Acute-to-chronic subdural hematoma: radiographic and clinical progression from acute subdural hematoma.

INTRODUCTION: The pathogenesis of chronic subdural hematoma (CSDH) has not been completely understood. However, different mechanisms can result in space-occupying subdural fluid collections, one pathway can be the transformation of an original trauma-induced acute subdural hematoma (ASDH) into a CSDH. MATERIALS AND METHODS: All patients with unilateral CSDH, requiring burr hole trephination between 2018 and 2023 were included. The population was distributed into an acute-to-chronic group (group A, n = 41) and into a conventional group (group B, n = 282). Clinical and radiographic parameters were analyzed. In analysis A, changes of parameters after trauma within group A are compared. In analysis B, parameters between the two groups before surgery were correlated. RESULTS: In group A, volume and midline shift increased significantly during the progression from acute-to-chronic (p < 0.001, resp.). Clinical performance (modified Rankin scale, Glasgow Coma Scale) dropped significantly (p = 0.035, p < 0.001, resp.). Median time between trauma with ASDH and surgery for CSDH was 12 days. Patients treated up to the 12th day presented with larger volume of ASDH (p = 0.012). Before burr hole trephination, patients in group A presented with disturbance of consciousness (DOC) more often (p = 0.002), however less commonly with a new motor deficit (p = 0.014). Despite similar midline shift between the groups (p = 0.8), the maximal hematoma width was greater in group B (p < 0.001). CONCLUSION: If ASDH transforms to CSDH, treatment may become mandatory early due to increase in volume and midline shift. Close monitoring of these patients is crucial since DOC and rapid deterioration is common in this type of SDH.

Middle Meningeal Artery Embolization for Subdural Hematoma: An Institutional Cohort and Propensity Score-Matched Comparison with Conventional Management.

BACKGROUND: The treatment of non-acute subdural hematoma (NASDH) is challenging due to its high recurrence rates and comorbidities of mostly elderly patients. Middle meningeal artery embolization (MMAE) recently emerged as an alternative to surgery in the treatment of NASDH. OBJECTIVE: To describe a single center's experience of MMAE with Onyx for NASDH and compare it to a surgically treated historical cohort. METHODS: We performed a retrospective analysis of patients undergoing MMAE for NASDH from 2019 to 2021. MMAE was performed with ethylene vinyl alcohol copolymer (Onyx). Comparisons were made with a historical cohort from 2010 to 2018 who underwent surgical evacuation only, before and after propensity score matching. Outcomes were assessed clinically and radiographically. RESULTS: We included 44 consecutive patients (55 MMAEs) who underwent MMAE, with a median follow-up of 63.5 days. Twenty-four NASDHs underwent upfront embolization, 17 adjunctive, and 14 for recurrence after prior surgical evacuation, with no significant differences in hematoma and mRS reduction between them. Two patients died during hospitalization and 2 during follow-up, unrelated to the procedure. Mean SDH thickness decreased by 48.3% ± 38.1% (P < 0.001) on last follow-up, which did not correlate with the amount of Onyx injected. Six (13.6%) patients required surgical rescue after embolization. There were no procedure-related complications. The mean modified Rankin Scale (mRS) on admission was 2.8 ± 1.5, which decreased significantly to 1 [1,4] at the last follow-up (P = 0.033). The MMAE (41 hematomas; upfront and adjunctive embolization) and Surgical Evacuation-only (461 hematomas) cohorts were balanced with propensity score mathing. Matching was successful for 41 MMAE and 41 surgical-only hematoma pairs, and only hypertension remained significantly different between the two groups, but there was no significant difference in any outcome. CONCLUSION: MMAE for NASDH seems safe and effective in appropriately selected patients, non-inferior to surgery, and may become a minimally-invasive alternative. Given our encouraging results, large-scale clinical randomized trials are warranted.

Clinical Outcomes After Nonoperative Management of Large Acute Traumatic Subdural Hematomas in Older Patients: A Propensity-Scored Retrospective Analysis.

