Abstract

Background: Acute spontaneous subdural hematoma is rare. For patients under 40 years of age, we found only five previous reports. Here, we have presented a sixth case study.

Case Description: A 27-year-old male initially presented with a high-intensity headache without any neurological deficits. The brain computed tomography revealed a left frontoparietal lesion, consistent with an acute epidural hematoma. However, the bone window examination showed no fracture, and at surgery, this lesion proved to be an acute subdural hematoma. Additional studies, including cerebral angiography, brain magnetic resonance imaging, and a complete coagulation work-up, were all negative.

Conclusion: This case report and literature review focused on the rarity of acute idiopathic/spontaneous subdural hematomas.

Keywords: Intracranial hematoma, Neurosurgery, Subdural hematoma, Traumatic brain injury

INTRODUCTION

There are few documented cases of acute spontaneous subdural hematomas (ASSDH) occurring in healthy young men without a history of trauma [ Table 1 ].[ 4 ] Here, we present a 27-year-old male with an ASSDH and reviewed five other cases of idiopathic ASSDH in the patient under 40 years of age.

Table 1:

Spontaneous subdural hematoma in patients under 40 years old reported in literature.

CASE REPORT

A 27-year-old male presented with a high-intensity headache of 3 h duration. He exhibited no focal neurological deficit or any laboratory/coagulation abnormalities [ Table 2 ]. The brain computed tomography (CT) scan documented a left frontoparietal lesion (e.g., 16 mm side), consistent with an acute epidural hematoma. However, the bone window CT showed no underlying fracture, and at surgery (e.g., a routine craniotomy), the lesion proved to be an acute subdural hematoma [ Figure 1 ]. The postoperative CT confirmed adequate removal of the clot [ Figure 2 ]. Subsequently, the patient’s additional studies including cerebral angiography, brain magnetic resonance (MR), and an additional full coagulation work-up all proved negative [ Figures 2 - 5 ].

Table 2:

Laboratorial investigation.

Figure 1:

The preoperative computed tomography (CT) scan showed the left parietal subdural hematoma. Due to its lenticular configuration, this could easily be misinterpreted as an epidural hematoma.

Figure 2:

Notably, the bone window CT demonstrated no accompanying skull fracture.

Figure 3:

The postoperative computed tomography scan showed complete resection of the hematoma.

Figure 4:

Left cerebral angiography was normal.

Figure 5:

Postoperative T1-weighted enhanced brain magnetic resonance (MR) imaging. The postoperative brain MR performed with gadolinium diethylenetriaminepentaacetic acid was negative.

DISCUSSION

History of ASSDH

Munro, in 1934, was the first to report an ASSDH; a decade later, Scott reported two more cases.[ 9 ] In 1971, Talalla and McKissock coined the phrase “acute spontaneous SDH (ASSDH).”[ 10 , 11 ] The previous reports indicated that ASSDH typically occurred in male teenagers and correlated with good outcomes when diagnosed and treated early in the clinical course (e.g., before the onset of a severe neurological deficit).[ 2 , 5 , 8 , 13 ]

Risk factors for ASSDH

Risk factors for ASSDH included hypertension, vascular malformations, neoplasia (e.g., hematological malignancies causing thrombocytopenia), other solid tumors, dural metastases, hypervitaminosis, coagulopathy/alcoholism, and bleeding from cerebral artery aneurysms/cortical arteries. In the case presented, the patient had none of these risk factors. Notable, however, was the CT finding of a lenticular clot pathognomonic for an epidural hematoma (e.g., only 8% of subdural hematomas demonstrate this radiological shape), but without a fracture on the bone window CT.[ 12 ] At surgery, this proved to be an ASSDH.

CONCLUSION

Spontaneous intracranial hematomas are rare life-threatening lesions that typically present with mild symptoms and less severe neurological findings versus traumatic acute subdural hematomas. In addition to obtaining preoperative noncontrast CT bone and soft-tissue studies, patients postoperatively should undergo brain MR scans, cerebral angiography, and a full coagulation work-up to rule out other etiologies of these rare lesions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1. Arnold PM, Christiano LD, Klemp JA, Anderson KK. Nontraumatic spontaneous acute subdural hematoma in identical teenage twins 1 year apart. Pediatr Emerg Care. 2011. 27: 649-51

2. Avis SP. Nontraumatic acute subdural hematoma. A case report and review of the literature. Am J Forensic Med Pathol. 1993. 14: 130-4

3. Brennan PM, Fuller E, Shanmuganathan M, Keston P, Fouyas I. Spontaneous subdural haematoma in a healthy young male. BMJ Case Rep. 2011. 2011: bcr0120113694-

4. Coombs JB, Coombs BL, Chin EJ. Acute spontaneous subdural hematoma in middle aged adult: Case report and literature review. J Emerg Med. 2014. 212: 1-6

5. Depreitere B, Van Calenbergh F, van Loon J. A clinical comparison of non-traumatic acute subdural haematomas either related to coagulopathy or of arterial origin without coagulopathy. Acta Neurochir (Wien). 2003. 145: 541-6

6. Kulah A, Taşdemir N, Fiskeci C. Acute spontaneous subdural hematoma in a teenager. Childs Nerv Syst. 1992. 8: 343-6

7. Marconi F, Fiori L, Parenti G, Ravelli V. Acute spontaneous subdural haematoma. Description of four clinical cases. J Neurosurg Sci. 1991. 35: 97-102

8. Missori P, Fenga L, Maraglino C, Rocchi G, Nardacci B, Calderaro G. Spontaneous acute subdural hematomas. A clinical comparison with traumatic acute subdural hematomas. Acta Neurochir (Wien). 2000. 142: 697-701

9. Monsivais D, Choi HA, Kitagawa R, Franch M, Cai C. A retrospective analysis of surgical outcomes for acute subdural hematoma in an elderly cohort. Interdiscip Neurosurg. 2018. 14: 130-4

10. Munro D. The diagnosis and treatment of subdural hematoma. A report of sixty two cases. N Engl J Med. 1934. 210: 1145-60

11. Scott M. Spontaneous nontraumatic subdural hematomas. J Am Med Assoc. 1949. 141: 596-602

12. Su IC, Wang KC, Huang SH, Li CH, Kuo LT, Lee JE. Differential CT features of acute lentiform subdural hematoma and epidural hematoma. Clin Neurol Neurosurg. 2010. 112: 552-6

13. Talalla A, McKissock W Acute. “spontaneous” subdural hemorrhage. An unusual form of cerebrovascular accident. Neurology. 1971. 21: 19-25