Application of deep learning models for detection of subdural hematoma: a systematic review and meta-analysis.

BACKGROUND: This study aimed to investigate the application of deep learning (DL) models for the detection of subdural hematoma (SDH). METHODS: We conducted a comprehensive search using relevant keywords. Articles extracted were original studies in which sensitivity and/or specificity were reported. Two different approaches of frequentist and Bayesian inference were applied. For quality and risk of bias assessment we used Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: We analyzed 22 articles that included 1,997,749 patients. In the first step, the frequentist method showed a pooled sensitivity of 88.8% (95% confidence interval (CI): 83.9% to 92.4%) and a specificity of 97.2% (95% CI 94.6% to 98.6%). In the second step, using Bayesian methods including 11 studies that reported sensitivity and specificity, a sensitivity rate of 86.8% (95% CI: 77.6% to 92.9%) at a specificity level of 86.9% (95% CI: 60.9% to 97.2%) was achieved. The risk of bias assessment was not remarkable using QUADAS-2. CONCLUSION: DL models might be an appropriate tool for detecting SDHs with a reasonably high sensitivity and specificity.

Pitfalls in the diagnosis of subdural hemorrhage - Mimics and uncommon causes.

PURPOSE: Subdural hemorrhage (SDH), the accumulation of blood between the dura and arachnoid mater, is one of the most commonly encountered traumatic findings in emergency radiology setting. The purpose of this essay is to review the pitfalls in the diagnosis of SDH including a) mimics on CT imaging and b) etiology other than accidental trauma. We describe several entities that closely mimic SDH on non-contrast CT scans. A knowledge of these mimics is essential in the emergency setting since overdiagnosis of SDH can lead to unnecessary hospital admissions, potentially invasive procedures, or even delay in necessary treatment. The mimics of SDH on non-contrast head CT include: PATHOLOGIC ENTITIES IATROGENIC MIMICS ANATOMIC/PHYSIOLOGIC MIMICS ARTIFACTUAL MIMICSWe also briefly review non-accidental and non-traumatic causes of SDH. Although, the most common cause of SDH is accidental trauma, other routinely encountered causes of SDH include coagulopathy, non-accidental trauma, cranial surgery, vascular malformations etc. CONCLUSION: Clinicians dealing with SDH in the emergency setting should consider SDH mimics and less common etiologies of SDH in order to facilitate appropriate patient management.

Subdural haematoma, the great imitator, mimicking acute spinal cord lesion.

Acute non-traumatic paraparesis is usually caused by vascular, inflammatory or neoplastic myelopathies; however, it is sometimes caused by non-myelopathic pathologies, including polyradiculoneuropathies, myopathies, psychogenic aetiologies or parasagittal cortical pathologies. A 73-year-old woman reported weakness of the bilateral lower limbs and urinary incontinence. Together with the sensory level at the left T6 dermatome, we initially considered thoracic myelopathy as the most likely diagnosis. However, MRI of the cervicothoracic cord was negative and subsequent cranial CT revealed a bilateral subdural haematoma. A parasagittal cortical pathology should not be excluded from differential diagnoses as a rare cause of paraparesis until its possibility is carefully ruled out.

Subdural Hematoma: Predictors of Outcome and a Score to Guide Surgical Decision-Making.