BACKGROUND: Large (≥1 cm) acute traumatic subdural hematomas (aSDHs) are neurosurgical emergencies. Elderly patients with asymptomatic large aSDHs may benefit from conservative management. OBJECTIVE: To investigate inpatient mortality after conservative management of large aSDHs. METHODS: Single-center retrospective review of adult patients with traumatic brain injury from 2018 to 2021 revealed 45 large aSDHs that met inclusion criteria. Inpatient outcomes included mortality, length of stay, and discharge disposition. Follow-up data included rate of surgery for chronic SDH progression. Patients with large aSDHs were 2:1 propensity score-matched to patients with small (<1 cm) aSDHs based on age, Injury Severity Scale, Glasgow Coma Scale, and Rotterdam computed tomography scale. RESULTS: Median age (78 years), sex (male 52%), and race (Caucasian 91%) were similar between both groups. Inpatient outcomes including length of stay ( P = .32), mortality ( P = .37), and discharge home ( P = .28) were similar between those with small and large aSDHs. On multivariate logistic regression (odds ratio [95% CI]), increased in-hospital mortality was predicted by Injury Severity Scale (1.3 [1.0-1.6]), Rotterdam computed tomography scale 3 to 4 (99.5 [2.1-4754.0), parafalcine (28.3 [1.7-461.7]), tentorial location (196.7 [2.9-13 325.6]), or presence of an intracranial contusion (52.8 [4.0-690.1]). Patients with large aSDHs trended toward higher progression on follow-up computed tomography of the head (36% vs 16%; P = .225) and higher rates of chronic SDH surgery (25% vs 7%; P = .110). CONCLUSION: In conservatively managed patients with minimal symptoms and mass effect on computed tomography of the head, increasing SDH size did not contribute to worsened in-hospital mortality or length of stay. Patients with large aSDHs may undergo an initial course of nonoperative management if symptoms and the degree of mass effect are mild.

Giant cell glioblastoma multiforme presents as acute pathological nontraumatic subdural haematoma.

We describe a case of giant cell glioblastoma multiforme (GBM) that presented with a non-traumatic acute subdural haematoma (NASDH). A 57-year-old male had a sudden onset headache and rapid deterioration in conscious level with Glasgow Coma Scale (GCS) of 5 and dilated unreactive left pupil. CT of the head revealed a left acute subdural haematoma with mass effect and a left parietal lesion. Our literature review revealed that glioblastoma presenting as an acute subdural haematoma is extremely unusual. To our knowledge, we report the second case. We propose an invasion of the arachnoid and cortical veins by the aggressive tumour as a possible underlying mechanism.

Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review.

Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.

Acute Traumatic Subdural Hematoma and Anticoagulation Risk.

BACKGROUND: Anticoagulation is used to prevent thromboembolic events. It is a common practice to hold anticoagulation in the first few days following a traumatic brain injury (TBI) with intracranial hemorrhage. However, traumatic subdural hematomas (SDH) are prone to re-hemorrhage long after the trauma. Data are scarce in the literature on the best timing to resume anticoagulation following a TBI. METHODS: Review of 95 consecutive patients admitted to a level 1 trauma center with a diagnosis of traumatic SDH and requiring anticoagulation. The reasons for anticoagulation, the amount of time without anticoagulation, CT characteristics, and the incidence of thromboembolic events or SDH re-hemorrhage were collected. RESULTS: 41.3% used anticoagulation for coronary artery disease and peripheral vascular disease, 24% for atrial fibrillation, 12% for cardiac valve replacement, and 12% for venous thromboembolic events. Anticoagulation was held a median of 67 days. For most patients (82.1%), anticoagulation was re-introduced once the SDH had completely resolved. For 17.9%, anticoagulation was restarted while the SDH had not completely resolved. One (1.1%) patient suffered from an atrial clot while anticoagulation was held. For those with residual SDH, 41.2% suffered from a SDH re-hemorrhage and 17.6% required surgery. The risk of re-hemorrhage climbed to 62.5% if the SDH remnant was large. CONCLUSION: Anticoagulation while there is a residual SDH was associated with a significant risk of re-hemorrhage. This risk should be weighed against the risk of holding anticoagulation.

Intraoperative Ultrasonography for Surgery of Cranial Traumatic Acute Subdural Hematoma: Technical Note.

