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Year : 2010  |  Volume : 58  |  Issue : 4  |  Page : 654-658

Acute spontaneous subdural hematoma of arterial origin: A report of four cases and review of literature

1 Department of Neurosurgery, SKIMS, Soura, Srinagar, J&K - 190 017, India
2 Department of Neurosurgery, ASCOMS, Sidhra, Jammu, J&K - 180 004, India

Date of Acceptance10-Jun-2010
Date of Web Publication24-Aug-2010

Correspondence Address:
Sarbjit Singh Chhiber
Department of Neurosurgery, SKIMS, Soura, Srinager, J&K - 190 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.68698

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 » Abstract 

Acute spontaneous subdural hematoma of arterial origin, a neurosurgical emergency resulting from rupture of the perisylvian cortical artery, is a rare occurrence. We report four such patients who presented with progressive neurological deterioration. All the patients were operated and perisylvian cortical artery was identified as the source of bleeding in all the patients. Three of the patients had associated hypertension. We reviewed the clinical characteristics, etiology, and outcome of the reported cases in the literature. A high index of suspicion is necessary even in young patients in view of the phenomenon of re-rupture mimicking stroke. Early diagnosis and a wide craniotomy over the sylvian fissure to obtain hemostasis of bleeding points results in good outcome.

Keywords: Acute spontaneous subdural hematoma, arterial origin, cortical artery rupture, perisylvian region

How to cite this article:
Chhiber SS, Singh J P. Acute spontaneous subdural hematoma of arterial origin: A report of four cases and review of literature. Neurol India 2010;58:654-8

How to cite this URL:
Chhiber SS, Singh J P. Acute spontaneous subdural hematoma of arterial origin: A report of four cases and review of literature. Neurol India [serial online] 2010 [cited 2023 Feb 6];58:654-8. Available from: https://www.neurologyindia.com/text.asp?2010/58/4/654/68698

 » Introduction Top

Acute subdural haematoma is a neurological emergency and is often associated with disruption of superficial cerebral or cortical veins secondary to head trauma. Spontaneous subdural hematomas, however, are uncommon and is limited to case reports and small series. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] The etiological spectrum includes: arteriovenous malformation (AVM), [15] cocaine abuse, [16] dural metastasis, [17] coagulopathy, [11],[18] falx meningioma, [19] moyamoya disease, [11] and aneurysm rupture. [5],[20],[21],[22] Munro [23] was the first to describe a patient with subdural hematoma without history of head trauma. Acute spontaneous subdural hematoma (ASSDH) is a separate clinical entity with no apparent cause where the source of bleeding is almost invariably a branch of the middle cerebral artery (MCA) in the vicinity of the sylvian fissure. [11] The clinical characteristics of this entity were first described in 1971 by Tallalla and Mckissock and they referred to this clinical entity as a syndrome of "acute spontaneous subdural haematoma". [12] Tokoro et al. [1] termed it acute spontaneous subdural hematoma (ASSDH) of arterial origin and proposed the following diagnostic criteria: (a) no history of head trauma, (b) no damage to the underlying cortex, (c) no aneurysm or AVM around the affected artery, and (d) identification of hemorrhage as arterial at operation. Invariably, the site of the bleed has been identified near the sylvian fissure, affecting one of the cortical branches of the MCA. [1],[3],[4],[8],[9] We report four patients with ASSDH) who fulfilled the criteria proposed Tokoro et al.[1]

 » Case Report Top

Of the four patients seen during the period 2002-2006, two were male and two female and the age range was 24-59 years (mean: 44.25). The clinical features are summarized in [Table 1]. Three patients developed sudden onset headache associated with vomiting and two of them lapsed into coma. The fourth patient was irritable at the time of admission and became unconscious following generalized seizures. None of the patients had history of any bleeding disorder or recent head trauma. In all the patients the provisional diagnosis was stroke. Three of the patients had a history of hypertension (pregnancy-induced hypertension in one of the female). Both the males had history of diabetes mellitus. None of the patients had history of alcohol abuse. Computed tomography (CT) scan of head showed ASDH centered aroung the sylvian fissure with significant midline shift [Figure 1]a-d in all the four patients. In view of emergent situation, angiography was not done.
Figure 1 : (a-d) CT scans of patients 1 to 4 showing acute subdural hematomas centered around the sylvian fissures and associated with mass effect and midline shift

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Table 1 : Clinical features of the patients

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Operation was performed within 12 hours of onset of symptoms in one patient who presented directly to our hospital. Surgery was delayed beyond 24 hours in other three patients who were initially seen at other facility. All patients underwent large fronto-temporo-parietal craniotomy around the sylvian fissure and the source of bleeding was identified as a small cortical artery located near the sylvian fissure. Of the four patients, one patient who presented with bilaterally fixed dilated pupils and poor Glasgow Coma Scale (GCS) score (E1V1M2) died, whereas the others made remarkable recovery,and are back to their normal routines.