OBJECTIVE: There is little evidence to guide patient selection for subdural hemorrhage (SDH) evacuation. This study was designed to assess the benefit of surgical evacuation of SDH, identify predictors of functional outcome, and create a bedside score to guide the clinical management of SDH. METHODS: A cohort of 331 patients presenting to a single center from 2010 to 2014 with a principal diagnosis of subdural hemorrhage was identified. Clinical and radiographic information were extracted from the medical record. Outcomes of interest were (1) the occurrence of surgical evacuation of SDH, and (2) an unfavorable 90-day functional status represented by a modified Rankin score (mRS) ≥ 3. Propensity score matching and adjustment techniques were employed to assess the benefit of surgery accounting for confounding by indication. Multivariable logistic regression models predicting follow-up functional outcome were generated and bootstrapped separately among those with acute SDH and those with either subacute or chronic SDH. Clinical scores were created using model coefficients. RESULTS: In this cohort [65% male, mean age 67 years], 47% underwent surgery. Age, focal neurologic deficit, SDH thickness > 10 mm, midline shift > 5mm, and SDH acuity predicted undergoing surgery. Propensity score matching analysis demonstrated that operated patients overall were less likely to have unfavorable 90-day mRS outcome (OR 0.35, 95% C.I. 0.15-0.82). Among patients with acute SDH, age, female sex, pre-admission mRS, focal neurologic deficit, and neuropsychiatric symptoms predicted 90-day functional outcome (c-statistic 0.89, optimism-corrected c-statistic 0.87) and were incorporated into an acute SDH score (range 1-10). Patients with SDH score > 4 were significantly more likely to have an unfavorable outcome if treated medically versus surgically; there was no difference in 90-day functional status by treatment strategy among patients with SDH score ≤ 4. No difference in outcome was seen by surgical status across the spectrum of chronic SDH scores. CONCLUSIONS: Surgical evacuation of subdural hematomas overall is associated with favorable outcome. Patient selection for evacuation is enhanced by the application of the acute SDH score. Future studies are necessary to validate the SDH score in an external cohort.

Subdural Hematoma in Patients with Hematologic Malignancies: An Outcome Analysis and Examination of Risk Factors of Operative and Nonoperative Management.

BACKGROUND: Patients with hematologic disorders who present with subdural hematomas (SDH) present a surgical decision-making challenge. Because of intrinsic coagulopathy, platelet dysfunction, and immunosuppression, surgical intervention poses a unique set of risks. OBJECTIVE: To describe a clinical sample of patients with hematologic disorders and concurrent SDH, to compare baseline and outcome variables, including complication rates and survival, in surgical versus nonsurgical management, and to identify clinical variables that may predict outcomes. METHODS: A 12-year retrospective case-control study was carried out of 50 adult patients with hematologic malignancies and SDH. Patients underwent surgical evacuation for SDH. Controls did not. Outcomes included discharge disposition, Glasgow Outcome Scale score, 30-day mortality, and overall survival. Complications included seizure, reoperation, and readmission. A Fisher exact test or χ2 analysis compared categorical variables; continuous outcomes were compared with a Student t test. A Kaplan-Meier survival analysis was performed and multivariable Cox logistic regression evaluated variables associated with overall mortality. RESULTS: Surgical and nonsurgical groups differed only by Glasgow Coma Scale score, with slightly lower Glasgow Coma Scale scores in the surgical group. Complication rates did not differ; however, the 30-day reoperation rate was 35% for the surgical cohort. Overall, seizure incidence was 18%, readmission was 30%, 30-day mortality was 38%, median survival was 140.5 days, and 75% had a Glasgow Outcome Scale score of 1-3 at censorship. Increased age, low hemoglobin levels, and low platelet levels were associated with increased risk of mortality. CONCLUSIONS: Low platelet and hemoglobin levels are consistent markers of poor prognosis and surgical intervention, either as a proxy of or as a cause for clinical deterioration, is associated with increased mortality risk.

