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shifted to one side, or an unexpected fracture line is found The EEG is usually abnormal bilaterally, sometimes with reduced voltage over the hematoma and high-voltage slow waves over the opposite side In an arteriogram, the cortical branches of the middle cerebral artery are separated from the inner surface of the skull, and the anterior cerebral artery may be displaced contralaterally The CSF may be clear and acellular but more often is bloody or xanthochromic depending on the presence or absence of recent or old contusions and subarachnoid hemorrhage; the pressure may be elevated or normal A xanthochromic uid with relatively low protein content should always raise the suspicion of chronic subdural hematoma The chronic subdural hematoma becomes gradually encysted by brous membranes (pseudomembranes) that grow from the dura Some hematomas probably those in which the initial bleeding was slight (see below) resorb spontaneously Others expand slowly and act as space-occupying masses (Fig 35-11) Gardner, in 1932, rst postulated that the gradual enlargement of the hematoma was due to the accession of uid, particularly CSF, which was drawn into the hemorrhagic cyst by its increasing osmotic tension as red blood cells (RBCs) hemolyzed and protein was liberated This hypothesis, which came to be widely accepted, is not supported by the available data Rabe and colleagues demonstrated that the breakdown of RBCs contributes little if at all to the accumulation of uid in the subdural space According to the latter authors, the most important factor in the accumulation of subdural uid is a pathologic permeability of the developing capillaries in the outer pseudomembrane of the hematoma The CSF plays no discernible role in this process, contrary to the original view of Munro and Merritt In any event, as the hematoma enlarges, the compressive effects increase gradually Severe cerebral compression and displacement with temporal lobe tentorial herniation are the usual causes of death.

hemisphere to expand after removal of a large clot The dif culty of managing these patients surgically should not be underestimated Elderly patients may be slow to recover after removal of the chronic hematoma or may have a prolonged period of confusion Postoperative expansion of the brain can be followed by serial CT scans and may take weeks Small, asymptomatic chronic collections are usually left alone and followed serially by clinical and CT examination, rst at weekly and then monthly and yearly intervals Although no longer a common practice, the administration of corticosteroids is an alternative to surgical removal of subacute and chronic subdural hematomas in patients with minor symptoms or with some contraindication to surgery Headache and other symptoms, such as gait dif culty or limb clumsiness, may resolve satisfactorily after several weeks of medication and may remain abated when the steroids are slowly reduced

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This encapsulated collection of clear or xanthochromic uid in the subdural space may form after an injury as well as after meningitis (in an infant or young child) More often subdural hygromas appear without infection, presumably due to a ball-valve effect of an arachnoidal tear that allows cerebrospinal uid to collect in the space between the arachnoid and the dura; brain atrophy is conducive to this process Occasionally a hygroma originates from a tear in an arachnoidal cyst It may be dif cult to differentiate a long-standing subdural hematoma from hygroma, and some chronic subdural hematomas are probably the result of repeated small hemorrhages that arise from the membranes of hygromas Shrinkage of the hydrocephalic brain after ventriculoperitoneal shunting is also conducive to the formation of a subdural hematoma or hygroma, in which case drowsiness, confusion, irritability, and low-grade fever are relieved when the subdural uid is aspirated or drained In adults, hygromas are usually asymptomatic and do not require treatment

Figure 35-11 Chronic subdural hematomas over both cerebral hemispheres, without shift of the ventricular system Chronicity results in hypodense appearance of the clots Some old blood can still be seen on the right side The bilaterally balanced masses result in an absence of horizontal displacement, but they may compress the upper brainstem

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Why somewhat less than one-half of all subdural hematomas remain solid and nonenlarging and the remainder liquefy and then enlarge is not known The experimental observations of Labadie and Glover suggest that the volume of the original clot is a critical factor: the larger its initial size, the more likely it will be to enlarge An in ammatory reaction, triggered by the breakdown products of blood elements in the clot, appears to be an additional stimulus for growth as well as for neomembrane formation and its vascularization Treatment of Subdural Hematoma In most cases of acute hematoma, it is suf cient to place burr holes and evacuate the clot before deep coma has developed Treatment of larger hematomas, particularly after several hours have passed and the blood has clotted, consists of wide craniotomy to permit control of the bleeding and removal of the clot As one would expect, the interval between loss of consciousness and the surgical drainage of the clot is perhaps the most important determinant of outcome in serious cases Thin, crescentic clots can be observed and followed over several weeks and surgery undertaken only if focal signs or indications of increasing intracranial pressure arise (headache, vomiting, and bradycardia) Small subdural hematomas causing no symptoms and followed by CT scans will self-absorb, leaving only a deep yellow, sometimes calci ed membrane attached to the inner dural surface If the acute clot is too small to explain the coma or other symptoms, there is probably extensive contusion and laceration of the cerebrum To remove the more chronic hematomas, a craniotomy must be performed and an attempt made to strip the membranes that surround the clot This diminishes the likelihood of reaccumulation of uid but it is not always successful Other causes of operative failure are swelling of the compressed hemisphere or failure of the.