Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establish reliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm rupture results in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determining initial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and the mixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinical and radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmal subarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past 20 years are discussed and summarized in a proposed treatment flowchart.
Rupture of a cerebral aneurysm normally results in subarachnoid hemorrhage (SAH) and is often complicated by intracerebral hematoma (ICH), but only on rare occasions does it cause acute subdural hematoma (aSDH) [
Rapid decision making is required to treat this life-threatening condition. The majority of patients with aneurysmal SAH and coincidental acute subdural bleeding present in a severe clinical condition, and immediate surgical management is required [
The incidence of combined SAH and aSDH varies from 0.5% [
The literature was screened for case studies of acute subdural hematoma secondary to ruptured intracranial aneurysm. Articles for this review were identified by MEDLINE PubMed database searches of the literature from January 1990 through December 2009 using the terms “acute subdural hematoma,” “subarachnoid hemorrhage,” and “cerebral aneurysm” (by using the Boolean operator AND) (Table
Search Strategy*.
Search number | Process description | Results |
---|---|---|
(“key words”) | (no. of articles) | |
no. 1 | Search “cerebral aneurysm” | |
no. 2 | Search “subarachnoid hemorrhage” | |
no. 3 | Search “subdural hematoma” | |
no. 4 | Search #1 AND #2 AND #3 | |
no. 5 | Search “01/1990–12/2009” AND #4 |
*All searches for this study were performed on August 28, 2010, by the first author and verified by the second author on August 30, 2010. The publication date limits were set to January 1990–December 2009.
Articles were excluded based on title and abstract because they (i) were not written in the English language, (ii) were technical notes or laboratory investigations, or (iii) were not peer-reviewed/original studies. The remaining articles were selected for inclusion if the patients were adults and the single cases or case series provided detailed descriptions of clinical characteristics and patient management.
From selected cases, we extracted the following characteristics and recorded them in a data sheet: age; gender; initial clinical findings, including Glasgow Coma Scale (GCS) [
The initial search retrieved 85 publications which matched the terms “cerebral aneurysm” AND “subarachnoid hemorrhage” AND “acute subdural hematoma.” 59 publications were excluded after screening of titles and abstracts. This left 26 articles potentially eligible for detailed evaluation. Six articles were not included as they did not match the selection criteria. The remaining 20 articles including 82 cases underwent detailed analysis [
Patient characteristics
Series/year of publication | Case no. | Age/sex | Initial clinical findings | Initial diagnostics | SAH | ICH | Side of aSDH | Size of aSDH | MLS | Location of aneurysm | Size of aneurysm | Management (hours from ictus) | Outcome |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Watanabe et al. [ | 1 | 51/m | WFNS 5, GCS 4, decerebrate posture, bilaterally dilated fixed pupils ataxic breath | CT scan | No | No | Lt | — | — | Lt Pcal (ACA) | — | Emergency craniectomy and hematoma evacuation (1 h) | Deceased, GOS 1, mRS 6 |