Intravenous Tranexamic Acid for Subdural and Epidural Intracranial Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Recovery of patients with traumatic brain injury largely depends on the reduction in secondary brain damage. The present study aims at investigating the effect of Tranexamic Acid (TXA) administration within the first hours of brain trauma in the emergency department (ED). METHODS: This randomized, double-blind, placebo-controlled clinical trial was carried out in patients with subdural and epidural hemorrhage. Patients with any type of bleeding were assigned into two groups of TXA and 0.9% normal saline as placebo. The rate of intracranial hemorrhage after surgery was assessed by CT-scan and amount of hemoglobin (Hb) was measured immediately before surgery and after 6 hours of surgery. RESULTS: A total of 80 participants were randomly assigned into four groups of 20 people. There was a significant difference in the mean of intraoperative bleeding during surgery in patients receiving TXA and placebo in both SDH (Subdural hematoma) and EDH (Epidural Hemorrhage) groups (P= 0.012). The Hb drop amount had no significant difference with placebo (P< 0.0001). No complications were observed in any of the intervention and control groups during the study as well. CONCLUSION: The use of TXA may reduce bleeding, however, based on the results of this study, such effect was not statistically significant in controlling the epidural and subdural hemorrhage, but clinical trials with a higher sample size are suggested for further investigation in this regard.

First case report of spontaneous posterior fossa subdural hemorrhage - A rare cause of neonatal encephalopathy.

Posterior fossa subdural hemorrhage (PFSDH) in term neonates is rare and unknown in the absence of obvious trauma. Its management is challenging and decided case to case basis. Here we report two cases of posterior fossa subdural hemorrhage in term babies with normal transition at birth and presenting later with neonatal encephalopathy. First baby was born by elective caesarean section and the second baby by assisted vaginal delivery. They presented at 60 h and 48 h respectively. Both babies had similar clinical presentation in the form of poor feeding, shrill cry and posturing. But they had contrasting clinical course with features of brainstem compression in the first baby requiring ventilation. Coagulation workup was normal in the first baby but fibrinogen level was low in the second baby. Magnetic resonance imaging of the first baby showed PFSDH with tonsillar herniation while in the second baby, there was no midline shift or herniation associated with the PFSDH. Management was tailor made to suit the clinical course and imaging findings. Craniotomy and clot evacuation was done in the first case and in the second baby, management was conservative. Neurological examination was normal at discharge. Both are developmentally normal on follow up. There is no evidence of hydrocephalus in both. Management of PFSDH depends on clinical course and MRI findings. Timely intervention leads to good outcome.

Metastatic Subdural Hematoma with Dural Metastasis Secondary to Poorly Differentiated Adenocarcinoma of Unknown Origin.

BACKGROUND: Metastatic subdural hematoma with dural metastasis in the setting of an underlying malignancy is a rare condition that is difficult to diagnose and associated with a poor prognosis. Knowledge of this rare entity is of a paramount importance to neurosurgeons, as its diagnosis may affect the management plan and overall survival. Here, we report a rare case of atraumatic subdural hematoma with dural metastasis in a patient with poorly differentiated adenocarcinoma of unknown origin. CASE DESCRIPTION: A 34-year-old man presented with an insidious onset of headaches, severe light headedness, progressive low back pain, and generalized weakness for 2 weeks. On imaging, he was found to have left-sided acute on chronic subdural hematoma with midline shift. The patient underwent surgical evacuation of the hematoma and the subdural membrane was biopsied. Histopathologic examination revealed metastatic poorly differentiated adenocarcinoma of unclear origin. A full metastatic workup was unremarkable. CONCLUSIONS: Metastatic subdural hematoma with dural metastasis should be included in differential diagnosis of subdural hematoma, especially in patients with atypical presentation and in the presence of an underlying malignancy, as it may affect the management plan and overall survival.

Metastatic prostate cancer mimicking a subdural hematoma: A case report and literature review.

Occurrences of metastatic prostate cancer imitating a subdural hematoma are limited to a small number of case reports, even though prostate cancer spreads to the dura more than other types of cancer. Here, we present the case of a 64 year-old male whose prostate carcinoma's metastasis mimicked a subdural hematoma, and he suffered a middle cerebral artery stroke. Prostate cancer's high rate of progression to the dura is disproportionate to its relatively low rate of brain metastasis. Furthermore, we explore the potential molecular implications of prostate cancer's propensity to spread to the dura.

