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CASE REPORT
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 77-79

Bifrontal acute subdural hematoma


1 Department of Neurosurgery, NMCH, Nellore, Andhra Pradesh, India
2 Department of Maxillofacial Surgery, NMCH, Nellore, Andhra Pradesh, India
3 Department of Neurology, NMCH, Nellore, Andhra Pradesh, India

Date of Web Publication19-Jul-2013

Correspondence Address:
Suryapratap Singh
Senior registrar, Chinthareddypalam, Nellore - 524 002, Andhra Pradesh
India
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DOI: 10.4103/1118-8561.115268

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  Abstract 

Though, acute subdural hematoma (ASDH) is one of the most common emergencies in neurological surgery practice, bilateral bifrontal ASDH is uncommon and may constitute diagnostic and therapeutic challenge. Computer tomography and magnetic resonance imaging have important roles in the diagnosis of ASDH. We present a case of bifrontal ASDH that was successfully managed in our institution.

Keywords: Acute bifrontal subdural hematoma, craniotomy, radiological imaging


How to cite this article:
Singh S, Mohammad A, Bedi SS. Bifrontal acute subdural hematoma. Sahel Med J 2013;16:77-9

How to cite this URL:
Singh S, Mohammad A, Bedi SS. Bifrontal acute subdural hematoma. Sahel Med J [serial online] 2013 [cited 2019 Dec 15];16:77-9. Available from: http://www.smjonline.org/text.asp?2013/16/2/77/115268


  Introduction Top


Acute subdural hematoma is a collection of blood between the dura mater and arachnoid. [1],[2] In neurosurgery practice, acute and chronic subdural hematoma (CSDH) is common.[1],[3] Acute bilateral bifrontal subdural hematoma is however a rare entity. The pathophysiology of severe head trauma and its complications are still unclear. Maintenance of intracranial pressure in all kind of head injury patients is now an accepted procedure. [4],[5],[6]

We present a patient with clinical and radiological evidence of acute bifrontal subdural hematoma that was successfully managed.


  Case Report Top


A 19-year-old male was brought by his relatives in the emergency department with history of road traffic accident. There was vomiting and loss of consciousness for 10 minutes. On examination, he was drowsy with altered sensorium. Glasgow coma scale was E2V3M5. Routine blood investigation reports and coagulation profile were within normal limits. Computed tomography (CT) scan revealed a bifrontal hyperdense lesion with a mass effect on rest of the brain and ventricles [Figure 1]. The lesion was more on the right side. A diagnosis of acute subdural hematoma was made. In view of low Glasgow coma scale and mass effect, we decided to do hematoma evacuation by craniotomy via standard bicoronal incision [Figure 2]. This was followed by duroplasty. The patient improved with the first post-operative Glasgow coma scale of E4V5M5. Post-operative CT brain reveled frontal lobe edema with total removal of acute subdural hematoma with bifrontal craniotomy defect in CT scan bone window [Figure 3] and [Figure 4]. The Glasgow coma scale improved further to E4V5M6 by third post-operative day. He was discharged on the 9th postoperative day and remained stable during follow up.
Figure 1: Computed tomogram reveals large bifrontal acute subdural hematoma with closed ventricles and edematous brain parenchyma

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Figure 2: Bifrontal craniotomy intraoperatively

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Figure 3: Post-operative CT scan reveals bifrontal craniotomy defect

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Figure 4: Post-operative CT scan shows total removal of bilateral bifrontal ASDH with brain edema

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  Discussion Top


Intracranial hematoma in head injury patient is a very common presentation in emergency department. [1] Bilateral subdural is very rare and can be challenging to the neurosurgeons in the emergency room, [2] where quick assessment and accurate diagnosis and management are crucial in reducing the risk of complications.

CT and MRI scan are important diagnostic tools in ASDH. [2],[3],[7] CT scan findings include obliteration of ipsilateral ventricle and displacement of ipsilateral brain parenchyma from the bone of skull. Concave hyperdense lesion is seen in classical subdural hematoma. Other findings may include midline shift and mass effect with the absence of basal cisterns. [3],[8],[9] Apart from this, CT scan of bilateral subdural hematoma shows distorted bilateral ventricular anatomy, closed sulci and gyri of brain, and edematous brain parenchyma with bilateral hyperdense lesion. [3],[8],[9],[10]

In the current case presentation, we observed distorted bilateral ventricular anatomy, closed sulci gyri of brain, and edematous brain parenchyma with bilateral hyperdense lesion.

