Subdural hygromas refer to the accumulation of fluid in the subdural space. In many cases, it is considered an epiphenomenon of head injury when it is called a traumatic subdural hygroma. Subdural hygromas are encountered in all age-groups but are overall most common in the elderly 7. The demographics will depend on the underlying cause which includes:.
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Traumatic subdural hygroma: five cases with changed density and spontaneous resolution. Thirty-four consecutive adult patients with subdural traumatic hygroma were analysed for clinical evolution, serial computed tomography scan CT , and magnetic resonance imaging MRI over a period of several months. Five of the patients presented CT scan and MRI evolution data showing increasing density over a period of 11 days to 6 months post trauma.
In these five patients, final clinical and CT scan data were benign, with complete spontaneous resolution. Descriptions in literature of evolving traumatic subdural hygroma have presented CT scan density modifications changing into chronic subdural hematoma. Our patients show another possibility, density transformation, which sometimes show as subdural hematoma in CT scan and MRI, but with final evolution where clinical condition and CT scan return to normal. Key words: traumatic subdural hygroma, evolution, head injury, CT scan.
Post-traumatic subdural hygroma is common, but its natural history is not well defined because there are few reports of clinical and computed tomography scan CT evolution data.
These reports lack a uniform approach to method and segment time Some authors have reported traumatic subdural hygroma presenting density modifications in the CT scan with change to chronic subdural hematoma 4,7,9,10,12,13, This study reports a series of South American adult patients with traumatic subdural hygroma, with emphasis on the evolution of clinical and CT scan data. Thirty-four 34 consecutive adult patients with subdural traumatic hygroma were analyzed; they were analyzed with emphasis on patients who presented density modifications over a follow-up time segment.
Each patient was studied for clinical evolution, serial CT scan and magnetic resonance imaging MRI data for several months. There were 34 patients, with ages ranging from 16 to 85 years mean 40 , seventeen between 16 and 40 years. Mean evolution time was days. Road traffic accidents were the main cause of head injury. The mean evolution time for subdural hygroma diagnosis was 9 days. Twenty-one patients He was confused Glasgow Coma Scale score On admission, the CT scan showed left parietal hemorrhagic contusion that required surgery.
The CT scan on the 9th day showed bilateral frontal subdural hygroma, mainly on the left side Fig 1A , which presented progressive enlargement and compression of the cerebral parenchyma. On the 18 th day he was submitted to simple burr hole aspiration and irrigation of the left frontal collection.
A slight xantochromic high-pressure subdural fluid was observed. On the 53 rd day, CT scan showed the hygroma with enhanced density and heterogeneous aspect Fig 1B.
The patient presented progressive clinical improvement and a conservative approach was chosen. The CT scan on the th day showed reduction in hygroma size, with probable neomembrane, and without compression on the underlying cerebral parenquima Fig 1C. The CT scan on the th day showed cerebral expansion and spontaneous resolution of the subdural collection Fig 1D.
He was comatose with right midriasis Glasgow Coma Scale score 7. On admission, the CT scan showed probable cerebral edema. The CT scan on the 12 th day showed bilateral frontal subdural hygroma Fig 2A.
On the following days he presented slow and progressive neurological improvement. MRI on the st day showed laminar subdural hematoma, without compression on the cerebral parenquima Fig 2B. The image was enhanced after endovenous injection of paramagnetic contrast, mainly on the right side Fig 2C. The CT scan on the th day showed complete resolution of the subdural collection Fig 2D. On later examination the patient was asymptomatic. He presented a transient decreased conscience state and later reported headache Glasgow Coma Scale score On admission, the CT scan showed diffuse subarachnoid hemorrhage and small subdural effusion in the left frontal region Fig 3A ; on the 4 th day this had evolved into subdural hygroma, with probable compression of the underlying brain Fig 3B.
For the next 10 days, he presented with headache and somnolence, with subsequent improvement. The CT scan on the 77 th day showed enhanced density and increased volume of the hygroma, with probable ipsilateral compression of the cortical sulci and ventricles Fig 3C.
As his clinical examination was good, a conservative approach was chosen. Two years later he was asymptomatic, and the subdural collection had disappeared Fig 3D. He was confused and agitated Glasgow Coma Scale score On admission, the CT scan showed subarachnoid hemorrhage and cerebral edema Fig 4A.
The CT scan on the 26 th day showed left frontoparietal subdural hygroma with probable compression of the underlying brain Fig 4B. On the 27 th day he was submitted to simple burr hole aspiration and irrigation of the left frontoparietal collection. A slight hemorrhagic clear subdural fluid was observed. He presented progressive clinical improvement. The CT scan on the 50 th day showed enhanced hygroma density Fig 4C. Conservative treatment was chosen.
The CT scan on the th day showed a reduction in size of the subdural collection, with probable neomembrane and septation Fig 4D. On admission, the CT scan showed laminar acute subdural hematoma in the right frontoparietal region Fig 5A. He was submitted to conservative treatment. The CT scan on the 7 th day showed right subdural hygroma adjacent to the subdural hematoma Fig 5B ; on the 11 th day, it presented decreased size and enhanced density Fig 5C.
There was a slow and progressive improvement in consciousness. Minimal cognitive deficits were observed on the 30 th day. The CT scan 2 years later only showed cortical atrophy Fig 5D.
For different authors subdural hygroma is more prevalent in older patients with some degree of cerebral atrophy 4,9,14, The mean age of 5 described cases was 43 years. Transformations from subdural hygroma to chronic subdural hematoma are well documented 4,,13,15, There were however few reports of mean transformation times: In our 5 patients mean transformation time was For these 5 patients with modified subdural collection after initial hygroma, enhanced density was a transitory phenomenon, and not one of our patients needs surgery.
Final clinical and imaging results presented resolution. It is not clear why our 5 patients did not develop chronic subdural hematoma from the enhanced density hygroma. This was more commonly seen in older patients 4,9,14,19 , where some degree of cerebral atrophy could provide the space for hematoma expansion. Four of our patients presented no cerebral atrophy. Collection in the subdural space for more than a few weeks may induce the migration and proliferation of inflammatory cells, derived from the dural border cells, originating the chronic subdural hematoma outer membrane 20,23, Our cases 1 and 4 presented septation inside the old and transformed hygroma delimiting areas with different densities.
So, for us, the origin of these membrane cells is not clearly defined, but we agree that enhanced hygroma density could represent the bleeding of membranes formed in chronic phases of subdural hygroma Diagnosis of extracerebral fluid collections by computed tomography. Am J Roentgenol ; Delayed evolution of postraumatic subdural hygroma. Surg Neurol ; Friede RL, Schachenmayr W.
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A subdural hygroma is a collection of cerebrospinal fluid CSF , without blood, located under the dural membrane. Most subdural hygromas are believed to be derived from chronic subdural hematomas. They are commonly seen in elderly people after minor trauma but can also be seen in children after an infection. One of the common causes of subdural hygroma is a sudden decrease in pressure as a result of placing a ventricular shunt.