|Year : 2013 | Volume
| Issue : 2 | Page : 77-79
Bifrontal acute subdural hematoma
Suryapratap Singh1, Akheel Mohammad2, Saranjeet Singh Bedi3
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 Publication||19-Jul-2013|
Senior registrar, Chinthareddypalam, Nellore - 524 002, Andhra Pradesh
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
| Introduction|| |
Acute subdural hematoma is a collection of blood between the dura mater and arachnoid. , In neurosurgery practice, acute and chronic subdural hematoma (CSDH) is common., 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. ,,
We present a patient with clinical and radiological evidence of acute bifrontal subdural hematoma that was successfully managed.
| Case Report|| |
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 4: Post-operative CT scan shows total removal of bilateral bifrontal ASDH with brain edema|
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| Discussion|| |
Intracranial hematoma in head injury patient is a very common presentation in emergency department.  Bilateral subdural is very rare and can be challenging to the neurosurgeons in the emergency room,  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. ,, 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. ,, 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. ,,,
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. ,,, 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.  We applied standard treatment strategy of bicoronal incision by undertaking bifrontal craniotomy and duroplasty with good postoperative clinical and cosmetic outcomes. ,, Early bifrontal craniotomy as done in our patient has greater benefit in patients with acute subdural or epidural hematomas.  Emergency bifrontal craniectomy plays major role in the removal of acute subdural collection and reduction of intracranial pressure.  In fact, direct surgical removal of the hematoma and duroplasty are indicated wherever there is hematoma-induced intracranial hypertension. ,
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.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]