Watanabe et al. [ | 2 | 72/f | WFNS 4, GCS 12, right hemiparesis | CT scan, DSA | Yes | No | Lt | — | — | Rt Pcal (ACA) | — | Clipping (on day 15) | Returned to normal daily life, GOS 5, mRS 1 |
Watanabe et al. [ | 3 | 74/f | WFNS 5, GCS 4, decerebrate posture, ataxic breath, dilation of the left pupil | CT scan, DSA failed | Yes | No | Rt | — | — | Lt Pcal (ACA) (found at autopsy) | — | Inoperable | Deceased (3 days after onset), GOS 1, mRS 6 |
Kamiya et al. [ | 4 | 67/f | H&H IV, paresis | CT scan, DSA | Yes | No | — | — | — | MCA | 30 mm | Craniotomy, hematoma evacuation, and immediate clipping | Vegetative state, GOS 2, mRS 5 |
Kamiya et al. [ | 5 | 50/f | H&H III | CT scan, DSA | Yes | Yes | — | — | — | ICA | 28 mm | Inoperable because of rerupture on admission | Decubitus and pneumonia, deceased, GOS 1, mRs 6 |
Kamiya et al. [ | 6 | 67/f | H&H V, paresis | CT scan, DSA | Yes | Yes | — | — | — | MCA | 4 mm | Inoperable | Deceased (on arrival), GOS 1, mRs 6 |
Kamiya et al. [ | 7 | 52/f | H&H V | CT scan, DSA | Yes | Yes | — | — | — | Not detected | — | Inoperable | Deceased (on arrival), GOS 1, mRs 6 |
Kamiya et al. [ | 8 | 69/f | H&H II | CT scan, DSA | Yes | Yes | — | — | — | Acom | 27 mm | Inoperable because of severe spasm on admission | Deceased, GOS 1, mRs 6 |
Kamiya et al. [ | 9 | 63/f | H&H II | CT scan, DSA | Yes | No | — | — | — | MCA | 4 mm | Craniotomy, hematoma evacuation, and immediate clipping | Good recovery, GOS 5, mRs 1 |
Kamiya et al. [ | 10 | 73/m | H&H IV, paresis | CT scan, DSA | Yes | No | — | — | — | Acom | 7 mm | Clinical deterioration, no operation impossible | Deceased, GOS 1, mRs 6 |
Kamiya et al. [ | 11 | 64/m | H&H V, preoperative rerupture, cardiac failure | CT scan, DSA failed | Yes | No | — | — | — | Not detected | — | Inoperable | Deceased (nonfilling state DSA), GOS 1, mRs 6 |
Kamiya et al. [ | 12 | 72/f | H&H IV, paresis | CT scan, DSA | Yes | Yes | — | — | — | Distal ACA | 4 mm | Hematoma evacuation and immediate clipping | Good recovery, GOS 5, mRs 1 |
Kamiya et al. [ | 13 | 70/m | H&H IV, paresis | CT scan, DSA | Yes | Yes | — | — | — | MCA | 6 mm | Hematoma evacuation and immediate clipping | Good recovery, GOS 5, mRs 1 |
Kamiya et al. [ | 14 | 72/f | H&H V | CT scan, DSA | Yes | Yes | — | — | — | ICA | 4 mm | Inoperable | Deceased (day 1), GOS 1, mRs 6 |
Kamiya et al. [ | 15 | 59/m | H&H V | CT scan, DSA | Yes | Yes | — | — | — | MCA | 22 mm | Inoperable | Deceased (day 2), GOS 1, mRs 6 |
Kamiya et al. [ | 16 | 39/f | WFNS 5, GCS 4, decerebrate posturing, dilation of the right pupil | CT scan, DSA | Yes | Yes | — | — | Moderate to marked | Distal ACA | 3 mm | Hematoma evacuation and immediate clipping | Good recovery, GOS 5, mRs 1 |
Kamiya et al. [ | 17 | 71/f | H&H III | CT scan, DSA | Yes | Yes | — | — | — | Acom | 11 mm | Hematoma evacuation and immediate clipping | Good recovery, GOS 5, mRs 1 |
Rusyniak et al. [ | 19 | 74/f | WFNS 5, GCS 4, decerebrate posturing, bilaterally miotic pupils | CT scan, CTA | Yes | Yes | Rt | — | — | Rt ICA-Pcom | — | Hematoma evacuation, immediate clipping | Complete recovery, GOS 5, mRS 1 |
Ragland et al. [ | 20 | 27/m | GCS 5 right pupil nonreactive left mydriasis | CT scan, DSA | No | no | Rt | — | Moderate to marked | Acom | 20 mm | Hematoma evacuation, Maximal medical treatment | Deceased, GOS 1, mRS 6 |