Bilateral Temporal Extradural Hematoma on Top of Bilateral Temporal Arachnoid Cyst: First Case Report and Extensive Literature Review.

BACKGROUND: The traumatic complication of an arachnoid cyst (AC) with intracystic and subdural hematoma has been reported in many cases. However, a unilateral extradural hematoma (EDH) as a complication of AC is extremely rare. Most arachnoid cysts are unilateral and are located in the middle cranial fossa. Bilateral temporal AC alone is an extremely rare condition, and a bilateral EDH on top of a bilateral temporal AC has never been reported in the literature, to our knowledge. CASE DESCRIPTION: We report the case of a 25-year-old man with a known bilateral AC who was involved in a motor vehicle accident and developed a bilateral temporal EDH. The brain computed tomography scan also showed fractures in the skull on both temporal areas. The patient was treated conservatively. He was discharge with Glasgow Coma Scale score of 5. CONCLUSIONS: Bilateral temporal EDH in a bilateral temporal AC has never been reported in the literature. The presence of an AC may predispose a patient to complications because of the anatomic changes in the area. It is important to educate asymptomatic patients and their families about these cysts and the importance of avoiding head injury and not being involved in contact sports or military service.

Intracraneal complications after raquis surgery. / Complicación intracraneal tras cirugía de raquis lumbar.

Intracraneal bleeding is a rare complication after raquis surgery. It is believed to occur as a drop in the intracraneal pressure after a loss of CSF secondary to an iatrogenic dural tear. We report a patient who after surgery for lumbar stenosis presented a subarachnoid haemorrhage, an intraparenchymal haematoma, and a subdural haematoma. To our knowledge, this is the first report in the literature with such complications after this type of surgery.

Life-threatening subdural hematoma after aortic valve replacement in a patient with Heyde syndrome: a case report.

BACKGROUND: Heyde syndrome is known as a triad of calcific aortic stenosis, anemia due to gastrointestinal bleeding from angiodysplasia, and acquired type 2A von Willebrand disease. This acquired hemorrhagic disorder is characterized by the loss of the large von Willebrand factor multimers due to the shear stress across the diseased aortic valve. The most frequently observed type of bleeding in these patients is mucosal or skin bleeding, such as epistaxis, followed by gastrointestinal bleeding. On the other hand, intracranial hemorrhage complicating Heyde syndrome is extremely rare. CASE PRESENTATION: A 77-year-old woman presented to our hospital with severe aortic stenosis and severe anemia due to gastrointestinal bleeding and was diagnosed with Heyde syndrome. Although aortic valve replacement was performed without recurrent gastrointestinal bleeding, postoperative life-threatening acute subdural hematoma occurred with a marked midline shift. Despite prompt surgical evacuation of the hematoma, she did not recover consciousness and she died 1 month after the operation. CONCLUSIONS: Postoperative subdural hematoma is rare, but it should be kept in mind as a devastating hemorrhagic complication, especially in patients with Heyde syndrome.

Microwave technology for detecting traumatic intracranial bleedings: tests on phantom of subdural hematoma and numerical simulations.

Traumatic brain injury is the leading cause of death and severe disability for young people and a major public health problem for elderly. Many patients with intracranial bleeding are treated too late, because they initially show no symptoms of severe injury and are not transported to a trauma center. There is a need for a method to detect intracranial bleedings in the prehospital setting. In this study, we investigate whether broadband microwave technology (MWT) in conjunction with a diagnostic algorithm can detect subdural hematoma (SDH). A human cranium phantom and numerical simulations of SDH are used. Four phantoms with SDH 0, 40, 70 and 110 mL are measured with a MWT instrument. The simulated dataset consists of 1500 observations. Classification accuracy is assessed using fivefold cross-validation, and a validation dataset never used for training. The total accuracy is 100 and 82-96 % for phantom measurements and simulated data, respectively. Sensitivity and specificity for bleeding detection were 100 and 96 %, respectively, for the simulated data. SDH of different sizes is differentiated. The classifier requires training dataset size in order of 150 observations per class to achieve high accuracy. We conclude that the results indicate that MWT can detect and estimate the size of SDH. This is promising for developing MWT to be used for prehospital diagnosis of intracranial bleedings.