BACKGROUND: Intraoperative ultrasonography (IOUS) in traumatic brain injury is a fast, easy, and low-cost technique that has been poorly investigated so far even though it could potentially answer many of the intraoperative needs of the surgeon. The aim of this study was to investigate the role of IOUS in patients undergoing surgery for traumatic acute subdural hematoma (aSDH), focusing on its influence on intraoperative surgical strategy, particularly regarding the management of intracerebral contusions (ICCs) associated with aSDH. METHODS: Data of patients who consecutively underwent surgical evacuation of traumatic aSDH with IOUS assistance at our institution from May 2017 to December 2020 were retrospectively analyzed. Patients were dichotomized into an ICC group (ICCs associated with aSDH on preoperative computed tomography scan) and no ICC group (no ICCs associated with aSDH on preoperative computed tomography scan). RESULTS: The study included 41 patients. Before aSDH evacuation, IOUS findings were similar to preoperative computed tomography data. After aSDH evacuation, IOUS detected a new-onset ICC in 13% of patients in the no ICC group and a volume increase of the known ICCs in 22% of patients in the ICC group. Therefore, IOUS made it possible to evacuate these new-onset or expanding hematomas in the same operation, changing our surgical strategy and avoiding a delayed reintervention. CONCLUSIONS: Our study suggests that IOUS in patients undergoing surgery for traumatic aSDH can promptly identify possible evolution of a primary head injury, leading to early and effective treatment.

Impact of Thrombocytopenia on Preoperative Hematoma Expansion for Acute Traumatic Subdural Hematoma.

BACKGROUND: Acute subdural hematoma is a neurosurgical emergency. Thrombocytopenia poses a management challenge for these patients. We aimed to determine the impact of thrombocytopenia on preoperative hemorrhage expansion and postoperative outcomes. METHODS: This retrospective study evaluated patients presenting at our institution with acute subdural hematoma between 2009 and 2019. Patients who underwent surgery, had thrombocytopenia (platelets <150,000/µL), and had multiple preoperative computed tomography scans were included. Case control 1:1 matching was performed to generate a matched cohort with no thrombocytopenia. Univariate analyses were conducted to determine changes in subdural thickness and midline shift, postoperative Glasgow Coma Scale score, mortality, length of stay, and readmission rates. RESULTS: We identified 19 patients with both thrombocytopenia and multiple preoperative computed tomography scans. Median platelet count was 112,000/µL (Q1 69,000, Q3 127,000). Comparing the thrombocytopenia cohort with the control group, there was a statistically significant difference in change in subdural thickness (median 5 mm [Q1 2, Q3 7.4] vs. 0 mm [Q1 0, Q3 1.5]; P = 0.001) and change in midline shift (median 3 mm [Q1 0, Q3 9.5] vs. median 0.5 mm [Q1 0, Q3 1.5]; P = 0.018). The thrombocytopenia cohort had higher in-hospital mortality (10 [52.6%] vs. 2 [10.5%]; P = 0.003). No significant differences were found in postoperative Glasgow Coma Scale score, length of stay, number of readmissions, and number of reoperations. CONCLUSIONS: Thrombocytopenia is significantly associated with expansion of hematoma preoperatively in patients with acute subdural hematoma. While the benefit of early platelet correction cannot be determined from this study, patients who present with thrombocytopenia will benefit from close monitoring, a low threshold to obtain repeat imaging, and anticipating early surgical evacuation after platelet optimization.

Contralateral Acute Extradural Hematoma Following Decompressive Craniectomy for Subdural Hematoma Evacuation: A Rare Complication and a Short Literature Review.

Subdural hematoma (SDH) is a common intracranial lesion seen in severe traumatic brain injury (TBI). The development of contralateral delayed extradural hematoma (EDH) after surgery is well described. But limited literature available about immediate contralateral EDH after subdural hematoma (SDH) evacuation. We report a case of a young adult who developed contralateral EDH following decompressive surgery for acute SDH.

Differences in Presentation, Radiological Features, and Outcomes in Traumatic Versus Spontaneous Acute Subdural Hematomas-A Single-Institution Population-Based Study.