O’Sullivan et al. [ | 21 | 32/m | WFNS 5, GCS 4, bilaterally fixed pupils, hypertensive with bradycardia | CT scan | Yes | — | Lt | — | — | Lt ICA-Pcom | 12 mm | Mannitol, without effect on pupillary response (3 h), died before decompression | Deceased, GOS 1, mRS 6 |
O’Sullivan et al. [ | 22 | 48/f | WFNS 5, GCS 4, dilated unreactive pupils, unstable cardiopulmonary situation | CT scan, DSA | Yes | Yes | Rt | — | — | Rt ICA-Pcom | 15 mm | Manitol, without effect on pupillary response, hematoma evacuation, and clipping of the aneurysm (7 h) | Deceased, GOS 1, mRS 6 |
O’Sullivan et al. [ | 23 | 36/f | WFNS 5, GCS 3, bilaterally fixed pupils | CT scan, DSA | Yes | Yes | Rt | — | — | Rt MCA | 12 mm | Hematoma evacuation (4 h) and delayed clipping (day 4) | Residual mild left hemiparesis, returned to work as a teacher, GOS 4, mRS 3 |
O’Sullivan et al. [ | 24 | 63/f | WFNS 5, GCS 3, dilated unreactive pupils | CT scan, DSA | Yes | — | Rt | — | — | Rt ICA-Pcom | 20 mm | Hematoma evacuation (4 h) and delayed clipping (day 7) | Full recovery, returned to normal lifestyle, GOS 5, mRS 1 |
O’Sullivan et al. [ | 25 | 62/f | WFNS 3, GCS 14, mild left hemiparesis | CT scan, DSA | Yes | No | Rt | 20 mm | — | Rt ICA-Pcom | 4 mm | Hematoma evacuation and immediate clipping | Uneventful recovery, returned to normal lifestyle, GOS 5, mRS 1 |
Nowak et al. [ | 26 | 52/f | WFNS 5, GCS 3, dilated unreactive pupils, hypertensive crisis (systolic BP 280 mmHg) | CT scan | Yes | No | Rt | — | — | Rt Pcal (ACA) | — | Manitol, emergency hematoma evacuation | Deceased, GOS 1, mRS 6 |
Nowak et al. [ | 27 | 45/f | WFNS 1, GCS 15, disturbances of vision | CT scan, DSA | Yes | Yes | Rt | 10 mm | — | Rt MCA | — | Hematoma evacuation and clipping (day 1) | Full recovery, returned to normal lifestyle, GOS 5, mRS 1 |
Nowak et al. [ | 28 | 49/f | WFNS 5, GCS 3, mild left-sided hemiparesis | CT scan | Yes | — | Rt | — | Marked | Rt MCA | >25 mm | Emergency hematoma evacuation with gluing of the aneurysm | Deceased, GOS 1, mRS 6 (rebleeding) |
Nowak et al. [ | 29 | 63/m | WFNS 5, GCS < 6, right dilated pupil | CT scan, DSA | Yes | — | Rt | — | — | Rt MCA | 10 mm | Immediate hematoma evacuation and delayed clipping (week 5) | Full recovery, no serious neurological deficits, GOS 5, mRS 1 |
Ishibashi et al. [ | 30 | 54/f | WFNS 1, GCS 15, no neurological deficit | CT scan, DSA | No | No | Lt | — | — | Lt ICA-PCom | — | Craniotomy, hematoma evacuation, and immediate clipping (<24 h) | No neurological deficit, return to normal life, GOS 5, mRS 1 |
Nonaka et al. [ | 31 | 52/f | GCS 4, decerebrate rigidity, and left oculomotor paresis | CT scan, DSA | No | No | Lt | — | Moderate to marked | Lt ICA-PCom | 10 mm | Craniotomy, hematoma evacuation, and immediate clipping (>24 h) | Full recovery, no neurological deficits, GOS 5, mRS 1 |
Inamasu et al. [ | 32 | 68/m | WFNS 2, GCS 14, H&H II | CT scan, DSA | Yes | No | — | <25 cc | <5 mm | Acom | — | Craniotomy, hematoma evacuation, and immediate clipping (6 h) | Good recovery, GOS 5, mRs 1 |
Inamasu et al. [ | 33 | 61/f | WFNS 4, GCS 10, H&H IV | CT scan, DSA | Yes | Yes | — | <25 cc | <5 mm | Rt MCA | — | Craniotomy, hematoma evacuation, and immediate clipping (6 h) | Good recovery, GOS 5, mRs 1 |
