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CASE REPORT
Year : 2003  |  Volume : 51  |  Issue : 1  |  Page : 63-64

Interhemispheric subdural hematoma: An uncommon sequel of trauma


Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu-632004

Correspondence Address:
Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, Tamil Nadu-632004
mjoseph@cmcvellore.ac.in

 » Abstract 

Interhemispheric subdural hematomas are relatively uncommon and usually seen in patients with bleeding disorders. They may present with signs of the falx syndrome or seizures. The management options range from craniotomy and evacuation to conservative management. We report such a case in a patient with normal bleeding parameters, which was managed with a twist drill craniostomy and drainage of the hematoma.

How to cite this article:
Shankar A, Joseph M, Chandy M J. Interhemispheric subdural hematoma: An uncommon sequel of trauma . Neurol India 2003;51:63-4


How to cite this URL:
Shankar A, Joseph M, Chandy M J. Interhemispheric subdural hematoma: An uncommon sequel of trauma . Neurol India [serial online] 2003 [cited 2018 Nov 16];51:63-4. Available from: http://www.neurologyindia.com/text.asp?2003/51/1/63/1033


Interhemispheric subdural hematomas, first described by Aring and Evans[1] in 1940, constitute a rare type of subdural hematoma with only about 100 cases reported till 1997.[2],[3],[4],[5] They are usually considered to be a distinct entity because of their unusual location and the fact that their management is still a matter of debate. A recent case is reported and management options are reviewed.

  »   Case Report
 Top

A 65-year-old lady presented three days after a fall on level ground. She had been asymptomatic for a day following the fall, but then developed left-sided hemiparesis and altered sensorium, which worsened over a few hours, to become static till admission 48 hours later. There was no history of seizures or vomiting. She had suffered from an acute diarrhoeal disorder for two days prior to her injury.
On examination, she was dehydrated but hemodynamically stable. Her Glasgow Coma Scale was 13/15 (opening eyes to call, obeying commands and confused). Pupils were both equal and reacting, but fundi could not be visualized due to the presence of cataract. She had a left upper motor neuron type of seventh nerve paresis and a left hemiparesis with grade II power. Deep tendon reflexes were exaggerated and plantar was upgoing on the left side.
A CT scan of the brain showed a 1 cm thick subdural hematoma extending along the full length of the interhemispheric fissure [Figure - 1]. In addition, there was a thin right frontal subdural hematoma, and two small right frontal contusions - one in the convexity region and a second one postero-medially, in the region of the centrum semiovale, adjacent to the body of the lateral ventricle. All the hematomas were hyperdense, with a small loculated hypodensity in the interhemispheric fissure.
Her biochemical studies were within normal range. As her neurological condition had been stable for over 48 hours, she was treated conservatively with anti­convulsants, anti-edema measures and fluid replacement. Her sensorium remained stable over the next 2 days. However, on the third day, it was found that she was opening eyes only to pain, and was only localizing pain and making incomprehensible sounds (GCS Score 9/15). The power in the left upper and lower limbs had deteriorated to grade I. A repeat CT scan of the brain showed increase in the perilesional edema, but there was no change in the size of the hematoma. A paramedian twist drill craniostomy was done just anterior to the coronal suture and approximately 15 ml of dark altered blood clot was evacuated, following which her neurological condition improved.