 » Discussion Top

Spontaneous ASDH of arterial origin is relatively unrecognized entity. Diagnosis is based on the the criteria proposed by Tokoro et al. [1] Only 38 such cases have been reported in English literature up to September 2009 [Table 2]. ASDH is usually associated in the majority of cases with disruption of superficial cerebral or cortical vessels secondary to head trauma, and sometimes it is a result of extension from an intracerebral hemorrhage from ruptured intracranial aneurysms, AVMs, hypertensive intracerebral hematoma, neoplasms, coagulopathy, cerebral amyloid angiopathy, and AIDS. [11] ASSDH of arterial origin usually results from a ruptured cortical artery that is situated within 3 cm of the sylvian fissure. [4] All our patients had a perisylvian bleeding cortical artery, though in one patient the clot was seen at the site of rupture.

Several possible mechanisms have been proposed for ASSDH formation. Vance, [24] in his autopsy series found small twigs connecting to the dura mater that branched perpendicularly from the cortical arteries. These twigs were torn by the shearing forces causing ASSDH. Drake et al[25] found adhesions between the dura mater and cortical arteries, which led to laceration of the adherent arterial wall following trivial trauma. The points of rupture were always located at branch points of MCA. According to Talalla, [12] prior head injury forms subdural clots, which results in adhesions. The involved artery is lacerated due to frictional forces and bleeding occurs. McDermott [13] described the presence of a rete mirabile connecting a cortical artery and the dura mater and found that disruption of this connection by trauma caused ASDH. Though we could see a lacerated cortical artery in all the four patients, we could not demonstrate any of the mechanisms described above.
Table 2 : Cases of ASSDH of arterial origin reported in English Literature

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The source of bleeding was confirmed by angiography and/or at operation and in all the cases reported, invariably, a ruptured cortical artery at or near the sylvian fissure was found. Yasui et al. [9] demonstrated extravasation of contrast from a cortical branch of the MCA on angiography in three of their four patients, the fourth patient showed extravasation from one of the branches of posterior cerebral artery (PCA) and the contralateral anterior cerebral artery (ACA). This is the only reported case with a bleeding source other than a perisylvian artery. Matsuyama et al. [4] studied points of rupture of cortical arteries at surgery in 19 patients, out of which only four met the criteria laid down by Tokoro et al. [1] The authors found that all ruptured arteries were in the distribution of MCA and the bleeding points were within 3 cm of sylvian fissure. In all our patients, the source of bleeding was a perisylvian artery on the temporal side. The reason for this predilection is not known.

ASSDH is more commonly reported in the elderly males, [1],[2],[3],[14] however it has been reported in a teenager. [26] The mean age of our patients was 44 years. About 40% of patients with ASSDH have associated hypertension and alcohol abuse. The arteriosclerotic vessels in hypertensive patients may interface and bind to dura mater thus may predispose to rupture. [4] Patients with ASSDH have a progressive deterioration over hours or days. [12],[25] One of the explanation for this couse has been attributed to the persistent tiny opening of the ruptured cortical artery resulting in gradual expansion of the clot and subsequent sealing of the opening by the clot. [25] Tokoro et al. [1] attributed this to the phenomenon of re-rupture, where the initial minor hemorrhage is followed by a major arterial rupture. Probably this phenomenon of re-rupture may explain the course observed in our four patients. CT scan confirms the diagnosis and it is prudent to perform angiography only if the patient's condition permits the slight delay of angiogram [5] and also when the aneurysmal bleed is suspected. Preoperative CT angiography can be an option, but without delaying surgery. [20] Postoperative angiogram is complementary in the absence of identification of a cortical arterial bleed or other source of bleeding.

The reported mortality in ASSDH varies between 50% and 90%, [11] and in our series there was one death (25%). The possible factors for higher mortality are delay in diagnosis, arterial origin of the bleed. Significant factors associated with good outcome include early surgical evacuation, higher preoperative GCS scores, normal pupil reactivity, and young age. [5] A high index of suspicion is necessary as this rare entity can be a great mimic of stroke. Since the arterial bleed needs to be controlled, a wide craniotomy over the sylvian fissure has been the recommendation. [1],[2],[3],[4],[5],[8],[9],[11],[20] There are reports of spontaneous resolution of symptoms without emergency craniotomy. [11],[26] Microsuturing of the lacerated arterial wall instead of sacrificing the artery was suggested by Matsuyma et al., [4] whereas Pritz, in his comments on article by Koc et al. [3] suggested that biopsy of the artery may reveal the cause for the bleed. Strict adherence to the diagnostic criteria of ASSDH [1] is very much essential and coagulopathy-associated ASSDH should also be excluded as it is associated with high mortality. [11] In patients with ASSDH managed conservatively, angiographic evidence of cortical vessel extravasation can be considered as evidence of bleed from cortical vessel.