Inamasu et al. [ | 34 | 75/f | WFNS 4, GCS 11, H&H IV | CT scan, DSA | Yes | Yes | — | <25 cc | <5 mm | Lt MCA | — | Craniotomy, hematoma evacuation, and immediate clipping (6 h) | Severe disability, GOS 3, mRS 5 |
Inamasu et al. [ | 35 | 28/f | WFNS 5, GCS 5, H&H IV | CT scan, | No | No | Rt | <25 cc | >10 mm | Lt ICA-Pcom (autopsy) | — | Craniectomy and hematoma evacuation | Deceased (5 days after admission), GOS 1, mRS 6 |
Inamasu et al. [ | 36 | 53/f | WFNS 5, GCS 4, H&H V, bilaterally dilated pupils | CT scan, DSA | Yes | No | Rt | <25 cc | >10 mm | Rt ICA-Pcom | — | Craniotomy, hematoma evacuation, and clipping | Deceased (3 days after admission due to severe postoperative brain swelling), GOS 1, mRS 6 |
Inamasu et al. [ | 37 | 72/f | WFNS 5, GCS 4, H&H V | CT scan, | Yes | No | — | <25 cc | >10 mm | Lt ICA-Pcom (autopsy) | — | Infusions of manitol, burr hole | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 38 | 53/m | WFNS 5, GCS 5, H&H V | CT scan | Yes | No | — | <25 cc | >10 mm | Unknown | — | Infusions of manitol, burr hole | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 39 | 47/f | WFNS 5, GCS 4, H&H V | CT scan | Yes | No | — | <25 cc | >10 mm | Unknown | — | Infusions of manitol, burr hole | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 40 | 70/f | WFNS 5, GCS 4, H&H V | CT scan | Yes | Yes | — | <25 cc | >10 mm | Unknown | — | No response to manitol infusion, conservative treatment | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 41 | 81/f | WFNS 5, GCS 4, H&H V | CT scan | Yes | No | — | <25 cc | >10 mm | Unknown | — | No response to manitol infusion, conservative treatment | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 42 | 55/m | WFNS 5, GCS 3, H&H V | CT scan | Yes | No | — | <25 cc | >10 mm | Unknown | — | No response to manitol infusion, conservative treatment | Deceased, GOS 1, mRS 6 |
Inamasu et al. [ | 43 | 49/m | WFNS 5, GCS 3, H&H V | CT scan | Yes | No | — | <25 cc | >10 mm | Unknown | — | No response to manitol infusion, conservative treatment | Deceased, GOS 1, mRS 6 |
Gelabert-Gonzalez et al. [ | 44 | 68/f | WFNS 5, GCS 4, fixed pupils | CT scan, DSA | Yes | No | Lt | — | — | Lt ICA-Pcom | — | Hematoma evacuation and immediate clipping (4 h) | Mild right-sided hemiparesis, GOS 4, mRS 2 |
Gelabert-Gonzalez et al. [ | 45 | 64/f | WFNS 4, GCS 9, dilation of the right pupil | CT scan, CTA | Yes | — | Rt | — | Marked | Lt ICA-Pcom | — | Hematoma evacuation and immediate clipping (28 h) | Full recovery, neurologically intact, GOS 5, mRS 1 |
Gelabert-Gonzalez et al. [ | 46 | 41/f | WFNS 5, GCS 4, right oculomotor paresis | CT scan, DSA | Yes | Yes | Lt | — | Marked | Lt ICA-Pcom | — | Hematoma evacuation and immediate clipping (5 h) | Deceased, GOS 1, mRS 6 |
Gelabert-Gonzalez et al. [ | 47 | 59/f | WFNS 5, GCS 6, bilaterally fixed pupils | CT scan, DSA | Yes | No | Rt | — | — | Rt ICA | 3 mm | Hematoma evacuation and immediate clipping (9 h) | Deceased, GOS 1, mRS 6 |
Krishnaney et al. [ | 48 | 42/f | WFNS 2, GCS 14 | CT scan, MRI, MRA, DSA | No | No | Bilateral | — | — | Acom | 10 mm | Craniotomy, hematoma evacuation and clipping, (6 days) | Uneventful recovery, no neurological deficits, GOS 5, mRS 1 |
Kim et al. [ | 49 | 72/f | WFNS 2, GCS 14 | CT scan, DSA | Yes | Yes | Rt | 6 mm | 8 mm | Lt distal ACA | — | Hematoma evacuation and immediate clipping (48 h) | Dysphasia, right hemiparesis, GOS 3, mRS 4 |