BACKGROUND: Spontaneous acute subdural hematoma (sASDH) is a rare neurosurgical condition, with the literature mainly consisting of case reports. In the present study, we compared sASDH with traumatic ASDH (tASDH) to determine the differences in presentation, radiological features, and outcomes in a population-based setting. METHODS: All adult patients (age ≥18 years) who had undergone surgery for ASDH (n = 266), either spontaneous or traumatic, from 2010 to 2020 were included retrospectively. The cohort was divided into 2 groups for comparative analysis: sASDH group (n = 24) versus tASDH group (n = 242). RESULTS: Of the 266 patients, 24 (9.0%) had presented with sASDH. The sASDH group had a mean age of 66.2 years, and sudden headache was the most common presenting symptom (83.3%). The sASDH group had a higher Glasgow coma scale score at presentation compared with the tASDH group (Glasgow coma scale scores, 10 and 8, respectively; P < 0.01). The outcomes, assessed using the Glasgow outcome scale (GOS), revealed a greater incidence of more favorable outcomes (GOS score 4-5) for the sASDH group (72.7%) than for the tASDH group (41.5%). CONCLUSIONS: In the present population-based study of surgically evacuated ASDH cases, 9% were spontaneous without previous trauma. The outcomes (GOS scores) were significantly more favorable for those with sASDH than for those with tASDH. In one half of the patients with sASDH, arterial bleeding was noted perioperatively, although the preoperative radiological examinations revealed no abnormalities for most patients. However, the lack of sufficient examinations such as computed tomography angiography made it difficult to establish the most common etiology of bleeding in those with sASDH. Further research is warranted to determine the reference standard method for the investigation of sASDH.

Neurosurgical Treatment of Patients with Posterior Fossa Acute Subdural Hematoma Right after Cardiac Surgery.

As posterior fossa acute subdural hematoma (ASDH) right after cardiac surgery is extremely rare, the clinical course and optimal treatment strategy remain undetermined. We performed a retrospective analysis of patients with posterior fossa ASDH right after cardiac surgery requiring neurosurgical treatment at our institution over a 7-year period and, in this study, discussed the neurosurgical strategy and clinical course. Collected data included clinical history, laboratory results, time course, symptoms, neurosurgical treatment, outcome at discharge, and imaging studies. All six patients were women who had no history of head trauma and had received antithrombotic therapy during the perioperative period of cardiac surgery. All patients showed lower platelets count and were diagnosed with ASDH within 3 days (longest time 64 h) right after cardiac surgery. After discontinuation of anticoagulation therapy and administration of reversal agents, they underwent emergency hematoma evacuation craniotomy (n = 5) or burr hole drainage surgery (n = 1), which were performed in the prone (n = 4) or lateral (n = 2) positions. Four of these patients showed favorable outcomes, and two showed poor outcomes. One of the poor-outcome patients received three antithrombotic therapies, and another developed rapidly progressive ASDH. Posterior fossa ASDH associated with antithrombotic therapy right after cardiac surgery is frequently found in women, and emergent neurosurgical treatment with anticoagulation discontinuation and reversal agent administration can be performed safely. Burr hole drainage surgery might be acceptable in nonsevere cases. By contrast, we must pay attention to cases receiving both anticoagulant and antiplatelet drugs and rapid progression cases.

Functional Outcome After Primary Decompressive Craniectomy for Acute Subdural Hematoma in Severe Traumatic Brain Injury.

AIM: To evaluate the impact of primary decompressive craniectomy (DC) on the functional outcome in patients with post traumatic acute subdural hematoma (SDH). MATERIAL AND METHODS: A retrospective cohort analysis of 92 patients with post traumatic acute SDH who underwent primary DC and evacuation of SDH. The primary outcome variable is Glasgow outcome scale at 6 months follow up, while exposure variables are demographic data (age and gender), initial Glasgow coma scale, Marshall Classification Score of traumatic brain injury, midline shift, side of the lesion, surgery related complications and time of cranioplasty. RESULTS: Out of the 92 patients in this study, 89.1% were males and the mean age was 30.2 ± 14.4 years. At admission, the mean Glasgow Coma Scale (GCS) was 5.8 ± 2 and mean Marshall score was 4.7 ± 0.7, while the average midline shift was 8.8 ± 3.5 mm. Right decompressive craniectomy was performed in 46 (50%) patients, while in 2 (2.1%) cases, bi-frontal craniectomy was performed and left decompressive craniectomy was performed in 44 (47.8%) patients. Mortality was reported in 38 patients (41.3%) and poor outcome was reported in 24 patients (26.1%), while 30 patients (32.6%) showed good outcome. During the follow up period, cranioplasty for restoration of the bone defect was completed in 52 patients. CONCLUSION: Primary decompressive craniectomy after STBI for post-traumatic acute subdural hematoma improved the favorable outcome whenever the initial GCS > 4 among adult patients.

