POST-TRAUMATIC ACUTE-ON-CHRONIC SUBDURAL HAEMATOMA

Abstract

According to the investigation and data from the crime scene, the man had suffered repeated falls, one on the previous day, one in the same day of his admission in the hospital and others in the past. Internal examination revealed: right side epicranial haematoma, surgical resection of the right temporal muscle, craniotomy hole with brain herniation, free epidural space, surgical cut of the dura, subarachnoid haemorrhage, left midline shifting, atherosclerosis of cerebral vessels. Anatomopathological examination of dura mater fragments revealed: on the right hemisphere, recently haemorrhage with fibrin organisation, indicating an acute subdural haematoma and, on the left hemisphere, haemorrhage area with peripherally neoformation membrane and numerous neocapillaries and siderophages highlighted by Perl's staining, which indicated chronic subdural hematoma with re-bleeding (Figs. 3-5). Several cases reported in literature reviews show that CSDH appeared following a spinal anaesthesia, a calvarial bone and dura mater metastatic processes from a primary prostate cancer, anticoagulants and antiplatelet therapy, or other blood discrasias [4,5,10-12].

Headnote

Abstract

Acute Subdural Haematomas (ASDH) have great forensic significance, because a wide spectrum of forces (usually head trauma) can cause them. Chronic subdural haematoma (CSDH) is also an important condition, which does not necessarily imply a recent trauma. The authors report the case of a 73 year-old man, with repeated craniocerebral trauma, hospitalized with right ASDH and left CSDH, who died within 12 hours after admission. The autopsy revealed, at external examination, a lacerated wound in the right parietal region and multiple abrasions and bruises; on internal examination, right ASDH and left CSDH with recent bleeding and left midline shifting. Sometimes, in cases of repeated assault it is possible to discover acute-on-chronic subdural haematoma (ACSDH), explained by recent bleeding, usually near the anterior part of the haematoma. Such cases require the attention of the forensic pathologist who should search for signs of recent brain trauma which aggravated an underlying condition or caused death; also, histological sampling can provide important forensic information.

Keywords: acute subdural hematoma, chronic subdural hematoma, craniocerebral trauma.

1. INTRODUCTION

Subdural Haematoma (SDH) is one of the lesions with special forensic significance, because a wide spectrum of forces and also, many causal and contributing nontraumatic conditions can produce it. The most favoured locus of SDH is at or near the vertex of the brain, near the midline, extending out over the lateral portion of the cerebral hemispheres. The reason for this location could be the confluence of many cortical veins that entry the sagittal sinus [1].

The most frequently reported cause of acute subdural haematoma (ASDH) is usually some form of impact head trauma, an assault with similar characteristics, or low strain injuries, as could be seen in car accidents. There are some differences between age groups, according to the causal circumstances and severity of the injury. The source of bleeding in acute subdural haematoma is determined by a cortical vessel's injury from the site of cerebral contusion or cerebral destruction, or it can appear secondary to a rupture of an increasing intracerebral haematoma in the subdural space. Acute Subdural Haematoma appears as a fresh, dark red, clotted blood, without features of organization or resolution, and no membrane formation [1].

Chronic Subdural Haematoma (CSDH) represents a clinically and pathologically important group of subdural haemorrhages, whose special character has an important significance in forensic pathology. It has a distinct phase, that requires between 15 and 21 days to accomplish, with the formation of a cellular neomembrane that surrounds the haematoma, and a process of potential enlargement of the haematoma in time. The old, well-developed CSDH has a gross appearance that resembles a rubber sac with a content that may range from bloody brown fluid to nearly clear, strawcoloured fluid. The neomembranes are opalescent or comletely opaque, depending on their age. The arachnoid behind this process can show discoloration and thickening and adhesion to the underlying cortex, usually with associated old cortical contusion or softening. These areas will be tan, orange, or yellow in colour for a large period of time, even years, after the haematoma has been resolved. A clear-cut history of head trauma can be obtained only in about 50.0-66.0% of the cases with CSDH, when the trauma is minor and can include a simple bump on the head or a minor fall (high-strain fall in about 72% of cases) [1,2]. The source of bleeding in chronic subdural haematoma is, most probably, a bridging vein that has been torn or otherwise injured. Chronic subdural haematoma, in the case of elderly patients, can be asymptomatic for many months, and it can be discovered sometimes in the course of a dementia workup or during an autopsy. The symptoms observed in CSDH are often vague, and they may include headache, stumbling or loss of coordination and balance, gait problems, confusion, failure or blurring of vision, weakness, lethargy or apathy, loss of memory, slowing of intellect, personality changes, focal neurological deficit or other symptoms that might be interpreted as signs of old age or of a mild stroke [1,3-6]. Common co-morbidities reported were hypertension (59.0%), cardiopathies (36.0%) and previous strokes (23.6%) [2]. Analysis of any age might reveal such medical condition with strong impact upon the lifestyle and quality of life in general [7,8].