Kim et al. [ | 50 | 42/m | WFNS 5, GCS 3, bilaterally fixed pupils | CT scan, DSA | Yes | — | Lt | 6.5 mm | 10 mm | Lt ICA-Pcom | — | Hematoma evacuation and immediate clipping (3 h) | Mild left-sided arm paresis, GOS 4 mRS 3 |
Marinelli et al. [ | 51 | 62/f | WFNS 1, GCS 15, complete left third nerve palsy | CT scan, MRI, MRA, DSA | No | No | Lt | — | — | Lt ICA-Pcom | 10 mm | Endovascular embolization | Full recovery of left third nerve palsy, GOS 5, mRS 1 |
Hori et al. [ | 52 | 57/m | WFNS 2, GCS 13-14, incomplete right oculomotor palsy | CT scan, DSA | No | No | Rt | — | Moderate to marked | Rt MCA | 1.5 mm | Hematoma evacuation and immediate clipping | Full recovery, GOS 5, mRS 1 |
Koerbel et al. [ | 53 | 62/f | WFNS 4, GCS 10-11, rapid neurological deterioration | CT scan, DSA | No | No | Lt | — | Moderate to marked | Lt ICA-Pcom | 5 mm | Hematoma evacuation followed by coiling | Returned to normal lifestyle, GOS 5, mRS 1 |
Westermaier et al. [ | 54 | 55/f | WFNS 5, GCS 6, anisocoria right | CT scan, DSA | Yes | Yes | Rt | — | — | Rt Acom | — | EVD coiling and hematoma evacuation (24 h) | No formal deficits, mobile for short distance, GOS 4, Barthel 70 |
Westermaier et al. [ | 55 | 56/f | WFNS 5, GCS 3, MI, bilaterally fixed pupils, cardiopulmonary unstable | CT scan, DSA | Yes | Yes | Rt | — | — | Rt MCA | Large | Repeated infusions of manitol, hematoma evacuation, and immediate clipping (24 h) | Simple communication, left hemiparesis, permanent care, GOS 3, Barthel 20 |
Westermaier et al. [ | 56 | 55/f | WFNS 5, GCS 3, dilation of the right pupil | CT scan, DSA | Yes | No | Rt | — | — | Rt ICA-Pcom | — | Immediate hematoma evacuation, EVD and delayed coiling (24 h) | Mild left hemiparesis, GOS 4, Barthel 70 |
Westermaier et al. [ | 57 | 55/f | WFNS 5, GCS < 6, anisocoria right | CT scan, DSA | Yes | No | Rt | — | — | Rt Acom | — | Immediate hematoma evacuation, EVD, and delayed coiling (24 h) | Full recovery, return to work, GOS 5, mRS 1 |
Westermaier et al. [ | 58 | 43/f | WFNS 5, bilaterally fixed and dilated pupils | CT scan | Yes | No | Lt | — | — | Lt ICA-Pcom | — | Hematoma evacuation followed by coiling | Rt hemiparesis using a wheelchair for longer distances, GOS 3, Barthel 70 |
Westermaier et al. [ | 59 | 54/f | WFNS 5, GCS 3, dilation of the right pupil, cardiac instability | CT scan, DSA | Yes | — | Rt | — | — | Rt Acom | — | EVD, delayed coiling (24 h), hematoma evacuation three weeks later (burr hole) | Not able to walk, dependent on permanent care, GOS 3, Barthel 0 |
Westermaier et al. [ | 60 | 42/f | WFNS 5, dilation of the right pupil | CT scan, DSA | Yes | — | Rt | — | — | Rt ICA-Pcom | — | EVD, hematoma evacuation, and immediate clipping | Returned to normal lifestyle, GOS 5, Barthel 100 |
Westermaier et al. [ | 61 | 55/f | WFNS 5, bilaterally fixed pupils, cyanotic and hypoxic | CT scan | Yes | Yes | Rt | 5 mm | 4 mm | Rt MCA | 14 mm | No therapy as a result of prolonged hypoxia before admission | Deceased, GOS 1, mRS 6 |
Gilad et al. [ | 62 | 47/m | WFNS 1, GCS 15, partial left sixth cranial nerve palsy | CT scan, MRI, MRA, DSA | No | No | Tentorium midline | — | — | Intrasellar Acom | 13 mm | Coil embolization alone | Uneventful, no neurological deficits, GOS 5, mRS 1 |
Suhara et al. [ | 63 | 27/f | WFNS 4, GCS 8 | CT scan, DSA | No | No | Rt | — | — | Lt Pcal (ACA) | 7 mm | Craniectomy, immediate hematoma evacuation, and delayed clipping (5 days) | Uneventful recovery, no neurological deficits, GOS 5, mRS 1 |