Head computed tomographic measurement as a predictor of outcome in patients with subdural hematoma with cerebral edema.

BACKGROUND: The ability to predict outcome in patients with cerebral edema is important because it can influence treatment strategy. We evaluated whether differences in head computed tomographic (CT) measurements in Hounsfield units (HU) of white matter and gray matter can be used as a predictor of outcome in patients with subdural hematoma with cerebral edema. METHODS: We evaluated 34 patients who had subdural hematoma with cerebral edema following acute closed head trauma and had undergone head CT within a few hours of admission. We divided them into the survival (n = 24) group and death (n = 10) group, and measured the HU of white matter and gray matter at injury and non-injury sites. RESULTS: There were no significant differences in operation time or blood loss during surgery between the two groups. Only the HU of white matter in the injury site of patients in the death group were decreased significantly. A cut-off value of 31.5 for HU of white matter showed 80.0 % sensitivity and 99.9 % specificity for death; the area under the curve was 0.91. DISCUSSION: Our results are more evidence of the support of neurogenic edema in trauma rather than an important clinical tool at this stage. However, HU values in WM may be one factor in the decision-making process that affects patient outcome. Changing the treatment strategy in patients with a low HU value in the WM at the injury site may bring about an improvement in patient outcome. CONCLUSION: Measurement in HU of white matter at the injury site might be useful as a predictor of outcome in patients with subdural hematoma with cerebral edema.

Subdural Hematoma Mimickers: A Systematic Review.

BACKGROUND: A variety of subdural pathologies that may mimic hematomas are reported in the literature. We aimed to identify the atypical clinical and radiologic presentations of subdural masses that may mimic subdural hematomas. METHODS: A systematic review of MEDLINE and Embase was conducted independently by 2 reviewers to identify articles describing subdural hematoma mimickers. We also present a patient from our institution with a subdural pathology mimicking a subdural hematoma. We analyzed patient clinical presentations, underlying pathologies, radiologic findings, and clinical outcomes. RESULTS: We included 43 articles totaling 48 patients. The mean ± SD patient age was 55.7 ± 16.8 years. Of the 45 cases describing patient history, 13 patients (27%) had a history of trauma. The underlying pathologies of the 48 subdural collections were 10 metastasis (21%), 14 lymphoma (29%), 7 sarcoma (15%), 4 infectious (8%), 4 autoimmune (8%), and 9 miscellaneous (19%). Findings on computed tomography (CT) scan were 18 hyperdense (41%), 11 hypodense (25%), 9 isodense (20%), 3 isodense/hyperdense (7%), and 3 hypodense/isodense (7%). Thirty-four patients (71%) were treated surgically; among these patients, 65% had symptom resolution. Neither the pathology (P = 0.337) nor the management strategy (P = 0.671) was correlated with improved functional outcomes. CONCLUSIONS: Identification of atypical history and radiologic features should prompt further diagnostic tests, including magnetic resonance imaging (MRI), to elucidate the proper diagnosis, given that certain pathologies may be managed nonsurgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2-weighted MRI, along with a history of progressive headache with no trauma, may raise the suspicion of an atypical subdural pathology.

Reversible coma and Duret hemorrhage after intracranial hypotension from remote lumbar spine surgery: case report.

