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of a devastating craniocerebral injury A typical example is that of a child who has fallen from a bicycle or swing or has suffered some other hard blow to the head and was unconscious only momentarily A few hours or a day later (exceptionally, with venous bleeding the interval may be several days or a week), headache of increasing severity develops, with vomiting, drowsiness, confusion, aphasia, seizures (which may be one-sided), hemiparesis with slightly increased tendon re exes, and a Babinski sign As coma develops, the hemiparesis may give way to bilateral spasticity of the limbs and Babinski signs The pulse is often slow (below 60 beats per minute) and bounding, with a concomitant rise in systolic blood pressure (Cushing effect) The pupil may dilate on the side of the hematoma Physicians need not be reminded that lumbar puncture is contraindicated in this setting, particularly now that CT and MRI are available Death, which is almost invariable if the clot is not removed surgically, comes at the end of a comatose period and is due to respiratory arrest The visualization of a fracture line across the groove of the middle meningeal artery and knowledge of which side of the head was struck (the clot is usually on that side) are of aid in diagnosis and lateralization of the lesion However, meningeal vessels may occasionally be torn without fracture The CT scan reveals a lens-shaped clot with a smooth inner margin (Fig 35-8) The surgical procedure consists of placement of burr holes in an emergency situation or, preferably, a craniotomy, drainage of the hematoma, and identi cation and ligation of the bleeding vessel The operative results are excellent except in cases with extended fractures and laceration of the dural venous sinuses, in which the epidural hematoma may be bilateral rather than unilateral If coma, bilateral Babinski signs, spasticity, or decerebrate rigidity supervene before operation, it usually means that displacement of central structures and crushing of the midbrain have already occurred; prognosis is then poor Small epidural hemorrhages, followed by serial CT scanning, will be seen to enlarge gradually for a week or two and then be absorbed There is always controversy about removing these in a patient who has no symp-.

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Figure 35-9 Acute subdural hematoma over the right convexity, with substantial mass effect (displacement) of brain tissue but little edema

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less clear The head injury, especially in elderly persons and in those taking anticoagulant drugs, may have been trivial and may even have been forgotten A period of weeks then follows when headaches (not invariable), light-headedness, slowness in thinking, apathy and drowsiness, unsteady gait, and occasionally a seizure or two are the main symptoms The initial impression may be that the patient has a vascular lesion or brain tumor or is suffering from drug intoxication, a depressive illness, or Alzheimer disease A gradual expansion of the hematoma is believed to cause the progression of symptoms As with acute subdural hematoma, the disturbances of mentation and consciousness (drowsiness, inattentiveness, incoherence of thinking, and confusion) are more prominent than focal or lateralizing signs, and they may uctuate The focal signs usually consist of hemiparesis and rarely of an aphasic disturbance Homonymous hemianopia is seldom observed, probably because the geniculocalcarine pathway is deep and not easily compressed; similarly, hemiplegia, ie, complete paralysis of one arm and leg, is usually indicative of a lesion within the cerebral hemisphere rather than a compressive lesion on its surface An important feature of the hemiparesis from subdural hematoma, when it occurs, is that it may sometimes be ipsilateral to the clot, as a result of compression of the contralateral cerebral peduncle against the free edge of the tentorium by horizontal displacement of the midbrain (Kernohan-Woltman false localizing sign; see page 310) If the condition progresses, the patient becomes stuporous or comatose, but this course is often interrupted by striking uctuations of awareness With both large acute and chronic hematomas, dilatation of the ipsilateral pupil is a fairly reliable indicator of the side of the hematoma, though this sign may be misleading (occurring on the opposite side in 10 percent of cases, according to Pevehouse and coworkers) Convulsions are seen occasionally, most often in alcoholics or in patients with cerebral contusions, but they cannot be regarded as a cardinal sign of subdural hematoma Rare cases of internuclear ophthalmoplegia and of chorea have been reported but have not occurred in our material Presumably they are a result of distortion of deep structures Also, transient disturbances of neurologic function simulating transient ischemic attacks (TIAs) may occur In infants and children, enlargement of the head, vomiting, and convulsions are prominent manifestations of subdural hematoma CT scanning with contrast infusion and MRI are the most reliable diagnostic procedures On CT scans, the acute clot is initially hyperdense but becomes isodense after a period of time (Fig 35-10), during which it may be dif cult to detect except by the tissue shifts it causes It then becomes progressively hypodense (with respect to the cortex) over 2 to 6 weeks The evolution of signal changes in the MRI is similar to the sequential imaging changes found with parenchymal hematomas The acute clot is hypointense on T2-weighted images, re ecting the presence of deoxyhemoglobin Over the subsequent weeks, all image sequences show it as hyperintense as a result of methemoglobin formation Eventually the chronic clot again becomes hypointense on the T1weighted images With contrast infusion, both imaging procedures usually reveal the vascular and reactive border surrounding the clot Usually, by the fourth week, sometimes later, the hematoma becomes hypodense, typical of a chronic subdural hygroma Other formerly used investigative measures are seldom necessary but are mentioned here for completeness and in the event that the diagnosis is made in the course of evaluating some other neurologic problem Skull lms are helpful when there is calci cation surrounding a chronic hematoma, a calci ed pineal that is.

Figure 35-10 Subacute subdural hematoma on the left (reader s right) CT scans after administration of intravenous contrast material The lesion is isodense to the adjacent brain tissue, but its margin can be appreciated with contrast enhancement Note displacement of cerebral structures

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