Nishikawa et al. [ | 64 | 45/m | WFNS 5, GCS 5, dilated slowly reacting pupils | CT scan, MRI, MRA | No | Yes | Bilateral | — | Moderate to marked | Lt ICA | — | Emergency hematoma evacuation, and clipping | Deceased (cerebral herniation 6 days after admission), GOS 1, mRS 6 |
Kocak et al. [ | 65 | 68/f | WFNS 5, GCS 6 | CT scan, DSA | Yes | No | — | — | Rt ICA bifurcation | — | Patient died during resuscitation | Deceased, GOS 1, mRS 6 | |
Kocak et al. [ | 66 | 53/m | WFNS 2, GCS 14 | CT scan, DSA | Yes | No | — | — | Lt Pcom | — | Craniotomy, hematoma evacuation, and immediate clipping | Good recovery, GOS 5, mRs 1 | |
Kocak et al. [ | 67 | 48/f | WFNS 3, GCS 10 | CT scan, DSA (after hematoma evacuation) | Yes | No | — | Moderate to marked | Rt Pcom | — | Craniotomy and immediate hematoma evacuation, delayed clipping (6 days) | Severe disability, GOS 3, mRS 5 | |
Kocak et al. [ | 68 | 63/f | WFNS 1, GCS 15 | CT scan, DSA | Yes | No | — | — | Lt MCA | — | Craniotomy, hematoma evacuation, and immediate clipping | Good recovery, GOS 5, mRs 1 | |
Kocak et al. [ | 69 | 51/f | WFNS 2, GCS 14 | CT scan, DSA | Yes | No | — | — | Acom | — | Craniotomy, SDH evacuation, clipping | Good recovery, GOS 5, mRs 1 | |
Kocak et al. [ | 70 | 72/f | WFNS 4, GCS 8 | CT scan, DSA | Yes | Yes | — | Moderate to marked | Rt MCA | — | Craniotomy, hematoma evacuation (aSDH + ICH) and immediate clipping | Deceased, GOS 1, mRS 6 | |
Kocak et al. [ | 71 | 56/f | WFNS 4, GCS 7 | CT scan, DSA | Yes | Yes | — | Moderate to marked | Rt MCA | — | Craniotomy, hematoma evacuation (aSDH + ICH), and immediate clipping (6 h) | Deceased, GOS 1, mRS 6 | |
Kocak et al. [ | 72 | 67/m | WFNS 5, GCS 5 | CT scan, DSA (after hematoma evacuation) | Yes | No | — | Moderate to marked | Rt Pcom | — | Craniotomy and immediate hematoma evacuation, delayed clipping (8 days) | Severe disability, GOS 3, mRS 5 | |
Kocak et al. [ | 73 | 47/f | WFNS 1, GCS 15 | CT scan, CTA, DSA | No | No | — | — | Acom | — | Craniotomy, hematoma evacuation, and immediate clipping | Good recovery, GOS 5, mRs 1 | |
Kocak et al. [ | 74 | 57/f | WFNS 3, GCS 13 | CT scan, CTA, DSA | Yes | No | — | — | Lt Pcom | — | Craniotomy, hematoma evacuation, and immediate clipping | Good recovery, GOS 5, mRs 1 | |
Kocak et al. [ | 75 | 46/f | WFNS 4, GCS 12 | CT scan, CTA, DSA | Yes | No | — | — | Rt Pcom | — | Craniotomy, hematoma evacuation, and immediate clipping | Severe disability, GOS 3, mRS 5 | |
Marbacher et al. [ | 76 | 44/f | WFNS 5, GCS 3, bilaterally fixed pupils | CT scan, DSA | Yes | No | Rt | 15 mm | 10 mm | Rt Pcal (ACA) | 5 mm | Craniectomy, hematoma evacuation (4 h), and delayed clipping | Full recovery, mild cognitive deficits, GOS 5, mRS 1 |
Marbacher et al. [ | 77 | 50/f | WFNS 3, GCS 13, mild left-sided hemiparesis | CT scan, CTA | Yes | Yes | Rt | 9 mm | 23 mm | Rt MCA | 11 mm | Craniectomy, hematoma evacuation (12 h), and delayed coiling | Mild left-sided arm paresis, GOS 4, mRS 2 |
Marbacher et al. [ | 78 | 39/m | WFNS 5, GCS 4, bilaterally fixed pupils | CT scan, CTA | Yes | No | Rt | 10 mm | 14 mm | Rt ICA-Pcom | 5 mm | EVD, craniectomy, hematoma evacuation, and immediate clipping (18 h) | Residual left-sided hemiparesis, GOS 4, mRS 2 |
