Title Acute Interhemispheric Subdural Hematoma : Case Report andReview of Literature

Author(s)YAMAGAMI, TATSUHITO; HANDA, HAJIME;NAGASAWA, SHIRO; NAGATA, HIROKAZU; CHUNG,KWANG JIN

Citation 日本外科宝函 (1987), 56(1): 69-76

Issue Date 1987-01-01

URL http://hdl.handle.net/2433/204004

Right

Type Departmental Bulletin Paper

Textversion publisher

Kyoto University

Arch Jpn Chir 56(1), 69～76, Jan., 1986

症例

Acute Interhemispheric Subdural Hematoma

Case Report and Review of Literature

TATSUHITO YAMAGAMI, HAJIME RANDA, SHIRO i'iAGASAWA,

HIROKAZU NAGATA and KWANG JIN CHUNG

Department of :¥curosurgery, Faculty of Medicine, Kyoto Univ旧日tyReceived for Publication, Sept. 22, 1986.

Summary

Acute interhemispheric subdural hematoma is an unusual condition, where hemiparesis, more

severe in the lower limb, or monoparesis of the lower limb can be fo山 1don the contralateral side

of the hematoma. This falx syndrome has been regarded as being pathognomonic for inter-

hemispheric subdural hematoma. We encountered a 52-year-old female who did not show falx

syndrome and recovered without a craniotomy and hence, accentuates the signi凸canceof a direc-

tion of head trauma, a careful neurological examination and serial follow-up CT (computed

tomography).

Introduction

Subdural hematoma localizing in the interhemispheric space is rare in adults and not mor巴

than thirty cases have been reported since ARING and Ev ANS described an autopsy case in 1940

(1-28).

Head trauma is the most frequent cause. '.¥linor head trauma in patierts with hemorrhagic

diasthesis or under anticoagulant therapy, as well as a rupture of an anterior cerebral artery

aneurysm, bring about acute interhemispheric subdural hematoma.

Removal of the hematoma has been proposed as valid therapy in this disorder, however、a

few patients have been successfully managed by conservative treatment9,is，叫 2s,25). In this

report we present a case of acute traumatic interhemispheric subdural hematoma (AIHSH) and

a review of the literature.

Key words: Head injury, Interhemispheric subdural hematoma, CT scan, Traumatic interhemispheric sul》duralhematoma, Faix syndrome. 索引語：頭部外傷，大脳半球間硬膜下血IN!.CTスキャン，外傷性大脳半球間硬膜下血腫，大脳鎌症候群．Reprint request: Tatsuhito Yamagami, Department of Neurosurgery, Ijinkaitakeda Hospital, 28-1 :¥loriminami-cho, Ishida. Fushimi-ku, Kyoto 601-13, Japan

70 日外宝 第56巻第1号 （昭和62年 1月）

Case Report

八ftera 52 year-old female wa~ involved in a traffic t叫lision司、hewa、transferredto a local

hospital and a skin laceration of the mandibular region ¥¥・a, sutured. 九 lo州 ofconsciousness

"> Fig. la. （＇’l performed 1 hour after head trauma. 、、cmilun.1r high dcn,it＼・ ar1・a along

the left anterior half of the falx

CT performed 6 hours刈ftnhead trauma. :-; n apparent incrl'ase in the size of the h仁m.11りn1;1

人CTTEIYfERlfE\ll~PHERIC ~UBDURAL IIEλIAT0¥1.-¥ 71

occurred, and [a,ted about one hour. メincethe （”r taken one hour after the accident (Fig. la)

revealed a semilunar high density area along the falx cerebri, she was referred to our department.