Factors Favoring the Development of Chronic Subdural Hematoma After Traumatic Acute Subdural Hematoma in the Elderly.

INTRODUCTION: Traumatic acute subdural hematoma (TASDH) is by far the most common traumatic brain injury in elderly patients presented to the emergency department, and a number of those treated conservatively will develop chronic subdural hematoma (CSDH). The factors contributing to chronicity were not well studied in the elderly; therefore, we retrospectively analyzed our elderly patients with acute subdural hematomas to identify the risk factors which might contribute to the development of subsequent CSDH. METHODS: A retrospective analysis of 254 patients with TASDH admitted between 2012 and 2016 to our level 2 trauma department in a community hospital was collected. Data include age, sex, comorbid conditions, CT findings, anticoagulant therapy, surgical interventions, disposition after discharge, and mortality. Data on those readmitted within the first 2 months with the diagnosis of CSDH were also studied (group A), and compared to those not readmitted (group B). Multiple logistic regression was used to determine the risk factors associated with readmission at P ≤ .05. Institutional review board approval was obtained for this study. RESULTS: There were 254 patients who were admitted with TASDH, 144 male (56.7%) and 110 female (43.3%), with the mean age of 71.4 (SD ± 19.38) years. Only 37 patients (14.6%) went for surgery in their initial admission. A total of 14 patients (5.6%) were readmitted subsequently with the diagnosis of CSDH within two months of initial discharge (group A). Only four patients (28.5%) were on anticoagulant therapy and these patients went for emergency craniotomy for evacuation of hematoma. All 14 patients had a history of coronary artery disease and hypertension and only 5 (35.7%) were diabetic. Review of head CT on initial admission of those patients revealed 4 patients (28.5%) had multiple lesions and 4 (28.5%) had tentorial/falax bleeding and 4 (28.5%) had a shift. The initial size and thickness of the bleeding was 1.4-5 mm. The adjusted model identified diabetes, race, and initial disposition as significant risk factors (P < .05). CONCLUSION: Risk associated with the transformation of TASDH to CSDH is difficult to assess in those group of elderly patients because of the small number; however, diabetes, race, and initial disposition to home pointed toward a risk for future development of CSDH and those patients should be followed clinically and radiographically over the next few months after discharge, particularly those on anticoagulant therapy.

Acute subdural haematoma in the elderly: to operate or not to operate? A systematic review and meta-analysis of outcomes following surgery.

OBJECTIVES: Acute subdural haematoma (ASDH) is a devastating pathology commonly found on CT brain scans of patients with traumatic brain injury. The role of surgical intervention in the elderly has been increasingly questioned due to its associated morbidity and mortality. Therefore, a systematic review and meta-analysis of the literature to quantify the mortality and functional outcomes associated with surgical management of ASDH in the elderly was performed. DESIGN/SETTING: A multidatabase literature search between January 1990 and May 2020, and meta-analysis of proportions was performed to quantify mortality and unfavourable outcome (Glasgow Outcome scale 1-3; death/ severe disability) rates. PARTICIPANTS: Studies reporting patients aged 60 years or older. INTERVENTIONS: Craniotomy, decompressive craniectomy, conservative management. OUTCOME MEASURES: Mortality and functional outcomes (discharge, long-term follow-up (LTFU)). RESULTS: 2572 articles were screened, yielding 21 studies for final inclusion and 15 for meta-analysis. Pooled estimates of mortality were 39.83% (95% CI 32.73% to 47.14%; 10 studies, 308/739 patients, I2=73%) at discharge and 49.30% (95% CI 42.01% to 56.61%; 10 studies, 277/555 patients, I2=63%) at LTFU. Mean duration of follow-up was 7.1 months (range 2-12 months). Pooled estimate of percentage of poor outcomes was 81.18% (95% CI 75.61% to 86.21%; 6 studies, 363/451 patients, I2=45%) at discharge, and 79.25% (95% CI 72.42% to 85.37%; 8 studies, 402/511 patients, I2=66%) at LTFU. Mean duration of follow-up was 6.4 months (range 2-12 months). Potential risk factors for poor outcome included age, baseline functional status, preoperative neurological status and imaging parameters. CONCLUSIONS: Outcomes following surgical evacuation of ASDH in patients aged 60 years and above are poor. This constitutes the best level of evidence in the current literature that surgical intervention for ASDH in the elderly carries significant risks, which must be weighed against benefits. PROSPERO REGISTRATION NUMBER: CRD42020189508.