Sometimes, the CT scan may not be clearly diagnostic. In this situation, MRI would be helpful. [7],[11],[12],[13] Nonetheless, CT scan is the procedure of choice for head injury cases because of its easy availability, short procedure time, and ability to rule out other pathological lesions. [3] We applied standard treatment strategy of bicoronal incision by undertaking bifrontal craniotomy and duroplasty with good postoperative clinical and cosmetic outcomes. [2],[14],[15] Early bifrontal craniotomy as done in our patient has greater benefit in patients with acute subdural or epidural hematomas. [15] Emergency bifrontal craniectomy plays major role in the removal of acute subdural collection and reduction of intracranial pressure. [14] In fact, direct surgical removal of the hematoma and duroplasty are indicated wherever there is hematoma-induced intracranial hypertension. [15],[16]

In conclusion, acute bifrontal subdural hematoma requires prompt clinical and radiological evaluation with CT scan or MRI scan if the former is not helpful. Standard bicoronal incision and bifrontal craniotomy are useful with good outcome.

 
  References Top

1.Mori K, Maeda M. Surgical treatment of chronic subdural hematoma in 500 consecutive cases: Clinical characteristics, surgical outcome, complications, and recurrence rate. Neurol Med Chir (Tokyo) 2001;41:371-81.  Back to cited text no. 1
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2.Agrawal A. Bilateral biconvex frontal chronic subdural hematoma mimicking extradural hematoma. J Surg Tech Case Rep 2010;2:90-1.  Back to cited text no. 2
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3.Adhiyaman V, Asghar M, Ganeshram K, Bhowmick B. Chronic subdural haematoma in the elderly. Postgrad Med J 2002;78:71-5.  Back to cited text no. 3
    
4.Czosnyka M, Pickard J. Monitoring and interpretation of intracranial pressure. J Neurol Neurosurg Psychiatry 2004;75:813-21.  Back to cited text no. 4
    
5.Orakcioglu B, Beynon C, Kentar MM, Eymann R, Kiefer M, Sakowitz OW. Intracranial pressure telemetry: First experience of an experimental in vivo study using a new device. Acta Neurochir Suppl 2012;114:105-10.  Back to cited text no. 5
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6.Vanneste J. Diagnosis and management of normal-pressure hydrocephalus. J Neurol 2000;247:5-14.  Back to cited text no. 6
    
7.Fujisawa H, Nomura S, Kajiwara K, Kato S, Fujii M, Suzuki M. Various magnetic resonance imaging patterns of chronic subdural hematomas: indicators of the pathogenesis? Neurol Med Chir (Tokyo) 2006;46:333-9.  Back to cited text no. 7
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8.Baechli H, Nordmann A, Bucher H, Gratzl O. Demographics and prevalent risk factors of chronic subdural haematoma: Results of a large single-center cohort study. Neurosurg Rev 2004;27:263-6.  Back to cited text no. 8
    
9.De Noronha R, Sharrack B, Hadjivassiliou M, Romanowski C. Subdural haematoma: A potentially serious consequence of spontaneous intracranial hypotension. J Neurol Neurosurg Psychiatry 2003;74:752-5.  Back to cited text no. 9
    
10.Gelabert-González M, Iglesias-Pais M, García-Allut A, Martínez-Rumbo R. Chronic subdural haematoma: Surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 2005;107:223-9.  Back to cited text no. 10
    
11.Guenot M. Chronic subdural hematoma: Diagnostic imaging studies. Neurochirurgie 2001;47:473-8.  Back to cited text no. 11
    
12.Huisman TA, Schwamm LH, Schaefer PW, Koroshetz WJ, Shetty-Alva N, Ozsunar Y, et al. Diffusion tensor imaging as potential biomarker of white matter injury in diffuse axonal injury. Am J Neuroradiol 2004;25:370-6.  Back to cited text no. 12
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13.Tanikawa M, Mase M, Yamada K, Yamashita N, Matsumoto T, Banno T, et al. Surgical treatment of chronic subdural hematoma based onintrahematomal membrane structure on MRI. Acta Neurochirur (Wien) 2001;143:613-9.  Back to cited text no. 13
    
14.Ong Y, Goh K, Chan C. Bifrontal decompressive craniectomy for acute subdural empyema. Childs Nerv Syst 2002;18:340-3.  Back to cited text no. 14
    
15.Whitfield PC, Patel H, Hutchinson PJ, Czosnyka M, Parry D, Menon D, et al. Bifrontal decompressive craniectomy in the management of posttraumatic intracranial hypertension. Br J Neurosurg 2001;15:500-7.  Back to cited text no. 15
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16.Coplin WM, Cullen NK, Policherla PN, Vinas FC, Wilseck JM, Zafonte RD, et al. Safety and feasibility of craniectomy with duraplasty as the initial surgical intervention for severe traumatic brain injury. J Trauma 2001;50:1050-9.  Back to cited text no. 16
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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