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Year : 2003  |  Volume : 51  |  Issue : 3  |  Page : 422--424

Intracranial aneurysms causing spontaneous acute subdural hematoma

SN Shenoy, MG Kumar, A Raja 
 Department of Neurosurgery, Kasturba Medical College & Hospital, Manipal - 576119, Udupi, India

Correspondence Address:
S N Shenoy
Department of Neurosurgery, Kasturba Medical College & Hospital, Manipal - 576119, Udupi
India

Abstract

Acute subdural hematoma is an uncommon presentation of the rupture of an intracranial aneurysm. We report two cases of intracranial aneurysms causing spontaneous acute subdural hematoma.



How to cite this article:
Shenoy S N, Kumar M G, Raja A. Intracranial aneurysms causing spontaneous acute subdural hematoma .Neurol India 2003;51:422-424


How to cite this URL:
Shenoy S N, Kumar M G, Raja A. Intracranial aneurysms causing spontaneous acute subdural hematoma . Neurol India [serial online] 2003 [cited 2020 Mar 30 ];51:422-424
Available from: http://www.neurologyindia.com/text.asp?2003/51/3/422/1198


Full Text

  

   Introduction



Spontaneous acute subdural hematoma is an uncommon manifestation of the rupture of a cerebral aneurysm. Aneurysms of the internal carotid artery and middle cerebral artery are more commonly associated with the presentation of subdural hematoma.[1],[2],[3],[4]

During the last 15 years, 348 cases of intracranial aneurysms were operated at the Kasturba Hospital, Manipal. Of these, two patients had acute subdural hematoma secondary to the rupture of an intracranial aneurysm. We report these two cases of acute subdural hematoma and review the literature on the subject.



  

   Case Reports



Case1

A 45-year-old lady presented with sudden onset severe headache and blurring of vision for 7 days. She had been diagnosed earlier as having a polycystic kidney. She had bilateral sixth cranial nerve paresis and no other neurological deficits. Computed tomography (CT) scan revealed the presence of right fronto-temporo-parietal acute subdural hematoma causing mass effect with the compression of the ipsilateral ventricle and midline shift. Contrast enhanced CT scan revealed an enhancing speck in the region of the right middle cerebral artery bifurcation [Figure:1]. Investigations revealed impaired renal function with serum creatinine 2.3-mg%. In view of impaired renal function digital subtraction angiography and 3D-CT angiography was not done. Magnetic resonance angiography could not be done due to financial constraints. She underwent a pterional craniotomy and evacuation of the acute subdural hematoma and clipping of the middle cerebral artery bifurcation aneurysm. The arachnoid adjacent to the aneurysm was seen to be torn by the clot.



Case 2

A 78-year-old lady presented with sudden onset headache and a transient altered sensorium. She was conscious, obeyed all commands and was oriented and had left hemiparesis. CT scan showed a large right fronto-parietal acute subdural hematoma with significant mass effect [Figure:2]. There was also evidence of blood in the Sylvian fissure. 3D-CT angiography showed a right posterior communicating artery aneurysm [Figure:3]. She underwent a pterional craniotomy and evacuation of the acute subdural hematoma and clipping of the posterior communicating artery aneurysm. On close inspection under the microscope, it was noticed that the Sylvian arachnoid was torn at a site away from the aneurysm. Postoperatively, the patient was neurologically well preserved.



  

   Discussion



The various types of intracranial bleeding due to the rupture of a cerebral aneurysm are: subarachnoid hemorrhage (about 60%), intracerebral hematoma (30 to 40%) and intraventricular hematoma (12 to 17%).[2],[34] The incidence of spontaneous acute subdural hematoma due to aneurysm rupture varies from 0.5% to 7.9%.[1],[4],[5],[6]

Various mechanisms have been proposed to explain the causation of acute subdural hematoma after the rupture of saccular aneurysm. Firstly, the aneurysm adherent to the arachnoid may bleed directly into the subdural space when the arachnoid tear occurs after aneurysm rupture.[7] Secondly, the stream of blood may rupture through the arachnoid at some distant weak point.[8] Lastly, the subdural hematoma may develop secondary to the decompression of intracerebral hematoma into the subdural space following disruption of the arachnoid covering the cerebral cortex.[9]

Acute subdural hematoma has been described in association with aneurysms at almost all the branches of intracranial arteries.[2] Fox analyzed the world literature and found 56 reports containing 146 cases of subdural hematoma that were published between 1895 and 1978.[2] The commonest aneurysm associated with subdural hematoma was internal carotid artery aneurysm, followed by middle cerebral artery aneurysm.[2],[5] Similar to our cases, about 80% of the cases of subdural hematoma due to the rupture of cerebral aneurysms reported in the literature were seen in females.[2],[5] The majority of these patients presented with features suggestive of transtentorial herniation such as anisocoria, hemiplegia and altered consciousness.[4],[5],[9],[10] On the other hand, both the cases reported here presented in good clinical grade and had no lateralizing deficit.

An acute subdural hematoma in the absence of head trauma requires further neuro-radiological investigation to define its possible cause.[5],[10],[11] Weir et al reported various criteria to differentiate subdural hematoma due to a ruptured aneurysm from trauma in the CT scan.[4],[5],[10] If the patient is stable enough to allow further investigations before craniotomy, then angiographic study to define the vascular lesion must be considered. If the patient is in poor clinical grade, a 3D-CT angiography is the best investigation to detect the presence of an aneurysm.

Certain criteria must be assessed with regard to the timing of the operation in patients with aneurysm-related acute subdural hematoma.[5],[11] If the subdural hematoma is well tolerated like in the cases reported here, then relatively elective clipping of the aneurysm under optimal operating conditions along with evacuation of the subdural hematoma can be performed. However, in the face of rapid clinical deterioration, an emergency craniotomy for subdural evacuation should be performed before further investigations.[5],[10] Both cases reported here underwent early operation and improved postoperatively. The incidence of delayed ischemic deficit in these patients is reported to be low as compared to those patients who had subarachnoid hemorrhage.[2]

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