The treatment for Subdural Haematomas is surgical, usually with positive outcomes, although the recurrence rate is high and several important complications are associated with it, such as epileptic seizures [1,9].

2. CASE REPORT

The authors report a case of a 73 year-old man who suffered a craniocerebral trauma on 28th of October 2017, being hospitalized in a local neurosurgery department, then transferred in the same day to a university neurosurgery hospital. The admission diagnosis was Acute Right Hemisphere Subdural Haematoma, Chronic Left Hemisphere Subdural Haematoma, Fourth Grade Glasgow Coma Scale, Orotracheal Intubation, Repeated Craniocerebral Trauma. He was operated urgently to evacuate the ASDH through a correct craniectomy and drainage. The evolution was unfavourable, he had a cardio-respiratory arrest and died less than 12 hours since his admission in the hospital. According to the investigation and data from the crime scene, the man had suffered repeated falls, one on the previous day, one in the same day of his admission in the hospital and others in the past. He had not been hospitalized in the last months.

The body was brought for autopsy at the Iasi Forensic Institute. External examination revealed a surgical incision in the right fronto-parietotemporal region, a lacerated wound in the right parietal region, excoriation and bruises on the head, face and right upper leg. Internal examination revealed: right side epicranial haematoma, surgical resection of the right temporal muscle, craniotomy hole with brain herniation, free epidural space, surgical cut of the dura, subarachnoid haemorrhage, left midline shifting, atherosclerosis of cerebral vessels.

In the right subdural space, a dark red, coagulated blood collection was obseved, surrounding the entire right hemisphere, without features of organization or resolution, and no membrane formation (Fig. 1). In the left parietotemporal subdural region, it is revealed a completely opaque multi-layered membrane, which covers a brownish-yellow, solid collection with dimensions of 15/13/3 cm (Fig. 1). On the edges of this collection, a dark-red, coagulated blood collection was evidenced (Fig.2).

Examination of chest cavity revealed multiple right costal fractures with haemorrhagic infiltration, global heart hypertrophy, subepicardial fibrosis, coronary and aortic atherosclerosis.

Anatomopathological examination of dura mater fragments revealed: on the right hemisphere, recently haemorrhage with fibrin organisation, indicating an acute subdural haematoma and, on the left hemisphere, haemorrhage area with peripherally neoformation membrane and numerous neocapillaries and siderophages highlighted by Perl's staining, which indicated chronic subdural hematoma with re-bleeding (Figs. 3-5).

3. DISCUSSION

In elderly individuals, acute subdural haematomas are sometimes associated with minor trauma and absence of underlying contusions, which can be explained by the fact that they are more likely to follow an anticoagulant or antiplatelet therapy. In these cases, symptoms are produced by the volume of the haematoma [1].

In many older patients, CSDH is a marker of underlying co-morbidities rather than a primary event. Many causal and contributing nontraumatic conditions can produce CSDH. Several cases reported in literature reviews show that CSDH appeared following a spinal anaesthesia, a calvarial bone and dura mater metastatic processes from a primary prostate cancer, anticoagulants and antiplatelet therapy, or other blood discrasias [4,5,10-12].

After the age of 55, the cortico-spinalfluid space (subarachnoid space) is increasing, corresponding to a decrease in brain size (brain atrophy increase), that allows a larger movement of the brain inside the cranial vault. These can cause incidental accelerations, so that the bridging veins, which are longer, weaker and under strain, are more susceptible to tearing. This also increases the potential space to accommodate a larger haematoma before symptoms' manifestation [1,13].

The reported incidence for CSDH varies widely, from 1 to 8.2 per 100,000 individuals annually, with a maximum of 48 per 100,000 per year recorded in North Wales, and increased occurrence is expected as population's age increases [4,5]. The mean age reported was between 77.5± 10.5 years (from the first report) and 81 years (the second report), with a larger percentage for males [2,4].

The origin and enlargement of CSDH are multifactorial. In literature reviews, the mechanisms involved in the process of rebleeding, haemolysis and inhibition of blood coagulation through the neomembrane and vascular neoformation are more probable than ultrafiltration. This hypothesis is sustained by the presence of ß-2 transferrin and of substances related to cell breakdown and haemolysis in the haematoma. Edlmann E. and others, in their report, focused on several key processes involved in CSDH development: angiogenesis, fibrinolysis, and inflammation; they identified the neomembrane as a source of fluid exudation and haemorrhage. Angiogenic stimuli lead to the creation of fragile blood vessels within the membrane walls, while the fibrinolytic processes prevent clot formation, resulting in continued haemorrhage. There is an abundance of inflammatory cells and markers in the neomembranes and subdural fluid, which can contribute to propagating an inflammatory response [14-16].