Marbacher et al. [ | 79 | 58/f | WFNS 5, GCS 5, dilation of the right pupil | CT scan, CTA | Yes | Yes | Rt | 5 mm | 4 mm | Rt MCA | 14 mm | Craniectomy, hematoma evacuation, and immediate clipping (3 h) | Full recovery, mild cognitive deficits, GOS 5, mRS 1 |
Marbacher et al. [ | 80 | 45/f | WFNS 5, GCS 4, dilation of the right pupil | CT scan, DSA | Yes | No | Rt | 20 mm | 18 mm | Rt ICA-Pcom | 7 mm | Craniectomy, hematoma evacuation, and immediate clipping (2 h) | Gait ataxia, GOS 4, mRS 3 |
Marbacher et al. [ | 81 | 68/f | WFNS 1, GCS 15, right oculomotor paresis | CT scan, CTA | Yes | No | Rt | 10 mm | 6 mm | Rt Distal ICA-Pcom | 2 mm | Craniotomy, hematoma evacuation, and immediate clipping (6 h) | Full recovery, no symptoms at all, GOS 5, mRS 0 |
Marbacher et al. [ | 82 | 27/f | WFNS 5, GCS 3, bilaterally fixed mydriasis, unstable cardiopulmonary condition | CT scan, DSA | Yes | No | Rt | 10 mm | 7 mm | Rt Pcal (ACA) | 12 mm | Craniectomy, hematoma evacuation (1 h) | Deceased, GOS 1, mRS 6 |
*Summary (characteristics) of 82 cases from 20 clinical case series or case reports of aneurysmal acute subdural hematomas. Abbreviations: SAH = subarachnoid hemorrhage; ICH = intracerebral hemorrhage; aSDH = acute subdural hematoma; MLS = midline shift; mm = millimeter; f = female; m = male; WFNS = World Federation of Neurological Surgeons; GCS = Glasgow Coma Scale; CT = computed tomography; Rt = right; Lt = left; mRS = modified Rankin Score; GOS = Glasgow Outcome Scale; FU = followup; NOS = not otherwise specified; Barthel = Barthel Index; DSA = digital subtraction angiography; MRI = magnetic resonance imaging; MRA = magnetic resonance angiography; MCA = middle cerebral artery; CTA = CT angiography; ICA = internal carotid artery; Pcom = posterior communicating artery; Acom = anterior communicating artery; ACA = anterior cerebral artery; Pcal = pericallosal artery; EVD = external ventricular drainage; MI = myocardial infarction.
Data analysis of 82 cases of aneurysmal aSDH*. *Abbreviations: WFNS = World Federation of Neurological Surgeons; CT = computed tomography; DSA = digital subtraction angiography; CTA = CT angiography; MRA = Magnetic resonance angiography; mm = millimeter; Pcom = posterior communicating artery; MCA = middle cerebral artery; Acom = anterior communicating artery; Pcal = pericallosal artery; ICA = internal carotid artery; GOS = Glasgow Outcome Scale.
Most of the patients were admitted with the worst initial clinical SAH grades and with signs of uncal herniation. The distribution according to the WFNS was grade 5 (
For all patients, the first radiological assessment was a CT scan (
Illustrative case: Panels (a–d) display axial CT scans with 3D reconstructions showing a right acute subdural hematoma with midline shift after rupture of a giant aneurysm located in the right middle cerebral artery. Panels (a) and (b): noncontrast-enhanced and contrast-enhanced axial CT scan, demonstrating a large aneurysm in the right silvian fissure with surrounding SAH, right-sided aSDH, and uncal herniation. Panel (c) shows a marked midline shift due to the mass effect of the aSDH. Panel (d) depicts the aneurysm with outgoing vessels.
In most of the cases, the aneurysm was located in the posterior communicating artery (Pcom) (
The treatment strategies included urgent hematoma evacuation (
Half of the patients were reported to have favorable outcomes (GOS 5 and GOS 4,
Outcome stratified according to therapeutic strategies*.