Upon admittance, seven hours after the accident, ,;he was alert and free from nuchal rigidity and

motor weakness. Contusions were found in the forehead, the right hypochondrium, and the

right upper quadrant of the abdomen. Laboratory findings did not reveal hematological

disorders. A plain skull film showed no fractures. Because the size of the hematoma was found

to be unchanged on the successive CT (Fig. lb), conservative therapy was chosen. The next day

two episodes of vomiting occurred but the level of consciou、nessdid not worsen. A neurological

examination showed no hemiparesis or motor weakness in the lower limb・ Follow-upCT

scanning confirmed a gradual decrease of the inter hemispheric subdural hematoma (Fig. 2). Two

weeks later she was discharged without any los、ofneurological functioning. A CT performed 38

days later showed the complete disappearance of AIHSH (Fig. 3).

Fig. 2. Upper: ・℃T24 hours after the head trauma.人 decreasein the si日 ofthe hema-toma along the anterior half of the falx "・as con凸rmed. .¥ slight hematoma along

the posterior half of the falx """'' found. Lm\'t•r: CT 4 days after head trauma. .¥ belt-like high densit,・ area along the falx cerebri decreased in size

72 日外宝 引56巻第1号（ll?l自162年 1月）

Fig. 3. CT performed 38 d‘り、 afterthe head trauma. The intcrhemispheric >ul>dural

hematoma disappeared.

Discussion

A traumatic episode i,, the most frequent cau同 ofAJH:-;H えnotherinducing factor i、anticoagulant therapy13,2s> 'dinor head tr札umacomplicated by bleeding diasthesis, for ex

ample, hemophilia or thrombocytopenia give rise to AIHSH•·15,2a> h:.ASDO:¥ reported a case of

mild head trauma with a ventriculoperitoneal shunt17>. Ruptures of a callosomarginal aneurysm

were also de;-cribed 7・削. Z1 ~1MERMA:\ published 15 c<1:,C;, of child λbu刈 andshowed that A lHSH

in children is frequent in the parietooccipital region27,2s> A!HSH is not uncommon in

children2>

｛‘a，、

inducing factor are汎immarizedin Tabl巴 1. Impaぐtfrom the median direction, i.e. fτontal,

parietal, and occipital region are frequent. Our case mげ han・ had an impact in a median direc-

tion since the mandibular skin was lacer孔ted. This impact 111ay ha v・cproduced a rotational

injury, which stretched and disrupted the parasagittal bridging veins.

Interhemispheric subdural hematoma due to head trauma in adults (Table 1).

1) Age and sex

The yoはngestpatient w山 23year~ old and the oldest 78. 九Ialepreponder辻neewa, found

(male 15, female 7).

2) Clinical manifestation,

Almost all ca;,c, are symptomatic within the third day3,19>. Hemiparesis, more prominent

in the leg. or monoparesis of the kg, that is, folx syndrome is characteristic. ¥lotor wealくness

I nterllt'mispht•n c su l》dur'd ltematorna d uじ tohead trauma in adult札Table I.

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lsfort, 1967

Clein, 1969

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74 日外宝第56巻：Jq号（ll{if1l62'1-1月）

i式 u,;uallv contralateral to the hematom礼、butip、ilateralor bilateral motor weakness has been

reprted s, 11, 10, 11, 19>. I psilateral monoparesis or hemiparesis j, due to the compression of the

contralateral cerebral \•ascuLitur ＜.白

Other s戸nptomsare headache. vomiting川idseizure＇’l （‘!carド011刈、:iousnesswas retained

in manv cases. In our case a loss of consciousness continuing for about one hour occurred. Faix

syndrome which has been regarded as being pathognomonic for diagno叶sdid not appear during

the clinical course.

