TheJourna/of Emergency M&one, Vol 4, pp 103-107, INTERHEMISPHERIC 1986 Pmted in the USA l Copyng?t 0 1986 PergamonJournalsL.td SUBDURAL HEMATOMA Gilbert J. Toffol, DO, Jose Biller, MD, and Harold P. Adams, Jr., MD Department of Neurology, Dlvlsion of Cerebrovascular C&eases, Unlverslty of Iowa Hospitals and Clinics, Iowa City; and Iowa City Veterans Adminlstration Hospital Repnnt address: Gilbert J. Toffol. DO, Department of Neurology, Dlvlslon of Cerebrovascular University of Iowa Hospitals & Clinics, Iowa City, IA 52242 0 Abstract -A case of interhemispheric subdural hematoma (ISH) following closed head injury is reported. Our patient had seizures and mental status changes. Cranial computed tomography (CT) demonstrated areas of increased density along the right side of the falx cerebri and over the right leaf of the tentorium cerehelli. Conservative treatment was chosen and the patient recovered. Ten other patients with ISH were compared with ours. Head injury is the leading cause of ISH. Most patients display confusion, lethargy, or a “falx syndrome,” with a delayed interval of prominent neurological deficits from the time of injury until presentation. Although patients with ISH can be successfully treated by medical management, surgical intervention may be required. El Keywords- hematoma; falx; trauma; arteriography; craniotomy Diseases, lateral leg weakness or crural hemiparesis were labeled as having a “falx syndrome.“” The differential diagnosis of this neurological finding encompasses anterior cerebral artery territory infarctions, anterior communicating artery aneurysms with subarachnoid hemorrhage, and an ISH. On unenhanced CT scans, ISH is characterized by a crescentric hyperdensity with flat medial and convex lateral borders. Frequently the hematoma extends along the tentorium cerebelli.” These abnormalities on the CT scan may be confusing and lead to failure to diagnose a potentially treatable condition. We present a case with the typical ISH findings on CT scans who was successfully managed medically. Case Report Introduction Interhemispheric subdural hematoma (ISH) is often seen in child abuse cases where the child was given a severe shaking.L,2 However, ISH is rare among adults. ISH is usually of traumatic origin and has characteristic clinical features.3 Mental status changes appear several hours to days after the trauma; however, rapid deterioration without warning can occur.4 Before computed tomography (CT) patients who had a contraRECEIVED: 19 August A 66-year-old man with a history of chronic alcohol abuse was transferred to the Iowa City Veterans Administration Hospital with facial lacerations, seizures, and disorientation. Earlier in the day he fell and sustained a head injury. Several hours later, he had two generalized seizures. General physical examination showed no abnormalities. Neurological examination disclosed temporal disorientation, retrograde amnesia, and an unsteady, wide-based 1985; ACCEPTED: 26 December 1985 103 0736-4679/86 $3.00 + .OO 104 George J. Toffol, Jo& Biller, and Harold P. Adams, Jr. Figure 1. A: Initial CT scan shows areas of increased density along the right side of the falx cerebri (arrows). 6: Partial resolution of these areas two days later. gait. He did not have unilateral or bilateral leg paresis. Findings from routine laboratory tests were normal. A CT scan demonstrated a high-density lesion along the right side of the falx cerebri extending over the right tentorium cerebelli, consistent with an ISH (Figures 1 and 2). The EEG was normal. Because of his stable neurological condition, conservative management was elected. He was treated with phenytoin 100 mg three times daily, thiamine 100 mg/d and folate 1 mg/d. The patient’s mental status and gait improved. A second CT scan seven days later showed resolution of the right interhemispheric and tentorium cerebelli subdural hematoma (Figure 3). Discussion To determine the clinical presentation and possible therapeutic alternatives, we reviewed ten previously reported cases of ISH that had CT verification and adequate clinical notable information. We included our case and outlined the data in Table 1. Nine of the 11 patients had a history of head injury.3~4~7-11 The remaining two patients had spontaneous ISH, one caused by a bleeding diathesisla and the other by a ruptured saccular aneurysm.13 None of the patients with traumatic ISH experienced loss of consciousness at the time of injury. However, in seven patients mental status changes or lethargy later developed.3~4~7-9~1’ Seizures occurred in three patients,3,7 and six patients presented with a “falx syndrome.