Intracranial hypotension is a rare condition caused by spontaneous or iatrogenic CSF leaks that alter normal CSF dynamics. Symptoms range from mild headaches to transtentorial herniation, coma, and death. Duret hemorrhages have been reported to occur in some patients with this condition and are traditionally believed to be associated with a poor neurological outcome. A 73-year-old man with a remote history of spinal fusion presented with syncope and was found to have small subdural hematomas on head CT studies. He was managed nonoperatively and discharged with a Glasgow Coma Scale score of 15, only to return 3 days later with obtundation, fixed downward gaze, anisocoria, and absent cranial nerve reflexes. A CT scan showed Duret hemorrhages and subtle enlargement of the subdural hematomas, though the hematomas remained too small to account for his poor clinical condition. Magnetic resonance imaging of the spine revealed a large lumbar pseudomeningocele in the area of prior fusion. His condition dramatically improved when he was placed in the Trendelenburg position and underwent repair of the pseudomeningocele. He was kept flat for 7 days and was ultimately discharged in good condition. On long-term follow-up, his only identifiable deficit was diplopia due to an internuclear ophthalmoplegia. Intracranial hypotension is a rare condition that can cause profound morbidity, including tonsillar herniation and brainstem hemorrhage. With proper identification and treatment of the CSF leak, patients can make functional recoveries.

Bilateral subdural hematoma secondary to accidental dural puncture / Hematoma subdural bilateral secundário a punção dural acidental / Hematoma subdural bilateral secundario a punción dural accidental

We report the case of a 25-year-old woman, who received epidural analgesia for labor pain and subsequently presented post-dural puncture headache. Conservative treatment was applied and epidural blood patch was performed. In the absence of clinical improvement and due to changes in the postural component of the headache, a brain imaging test was performed showing a bilateral subdural hematoma. The post-dural puncture headache is relatively common, but the lack of response to established medical treatment as well as the change in its characteristics and the presence of neurological deficit, should raise the suspicion of a subdural hematoma, which although is rare, can be lethal if not diagnosed and treated at the right time.

Apresentamos o caso clínico de uma paciente de 25 anos na qual uma técnica peridural foi aplicada durante o trabalho de parto e posteriormente apresentou cefaleia com características de cefaleia pós-punção dural. Foi iniciado tratamento conservador e tampão de sangue peridural. Devido à ausência de melhoria clínica e à mudança do componente postural da cefaleia, decidiu-se fazer um exame de imagem cerebral que demonstrou a presença de hematoma subdural bilateral. A cefaleia pós-punção dural é relativamente frequente, mas a falta de resposta ao tratamento médico instaurado, assim como a mudança em suas características e a presença de foco neurológico, deve levantar a suspeita de presença de um hematoma subdural que, embora infrequente, pode chegar a ser devastador se não for diagnosticado e tratado oportunamente.

Presentamos el caso clínico de una paciente de 25 años de edad, a quien se le realizó una técnica epidural durante el trabajo de parto y posteriormente presentó cefalea con características de cefalea pospunción dural. Se inició tratamiento conservador y se realizó parche hemático epidural. Ante la falta de mejoría clínica y debido al cambio en el componente postural de la cefalea, se decidió realizar una prueba de imagen cerebral que demostró la presencia de hematoma subdural bilateral. La cefalea pospunción dural es relativamente frecuente, pero la falta de respuesta al tratamiento médico instaurado, así como el cambio en sus características y la presencia de focalidad neurológica, deben hacer sospechar la presencia de un hematoma subdural que, aunque infrecuente, puede llegar a ser devastador si no se diagnostica y trata oportunamente.

Progressive post traumatic tearing of an arachnoid cyst membrane resulting in intracystic and subdural haemorrhage.

We report the case of a 43-year-old man with a middle cranial fossa arachnoid cyst who presented post trauma with neurological symptoms. The initial CT scan of the brain did not detect acute changes in the arachnoid cyst but subsequent imaging revealed abnormalities which progressed over time. Arachnoid cysts are usually a benign and incidental finding. Rare complications such as intracystic haemorrhage and subdural haemorrhage can occur. It is important to be aware of these complications so that patients with arachnoid cysts are appropriately investigated when presenting with neurological symptoms.