Sometimes, a prior subdural haemorrhage can be found, usually partially or completely resolved, in individuals who have been repeatedly assaulted, such as epileptics, chronic alcoholics, ataxic individuals, stroke victims and derelicts. In these cases, it is possible to find an acute-on-chronic subdural haematoma, explained by the most recent bleeding, which is usually nearest to the anterior haematoma. Acute-onchronic subdural haematoma is a condition precipitated by a trauma, specific to older adults, and most frequently it is unilateral or asymmetrical and relatively asymptomatic. In these cases, chronic subdural haematomas with multiple layers in them can be found, sometimes with three or four 1 cm-thick layers, or more. Histological sampling of several portions of the subdural haematoma and of any other visible lesions of the dura provides important forensic information, although it is very difficult to evaluate a case in which aging and the date of a subdural haematoma are involved [1,16].

4. CONCLUSIONS

Overall, chronic subdural haematoma is an important condition in forensic pathology, not necessarily implying the presence of a recent trauma or of other conditions; it is frequently asymptomatic and easily to miss clinically.

Acute-on-chronic subdural haematoma is a rare condition, precipitated by trauma, which affects elderly individuals, a surgical emergency that may cause permanent disability or death, if untreated or treated too late. Such cases require the judgement of the forensic pathologist on a possible linkage of the haematoma with a trauma event. A good practice is to search for any other signs of recent traumatic lesions in the brain, such as contusions or new haematomas, which might support the hypothesis that a recent trauma aggravated an underlying condition or caused death.

Declaration of Conflicting Interests. The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding. The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

References

1. Jan E. Physical Injury to the Nervous System. In: Raton B, editor. Forensic Neuropathology Third Edition. London, New York: CRC Press Taylor & Francis Group; 2014. pp. 484-502.

2. Branco PM, Ratilai BO, Costa J, Sampaio C. Antiepileptic drugs for preventing seizures in patients with chronic subdural hematoma. Curr Pharm Design.2017;23(42):6442-5.

3. Adhiyaman V, Chattopadhyay I, Irshad F, Curran D, Abraham S. Increasing incidence of chronic subdural hematoma in the elderly. QJM. 2017;110(6):375-8.

4. Sahyouni R, Goshtasbi K, Mahmoodi A, Tran DK, Chen JW. Chronic subdural hematoma: a historical and clinical perspective. World Neurosurg. 2017;108:948-53.

5. Knieling A, Diac MM, Rişcanu LA, Zăvoi RE, Bulgaru Iliescu D. Subdural hematoma - a cause of death in the development of a prostatic adenocarcinoma with dural metastases: case report. Rom J Morphol Embryol. 2017;58(4):1549-53.

6. Iov T, Timofte D, Damian SI, Knieling A, Scripcaru C, Bulgaru-Iliescu D. Non-traumatic cervical hemorrhagic infiltration. Rom J Leg Med. 2018;26(2):141-4.

7. Crauciuc DV, Crauciuc EG, Iov CJ, Furnica C, Iov T. Non-invasive evaluation of neonatal cerebral status in the newborns of mothers addicted to alcohol and drugs. REV.CHIM.(Bucharest). 2018;69(11):4088-92.

8. Perju Dumbrava D, Radu CC, David S, Iov T, Iov CJ, Sandu I, Bulgaru Iliescu D. The importance of alcohol testing by gas chromatography vs the cordebard classical method modified in the medico legal investigation. REV.CHIM.(Bucharest).2018. 69(9):2407-10.

9. Metin KM, Güzel II, Oskovi A, Guzel AI. Chronic subdural hematom following spinal anesthesia for cesarean section. J Exp Ther Oncol. 2017;11(2):97-9.

10. Aygun A, Vuran HS, Aksut N, Karaca Y, Tatli O. A case of late diagnosis of chronic subdural hematom following spinal anesthesia. Turk J Emerg Med. 2017;17(2):68-9.

11. Lippa L, Cerase A, Cecconi F, Cacciola F. Posttraumatic acute-on-chronic subdural hematoma: an unusual presentation of skull metástasis from prostate carcinoma. BMJ Case Rep. 2017;2017.

12. Lucke-Wold BP, Turner RC, Josiah D, Knotts C, Bhatia S. Do age and anticoagulants affect the natural history of acute subdural hematomas? Arch Emerg Med Crit Care. 2016;1(2).

13. Jafari N, Gesner L, Koziol JM, Rotoli G, Hubschmann OR. The pathogenesis of chronic subdural hematoms: a study on the formation of chronic subdural hematomas and analysis of computed tomography findings. World Neurosurg. 2017;107:376-81.

14. Edlmann E, Giorgi-Coll S, Whitfield PC, Carpenter KLH, Hutchinson PJ. Pathophysiology of chronic subdural hematoma: inflammation angiogenesis and implications for pharmacotherapy. J Neuroinflammation. 2017;14(1):108.

15. Castellani RJ, Mojica-Sanchez G, Schwartzbauer G, Hersh DS. Symptomatic acute-on-chronic subdural hematoma: a clinicopathological study. Am J Forensic Med Pathol.2017;38(2): 126-30.