Case Report: Surgical Management in Acute Subdural Hematoma Induced by Chronic Myelogenous Leukemia.

BACKGROUND Chronic subdural hematoma is defined as collection in the subdural space for more than 3 weeks. The incidence ranges from 1 to 20 per 100 000/year, with increased prevalence in the elderly, in males, and with use of anticoagulants or antiplatelets. Chronic myeloid leukemia has been linked to spontaneous subdural hematoma, with the highest reported cases of 39 patients in Korea, but no management is mentioned in that paper. There are few reported cases of patients who are medically free with no use of anticoagulants, diagnosed as having a subdural hematoma and then later discovered to have chronic myelogenous leukemia. CASE REPORT We report the case of a 45-year-old man, with known hypertension and diabetes mellitus type 2, on aspirin weekly, who was referred from another hospital with a history of sudden-onset severe headache not related to trauma. Computed tomography (CT) of the brain done in the other hospital showed a left-side subdural hematoma with midline shift. He underwent left-sided acute subdural hematoma evacuation and decompressive hemicraniectomy. He was started on hydroxyurea for chronic myelogenous leukemia. CONCLUSIONS A lesson from this rare case is to look for a differential diagnosis and to keep chronic myelogenous leukemia in mind in patients with leukocytosis. Also, we recommend sending a hematology referral in nontraumatic subdural hematoma. There is no specific treatment or algorithm based on previous research, although from observed data and based on information from the American Heart Association, it is reasonable to perform craniectomy in extra-axial collections of more than 1 cm with midline shift to avoid mortality, as reaching a diagnosis would take too much time.

The usefulness of postmortem computed tomography angiography for subdural hematoma caused by rupture of the cortical artery: A report of two autopsy cases and a literature review.

Acute subdural hematoma (SDH) occurs following severe head trauma with brain contusion or rupture of bridging veins. Conversely, SDH caused by rupture of a cortical artery without trauma or with minor trauma is also possible. Although over 180 cases of the latter SDH have been reported, they were predominantly diagnosed only during surgery, and therefore, no adequate histological evaluation has been performed. Therefore, essential etiology of this SDH type has remained unclear. In addition, the scarcity of autopsy cases may be attributed to arterial rupture being missed if the microscopic findings are too minimal to detect during autopsy. Here, we describe two autopsy cases of SDH of cortical artery origin. Extravasation on postmortem computed tomography angiography and arterial leakage on macroscopic observation during autopsy facilitated detection of the ruptured artery and allowed detailed histological evaluation of the ruptured artery and adjacent dura mater. The etiology of arterial rupture is briefly described on the basis of histopathological findings in this study and the available literature.

Benign meningioma manifesting with acute subdural hematoma and cerebral edema: a case report and review of the literature.

BACKGROUND: Spontaneous subdural hematoma rarely presents with a hypervascular or malignant tumor but even less frequently in a benign tumor like meningioma. We encountered a patient with acute subdural hematoma associated with benign meningioma. Here, we report this case along with a review of previous reports, especially focusing on their clinical features and possible bleeding mechanisms. CASE PRESENTATION: A 53-year-old Asian woman presented with severe headache and progressive neurologic deterioration due to cerebral edema. The patient was submitted to open surgery for evacuation of the subdural hematoma and concurrent tumor removal on the ipsilateral parietal convexity. A hypervascular, encapsulated mass was identified during surgery and completely removed including the adjacent dura mater (Simpson grade 0). The tumor was histologically confirmed as an angiomatous meningioma (World Health Organization grade I). Her clinical course was uneventful after surgery. CONCLUSIONS: Although meningiomas are commonly benign according to their histological traits, they can lead to spontaneous bleeding and cause neurologically unstable condition. Therefore, meningiomas need to be considered as a cause of spontaneous subdural hematoma if radiologically suspicious, which should be reflected by proper management for a positive outcome.