 » References Top

1.Tokoro K, Nakajima F, Yamataki A. Acute subdural hematoma of arterial origin. Surg Neurol 1988;29:159-63.   Back to cited text no. 1  [PUBMED]    
2.Hesselbrock R, Sawaya R, Means ED. Acute spontaneous subdural hematoma. Surg Neurol 1984;21:363-6.  Back to cited text no. 2  [PUBMED]    
3.Koc RK, Pasaoglu A, Kurtsoy A, Oktem S, Karuncu I. Acute spontaneous subdural hematoma of arterial origin: A report of five cases. Surg Neurol 1997;47:9-11.   Back to cited text no. 3      
4.Matsuyama T, Shimomura T, Okumura Y, Sakaki T. Acute subdural hematomas due to rupture of cortical arteries: A study of the points of rupture in 19 cases. Surg Neurol 1997;47:423-37.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]  
5.Missori P, Fenga L, Maraglino C, Rocchi G, Nardacci B, Calderaro G, et al. Spontaneous acute subdural hematoma. A clinical comparison with traumatic acute subdural hematomas. Acta Neurochir (Wien) 2000;147:697-701.  Back to cited text no. 5      
6.Byun HS, Patel PP. Spontaneous subdural hematoma of arterial origin: report of two cases. Neurosurgery 1979;5:611-5.  Back to cited text no. 6      
7.Arai H. Acute hypertensive subdural hematoma from arterial rupture shortly after the onset of cerebral subcortical hemorrhage; leakage of contrast medium during angiography. Stroke 1983;14:281-5.   Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Yanai Y, Kohno N, Mitsui T. Acute spontaneous subdural hematoma of arterial origin. Surg Neurol 1985;23:417-20.  Back to cited text no. 8  [PUBMED]    
9.Yasui T, Komiyama M, Kishi H, Yagura H, Fu Y, Nagata Y, et al. Anigographic extravasation of contrast medium in acute "Spontaneous" Subdural hematoma. Surg Neurol 1995;43:61-7.   Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Borzone M, Altomonte M, Baldini M, Rivano C. Pure subdural hematomas of arteriolar origin. Acta Neurochir (Wien) 1993;121:109-12.   Back to cited text no. 10  [PUBMED]    
11.Depreitere B, Van Calen bergh F, Var Loon J. A clinical comparison of non traumatic acute subdural hematomas Either related to coagulopathy or of arterial origin without coagulopathy. Acta Neurochir (Wein) 2003;145:541-6.   Back to cited text no. 11      
12.Talalla A, McKissock W. Acute "spontaneous" subdural hemorrhage: an unusual form of cerebrovascular accident. Neurology 1971;21:19-25.  Back to cited text no. 12  [PUBMED]    
13.McDermott M, Fleming JF, Vanderlinden RG. Spontaneous arterial subdural hematoma. Neurosurgery 1984;14:13-8.  Back to cited text no. 13      
14.O'Brien PK, Norris JW, Tator CH. Acute subdural hematoma of arterial origin. J Neurosurg 1974;41:435-9.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Rengachary SS, Szymanski DC. Subdural hematomas of arterial origin. Neurosurgery 1981;8:166-72.   Back to cited text no. 15  [PUBMED]    
16.Keller TM, Chappel ET. Spontaneous acute subdural hematoma precipitated by cocaine abuse: Case report. Surg Neurol 1997;47:12-5.  Back to cited text no. 16      
17.Sato M, Saito K, Yamaguchi K, Sakuma H. A case of acute subdural hematoma due to dural metastasis from malignant pleural mesothelioma. No Shinki Geka 1994;22:247-51.  Back to cited text no. 17      
18.Saito K, Sakurai Y, Uenohara H, Seki K, Imaizumi S, Katakura R, et al. A case of subdural hematoma in the posterior fossa with idiopathic thromboaytopenia purpura. No Ro Shinkei 1992;44:377-81.   Back to cited text no. 18      
19.Okuno S, Touho H, Ohnishi H, Karasawa J. Falx meningioma presenting as acute subdural hematoma: Case report. Surg Neurol 1999;52:180-4.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  
20.Koerbel A, Ernemann U, Freudenstein D. Acute subdural hematoma without subarachnoid hemorrhage caused by rupture of internal carotid artery bifurcation aneurysm: case report and review of literature. Br J Radiol 2005;78:646-50.  Back to cited text no. 20  [PUBMED]  [FULLTEXT]  
21.Kohno K, Ueda T, Kadota O, Sakaki S. Subdural hemorrhage caused by the de novo aneurysm complicating extracranial intracranial bypass surgery: case report. Neurosurgery 1996;38:1051-5.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]  
22.Mclaughin RM, Jho HD, Kwon Y. Acute subdural hematoma caused by a ruptured gaint intracavernous aneurysm: case report. Neurosurgery 1996;38:388-92.  Back to cited text no. 22      
23.Munro D. The diagnosis and treatment of subdural hematoma: a report of sixty two cases. N Engl J Med 1934;210:1145-60.  Back to cited text no. 23      
24.Vance BM. Rupture of surface blood vessels on cerebral hemispheres as a cause of subdural hemorrhage. Arch Surg (Chicago) 1950;61:992-1006.   Back to cited text no. 24      
25.Drake CG. Subdural hematoma from arterial rupture. J Neurosurgery 1961;18:597-601.  Back to cited text no. 25      
26.Kulah A, Tasdemir N, Fiskeci C. Acute spontaneous subdural hematoma in a teenager. Childs Nerv Syst 1992;8:343-6.  Back to cited text no. 26      


  [Figure 1]

  [Table 1], [Table 2]

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