  »   Discussion Top


Interhemispheric subdural hematomas are uncommon lesions, usually occurring in patients with bleeding diatheses.[2] They are associated with trauma in 83% of cases.[3] Other reported causes include child abuse with shaking, forceps delivery or a history of birth trauma, hemodialysis, anticoagulation, aneurysmal bleeding[6] and penetrating injuries. The preceding trauma is frequently of low velocity, and injury to the bridging veins of the interhemispheric fissure is believed to be the cause of the hematoma. However, the vector of force that can produce an interhemispheric subdural hematoma remains controversial. Fruin et al[7] postulated that an occipital blow in the sagittal plane would lead to an interhemispheric subdural hematoma because of the anatomic orientation of the veins in the interhemispheric fissure, which tend to course antero-medially from the cortex to the midline sinuses. These lesions are usually unilateral, but bilateral hematomas have been reported.[8]
List[9] first described the falx syndrome in patients with interhemispheric subdural empyemas in 1955. Patients present with contralateral hemiparesis, the lower limb being involved more than the upper. Other presenting symptoms can include clouding of consciousness, focal or generalized seizures, dementia, language disorders, gait ataxia and oculomotor dysfunction.[10]
Conservative treatment and surgery are equally favored in the treatment of these patients[11]. Surgical interventions ranging from a twist drill craniostomy to craniotomy and evacuation of hematoma have been tried.[12] There is no difference in outcome between those treated by burr hole evacuation of hematomas and craniotomies. Though removal of the clot has proved to be a viable option in the management of these patients, there is some danger due to the proximity of the superior sagittal sinus and bridging veins. Furthermore, some of these hematomas migrate superiorly (to a more favorable position as regards surgery) with time, as they liquefy.[13] Another point in favor of conservative management is the fact that there is no significant difference in the outcomes of those treated by either modality. If at all, patients who underwent surgery had impaired consciousness for a longer period of time. Though there is no consensus on the ideal management of these rare hematomas, a flexible treatment plan has to be made, where surgical treatment is reserved for those who have pronounced symptoms or neurological deficits, and conservative treatment may be followed in those who are neurologically stable or have concurrent risk factors.[2],[3] 

 » References Top

1.Aring CD, Evans JP. Aberrant location of subdural hematoma. Arch Neurol Psychiatry 1940;44:1296-306.   Back to cited text no. 1    
2.Bartels RH, Verhagen WI, Prick MJ, Dalman JE. Interhemispheric subdural hematoma in adults: case reports and a review of the literature. Neurosurgery 1995;36:1210-4.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Sadrolhefazi A, Bloomfield SM. Interhemispheric and bilateral chronic subdural hematoma. Neurosurg Clin N Am 2000;11:455-63.  Back to cited text no. 3  [PUBMED]  
4.Houtteville JP, Toumi K, Theron J, Derlon JM, Benazza A, Hubert P. Interhemispheric subdural haematomas: seven cases and review of the literature. Br J Neurosurg 1988;2:357-67.  Back to cited text no. 4  [PUBMED]  
5.Rapana A, Lamaida E, Pizza V, Lepore P, Caputi F, Graziussi G. Inter-hemispheric scissure, a rare location for a traumatic subdural hematoma, case report and review of the literature. Clin Neurol Neurosurg 1997;99:124-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Ishikawa E, Sugimoto K, Yanaka K, Ayuzawa S, Iguchi M, Moritake T, et al. Interhemispheric subdural hematoma caused by a ruptured internal carotid artery aneurysm: case report. Surg Neurol 2000;54:82-6.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Fruin AH, Juhl GL, Taylon C. Interhemispheric subdural hematoma. Case report. J Neurosurg 1984;60:1300-2.  Back to cited text no. 7  [PUBMED]  
8.Kasdon DL, Magruder MR, Stevens EA, Paullus WS Jr. Bilateral interhemispheric subdural hematomas. Neurosurgery 1979;5:57-9.  Back to cited text no. 8  [PUBMED]  
9.List CF. Diagnosis and treatment of acute subdural empyemas. Neurology 1955;5:663.   Back to cited text no. 9  [PUBMED]  
10.Ogsbury JS, Schneck SA, Lehman RA. Aspects of interhemispheric subdural haematoma, including the falx syndrome. J Neurol Neurosurg Psychiatry 1978;41:72-5.  Back to cited text no. 10  [PUBMED]  
11.Furui T, Iwata K, Usui K. Interhemispheric subdural haematoma complicated by intracerebral haematoma: case report. Acta Neurochir (Wien) 1988;91:139-41.  Back to cited text no. 11  [PUBMED]  
12.Brill CB, Jarath V, Black P. Occipital interhemispheric acute subdural hematoma treated by lambdoid suture tap. Neurosurgery 1985;16:247-51.  Back to cited text no. 12  [PUBMED]  
13.Sibayan RQ, Gurdjian ES, Thomas LM. Interhemispheric chronic subdural hematoma. Report of a case. Neurology 1970;20:1215-8.  Back to cited text no. 13    

 

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