.1-0.6; and OR 0.91, 95% CI 0.84-0.99). Treatment with anti-epileptic drugs was related to unfavorable functional outcome (aOR 5.4, 95% CI 1.4-20.7).

CONCLUSION

TND was not a rare phenomenon in our cohort of CSDH patients. A TND episode of 5 min, aphasia/dysphasia and/or absence of 'positive' symptoms are suggestive of a different TND pathophysiology than symptomatic seizures. Our results further suggest that treatment of TND in CSDH deserves careful consideration as management choices might influence patient outcome.

[Chronic subdural hematoma in the elderly]

Chronic subdural hematoma (cSDH) is a common condition, the frequency of which further increases due to an aging population and more frequent use of antithrombotic drugs. It leads to unspecific symptoms and neurological deficits and is usually treated surgically. Burr hole trepanation and twist drill craniostomy have become the therapeutic standards with craniotomy being rarely used for recurrent cases. Although recurrences are relatively common, in most cases a good outcome can be achieved even in the elderly; however, as cSDH is associated with other comorbidities, it is indicative of an increased morbidity and mortality. Controlled trials need to be carried out to determine whether pharmacological therapies can also be beneficial in addition to surgical treatment.

Chronic subdural haematoma in the elderly

Chronic subdural haematoma is predominantly a disease of the elderly. It usually follows a minor trauma. A history of direct trauma to the head is absent in up to half the cases. The common manifestations are altered mental state and focal neurological deficit. Neurological state at the time of diagnosis is the most important prognostic factor. Morbidity and mortality is higher in the elderly but outcome is good in patients who undergo neurosurgical intervention.

Chronic subdural haematoma, an unusual injury from playing basketball

Although the literature records instances of acute epidural haematoma and acute subdural haematoma related to playing basketball, there has not been a report of chronic subdural haematoma as a basketball injury. With the burgeoning interest in this sport in the United Kingdom and Europe, the possibility of this particular neurotrauma increases. Such an injury, along with the diagnosis and management of this often insidious lesion, is documented in this case report.

Intracranial tumours that mimic transient cerebral ischaemia: lessons from a large multicentre trial. The UK TIA Study Group

The clinical records of patients withdrawn from the UK-TIA Aspirin Trial after identification of a brain tumour were reviewed. Certain features of transient focal neurological dysfunction were associated with an underlying brain tumour rather than transient ischaemia: a) focal jerking or shaking; b) pure sensory phenomena; c) loss of consciousness; d) isolated aphasia or speech arrest. In several patients the misdiagnosis occurred because these features were interpreted as the sequelae of previous ischaemic damage. When a transient focal neurological attack is associated with any of these features, a brain tumour must be considered. If patients later develop epilepsy the diagnosis of cerebral ischaemia should be reviewed.

Subdural haematoma presenting with transient neurological deficits

OBJECTIVE

To stress that transient neurological deficits do not always imply transient cerebral ischaemia, and may be produced by subdural haematoma.

CLINICAL FEATURES

An 80-year-old man was seen for intermittent gait disturbance, with normal findings on initial examination. He was then admitted after the onset of a fixed neurological deficit which worsened. Subdural haematoma was diagnosed by computed tomography (CT). An 80-year-old woman was seen after she had experienced left hemisphere transient neurological deficits. A CT scan showed a left-sided subdural haematoma.

INTERVENTION AND OUTCOME

Both patients underwent successful surgery with complete resolution of their symptoms and signs.

CONCLUSION

Subdural haematoma is relatively common and must be considered in those with unexplained transient neurological deficits. Magnetic resonance imaging or CT are the diagnostic procedures of choice. Antiplatelet or anticoagulant therapy must not be instituted until subdural haematoma is excluded.

Age-dependent changes of cerebral ventricular size. Part I: Review of intracranial fluid collections

The age distributions of communicating hydrocephalus (CH), pseudotumour cerebri (PC) slit-ventricle syndrome (SVS), and chronic subdural haematomas (CSH) were reviewed in the medical literature. An age-related incidence was found: CH and CSH predominated in neonates less than 2 years and adults older than 55 years, while PC and SVS occurred mainly in older children and young adults. The latter two patient groups seem to show a greater resistance to ventricular dilatation in the presence of decreased CSF absorption. This may be related to larger volume and state of maturity of the cerebrum. On the other hand, neonates and the elderly more readily develop enlarged ventricles, in association with impairment of CSF absorption, or subdural fluid collections. Factors including status of cranial sutures, cerebral atrophy, cerebral water content, degree of cerebral myelination, and glial cell composition, may contribute to the age-related incidence of the four disorders investigated. Similarly, the development of ventriculomegaly may depend upon cerebral elastic properties besides the pri mary disturbance of CSF dynamics. The authors postulate that the size of cerebral ventricles in disorders of the cerebrospinal fluid (CSF) absorption is related to the elastic properties and volume of the brain. Furthermore, cerebral volume and elastic properties may also contribute to the age distribution of chronic subdural haematomas (CSH).

Non surgical treatment of subdural hematoma in a hemodialysis patient

The development of subdural hematoma in the course of hemodialysis treatment has been well documented in the literature. We report a case of a subdural hematoma in a patient on hemodialysis, in whom surgery was contraindicated, due to her concurrent use of anticoagulants. Good recovery was achieved by steroid treatment. Although surgical removal constitutes the essential therapeutic approach for subdural hematoma, we emphasize the importance of medical management in special cases where surgery is contraindicated.

Chronic subdural hematoma with transient neurological deficits: a review of 15 cases

Fifteen patients with chronic subdural hematomas had transient neurological deficits. The important clinical features were aphasia in 9 patients, absence of headache in 8, and head injury in 8. Computed tomographic scan correctly identified all 15 cases of chronic subdural hematoma and should be considered mandatory before initiating anticoagulation in patients with transient ischemic attacks.