Document Detail

Clinical features, treatment, and prognosis of patients with acute subdural hematomas presenting in critical condition.
MedLine Citation:
PMID:  17881959     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: Spontaneous acute subdural hematoma (aSDH) may be caused by aneurysm rupture. Patients can present in very poor clinical condition with anisocoria or even bilaterally dilated pupils, absent brainstem reflexes, and cardiac insufficiency. For the clinician, the question is how should these patients be treated? Large series on this subject do not exist because aSDH is a rare event. This report focuses on the prognosis and adverse prognostic factors of these patients. CLINICAL PRESENTATION: We present eight cases of aSDH and subarachnoid hemorrhage attributable to aneurysm rupture. All patients were World Federation of Neurosurgical Societies Grade 5. Four presented with anisocoria, three presented with bilaterally fixed and dilated pupils, and one developed anisocoria in the course of treatment. TREATMENT: As a result of prolonged hypoxia before admission, one patient was not treated and died. In one patient, surgical decompression could not be performed in the acute phase as a result of significant comorbidity. All other patients received decompressive surgery, obliteration of the aneurysm, and medical therapy as well as extensive rehabilitation measures. After 6 months, four had no or only minor neurological deficits; one patient was independent despite hemiparesis. Two patients whose surgical decompression had to be delayed as a result of severe cardiac instability recovered poorly, showed severe neurological deficits, and required permanent care. However, none of the patients survived in a persistent vegetative state. CONCLUSION: Within the spectrum of aneurysmatic hemorrhage, patients with aSDH represent a distinct subgroup. Despite a very poor clinical condition on admission, recovery with only minor deficits or even without neurological deficit is possible. Mass effect and herniation induce a poor clinical condition, which is not directly related to the underlying subarachnoid hemorrhage. Hence, clinical grading systems such as the Hunt and Hess scale or World Federation of Neurosurgical Societies grading are not applicable. We suggest that whenever the medical condition allows, rapid surgical decompression should be performed even in patients who present in very poor neurological condition.
Thomas Westermaier; Jörg Eriskat; Ekkehard Kunze; Thomas Günthner-Lengsfeld; Giles H Vince; Klaus Roosen
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Publication Detail:
Type:  Case Reports; Journal Article    
Journal Detail:
Title:  Neurosurgery     Volume:  61     ISSN:  1524-4040     ISO Abbreviation:  Neurosurgery     Publication Date:  2007 Sep 
Date Detail:
Created Date:  2007-09-20     Completed Date:  2007-11-07     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  7802914     Medline TA:  Neurosurgery     Country:  United States    
Other Details:
Languages:  eng     Pagination:  482-7; discussion 487-8     Citation Subset:  IM    
Department of Neurosurgery, University of Würzburg, Würzburg, Germany.
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MeSH Terms
Critical Care / methods*
Critical Illness
Diagnosis, Differential
Hematoma, Subdural, Acute / diagnosis*,  therapy*
Middle Aged
Treatment Outcome

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