“7-12 Nine patients had a unilateral ISH;3~4~7-10*12 one was bilateral,” and the other had an evenly uniform appearance that widened the anterior interhemispheric space.13 Seven hematomas extended to the tentorium cerebelli.4~7-9~L’~‘3 Cerebral angiography was performed in four patients. One patient, who experienced sudden onset of a left third-nerve palsy, had two aneurysms of which one ruptured.13 Two patients had malalignment of anterior cerebral artery vessels,7,9 and a third had coexisting subdural hematomas located over the convex lateral sides of the brain.3 Craniotomy was performed in six patients; in four, evacuation of the hematoma was accomplished.4.7,9 One patient had placement of Jackson-Pratt drains in each interhemispheric fissure,” and the other patient had two intracranial aneurysms clipped.13 Burr holes were performed in 105 lnterhemisphenc Subdural Hematoma Figure 2. A: Initial CT scan shows extension of the hematoma to the right leaf of the tentorium cerebelli (arrow). B: Partial resolution of the hematoma two days later. B Figure 3. CT scan a week later shows complete tentorium cerebelli. resolution of the ISH and the hematoma three patients. Two patients had convexi- three of the nine surgically treated patients died.+‘* A CT scan accurately delineates ISH and may obviate the need for cerebral angiography in patients with known trauma. Although CT is helpful in identifying the configuration of an ISH, it is not useful in determining the underlying cause in all ty located subdural hematomas that were aspirated and drained through burr holes.3.4 The third patient, because of poor medical condition, has aspiration using a cone needle through a single burr hole for the ISH.‘* Medical therapy was used in the remaining two patients and both recovered.“’ At least over the Z Disorientation, seizures/l 0 h Amnestic/36 Normal/6 Normal/l8 Lethargy, confusion14 HT HT HT HT HT HT 62/M 27/M 24/M 61/M 59/M 431F 80/M 55/F 66/M 4 7 8 9 10 11 12 13 Present Case Seizures/3 HT d h h h h R ISH, tension R ISH Tentorium R ISH Bilateral Yes Yes Yes Yes Left hemiparesis, leg > arm ex- ND Recovered Recovered Expired Recovered Recovered ND, not done; AC anticoagulant; Medical Craniotomy for aneurysms Burr hole ND Ruptured PCoA SA, Unrup. L ICA SA Craniotomy, J-P drains Medical Recovered Craniotomy ND ND ACAs separated Recovered Recovered Expired Expired Recovered Outcome Craniotomy Craniotomy ACAs shifted ND Craniotomy Burr holes for CSH Burr holes for CSH Treatment ND ND L CSH Angiography HT, head trauma; L, left; R, right: CSH, convexity subdural hematoma; PCoA, posterior communicating artery; ICA, internal carotid artery. R ISH, Tentorium tension No Amnestic, unsteady gait Uniformed Tentorium No Left third-nerve palsy ISH, extension L ISH L ICH ISH, extension Yes Tentorium extension Tetraparesis, legs > arms Paraparesis, right arm weakness Headache, left leg weakness Lethargy, left leg weakness ex- L ISH, Tentorium tension Yes Right hemiparesis, legs > arms Tentorium ex- L ISH, Tentorium tension No Decerebrate ex- R ISH, R CSH No Decerebrate CT L ISH Falx Syndrome No Findings Confusion Clinical Abbreviations: ISH, interhemispheric subdural hematoma; CT, computed tomography; ICH, intracerebral hematoma; ACA, anterior cerebral artery; SA, saccular aneurysm; Headaches/ sudden Obtundationl 10d h SA AC Confusion/48 HT 54/M 4 h Normal/24 HT 44/M 3 Headaches, seizures/7 d Etiology Age/Sex Ref Presentation/ Interval Delay Table 1. Adult Cases of ISH With CT Documentation Interhemispheric Subdural Hematoma 107 hematomas. Cerebral arteriography gives added information in those patients who lack history of trauma. Once the diagnosis of ISH is made, a neurosurgical consultation should be obtained. Burr-hole aspiration is unlikely to result in complete drainage of the clot.8 Craniotomy with evacuation of the hematoma seems to be an acceptable treatment. However, approximately 50% of these hematomas are small and reabsorb spontaneously.‘4 Fruin and associates”’ have suggested initial conservative medical treatment with methods to control and monitor intracranial pressure, proceeding to craniotomy only if neurological deterioration occurrs. Our paient did not progress neurologically and did not develop increased intracranial pressure that might have warranted neurosurgical intervention. Summary Computed tomography is effective in confirming the diagnosis of ISH. Typical abnormalities of ISH include contralateral crural paresis, paraparesis, seizures, and delayed mental status changes. Patients with ISH should be closely monitored for neurological deterioration. The larger lesions associated with progressive neurological dysfunction should be removed. Parasagittal craniotomy appears to be the only safe and acceptable method under those circumstances. authors would like to thank Ms. Darla Drake for the preparation of this manuscript. Acknowledgment-The REFERENCES 1. Zimmerman RA, Bilaniuk LT, Bruce D, et al: Interhemispheric acute subdural hematoma: A computed tomographic manifestation of child abuse by shaking. Neurorudiology 1978; 16:39-40. 2. Zimmerman RA, Bilaniuk LT, Bruce D, et al: Computed tomography of craniocerebral injury in the abused child. Radiology 1979; 130:687-690. 3. Ogsbury JS, Schneck SA, Lehman RA: Aspects of interhemispheric subdural hematoma, including the falx syndrome. J Neural Neurosurg Psychiatry 1978; 41~72-75. 4. Pozzati E, Gaist G, Vinei A, et al: Traumatic interhemispheric subdural hematomas. J Traumu 1982; 22:241-243. 5. 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