Patients presenting with rapidly deteriorating neurological condition | Patients presenting without rapidly deteriorating neurological condition | ||||||
Urgent intervention (<24 h) | Delayed intervention (>24 h) | Urgent intervention (<24 h) | Delayed intervention (>24 h) | ||||
Outcome | Outcome | Outcome | Outcome | ||||
GOS 5 + 4 | 23 (64%) | GOS 5 + 4 | 6 (25%) | GOS 5 + 4 | 10 (100%) | GOS 5 + 4 | 5 (100%) |
GOS 3 + 2 | 5 (14%) | GOS 3 + 2 | 2 (8%) | GOS 3 + 2 | 0 (0%) | GOS 3 + 2 | 0 (0%) |
GOS 1 | 8 (22%) | GOS 1 | 16 (67%) | GOS 1 | 0 (0%) | GOS 1 | 0 (0%) |
*Abbreviations: GOS = Glasgow Outcome Scale.
All patients presenting in good clinical condition without rapid neurological deterioration (
This meta-analysis of 82 reported cases presenting with aneurysmal aSDH and rapid neurological deterioration revealed that urgent surgical decompression and immediate occlusion of the aneurysm seem to be an acceptable treatment strategy in order to achieve better outcome (GOS 5 and GOS 4 = 64%). Good outcomes are found in patients maintaining stable neurological condition irrespective of whether intervention was immediate or delayed (GOS 5 = 100%). Patients with pure aSDH due to a ruptured aneurysm demonstrated better outcomes than patients who suffered aneurysmal aSDH associated with SAH. Patients in unstable cardiopulmonary condition, with unstable blood pressure and serious ventricular arrhythmias, have the highest risk of unfavorable outcomes. All patients who did not meet the criteria for invasive treatment had fatal outcomes.
Poor clinical presentation per se is not associated with worse outcome. However, the combination of marginal cardiac output and reduced cerebral perfusion and cerebral blood flow due to the mass effect [
Pure aSDH due to ruptured intracranial aneurysm is extremely rare. Only 20 cases have been reported so far, including 14 cases during the last two decades [
Due to the rarity of the disease, no guidelines have been established. In most reports, patients have bad clinical features on admission, often presenting in a comatose state with pupillary abnormalities. Fast decision making is mandatory. Determining a differential diagnosis, as well as treatment modalities, can be complicated by the rapid clinical course and the mixture of symptoms due to the ruptured aneurysm or mass effect of the hematoma.
To address the lack of guidelines, we developed a flowchart for treatment of patients with aSDH. However, the evidence for the proposed treatment flowchart comes from case series and case reports with relatively small sample sizes. Therefore, the estimation of effects is imprecise, and clinical recommendations included in the management protocol are weak [
In patients who are in good neurological condition at the time of admission, management may proceed in a standard manner (Figure
Illustrative schematic diagram of the protocol (management algorithm) for diagnosis and treatment of aneurysmal acute subdural hematoma. CT = computed tomography. CTA = CT angiography. DSA = digital subtraction angiography. * = if available.
For the management of patients who are in a coma or whose level of consciousness is deteriorating rapidly, the choice of initial diagnostics is more demanding, and management decisions become difficult (Figure
Intraoperative DSA would allow safe and complete aneurysm occlusion to be carried out at the same time as urgent hematoma evacuation [
Due to the rarity of aneurysmal aSDH, it remains difficult to define a comprehensive management protocol. In patients with poor neurological grade at admission and rapidly deteriorating levels of consciousness, urgent surgical decompression and immediate aneurysm obliteration result in favorable outcome (GOS 5 and GOS 4; 64%). Delay of immediate treatment in patients with rapidly deteriorating neurological conditions decreases the likelihood of a favorable outcome (GOS 5 and GOS 4; 25%). Good outcomes are observed in patients maintaining stable neurological condition irrespective of whether the intervention was immediate or delayed (GOS 5; 100%). Overall outcome of patients who suffered aneurysmal aSDH without SAH proved to be better (GOS 5, 69.2%) than the outcome of patients who presented with aneurysmal aSDH and SAH (GOS 5; 31.4%).
The authors are solely responsible for the design and conduct of the presented study and report no conflict of interests. No funds were or will be received for this study.