3) :-¥ euroradiologicけlfindings

川、ullfractures are rarely found on a plain slくullx-r<1y. In our c川 rskull fractures were not

recognized. ¥¥-oLLSCH L主EGERdescribed the significant findings on仁AG:(1) midline situated

pericallosal artery、（2)d turning away from the midline of anterior川 dmiddle internal cerebral

branches of the pericallosal artery. (3) ava刈 ular-;pace・betweenpericallosal and callosomarginal

arteries. ( 4) no deviation of internal cerebral veins、and(5）九opositive findings in the lateral

view26' A decrease or disappearance of alpha出、ti¥-ity、deltafrequency‘and phase reversal were

shown on EEG3>. Unfortunately, neithei （‘A<; nor EEG叫，ι1.sperformed in our【、白討E DRλBEi (

showed that ζl S（、intigram叫・asal、‘

ト＇incethe advent of （‘，r、、 thisneuroradiological technique has at、quiredthe main role. ,¥

semilunar high densitv area along the midline, bounded medially by fo Ix cerebri, and laterally

by the convex border, are the common findings on CT13,2s>_ Even mild AIHSH出 our九 canbe

diagnosed lη・CT.

4) Therapv

< :raniotomy or burr hole formation with removal of th＜.‘ hematoma have been performed

routinely. Rt泊代、nt句ヘconservative therapy has Ii引、nemployed.

’！＇he prognc川、 isgood when the prim礼n・ head trauma is not fo ta I and appropriate diagnosis

is obtained. A craniotomy with removal of the hematoma may be recommended. In the case of

a small hematoma, without aggr川はtingclinical、igns.con叱 rvativetherapy with repeated CT

monitoring is also a刊叩table. Our case was treated con同 Ivatively because major neurological

deficits did not occur and size of hematoma did not incre川 rby sequential CTιラ；amination.

References

1) .-¥ring CD, E、an'JP: .-¥uerrant location of sulidural hematoma. .¥rch ¥<'urol Psychiat 1940; 44 1296 1306.

2) Brill <B. Jar川 h¥' Black P: （〕ccipitalinterhemispheri仁 川utcsuLdural hematoma treated l凡 lambdoidsuture tap. ~eurosurg 1985; 16: 247-251

3) Clein LJ, Bolton （ト Interhe・＂＇＂phni.-sulidural hematoma. (・a><・ report. J "ieurol :-.; eur<>'urg Psy・ chiat 1969: 32: 389-392.

41 I>r:1bek P, Kulm J, ¥Volny E: Interhemi,feralni叩 bduralnihcmatom. Kliniぐk＿＼－、angiogra凸ckya scinti・ gra自ck)'ol•raz. Cesk '¥eurol :"l!eurochir 1984; 47: 268-272

5) Esposito I JI' lJn・ kりい ］，（九mmalTl-:_ et al: Interhemisphericsuしduralhemat<>ni:i. ~outh ¥lじdJ 1984; 77: 379一381.

6) Fearnside ¥I Iえ‘ HallL町（、or¥,y( ( Interhヒrr】isphericsul.dur；巴tit】em.itomaf，【）llc》wir、ghead injur、Surg 1979; 49: 678-680.

7）卜t・in };¥I, Rovit RL. Interh<'111i.,ph1γM suLdural hemat川i1.1secondary tり hemorrhagefrom ,, calloso・

人CUTEI¥TERHE:'II I~l'HERI<：‘ SUBDU R人LHE:'II人TO¥!.¥ 75

marginal aneurysm. ¥ euroradiology 1966; 1: 183-186.

8) Friedman :'II B, Brant-Zawadzki :'II Interhemi,pheric ,ul.idural hemat＜汀】1a from ruptured ,111cury,m.

Com put Radio! 1983; 7・129-134.9) Fruin Al I、JuhlGI.、T:iylけrC: Intcrhemispheric subdural hematoma. Case report. J ＼じurosurg1984;

60：・ 1300-1302.

10) Fukamachi A, Wakao T, Kawafuchi J: Lim山 tionof admi引 ionCT in a山 tehead injury.-Report of three

autopsy case,- ヌピurolSurg (Tokyo) 1981; 9：・ 349355.

11) Cannon ¥¥'E Interhemispheric sul.idural hematoma: Case report. _J '.'J eurosurg 1961; 18: 829 830.

12) Glista c;c, Reichm川 1OH, Brumlik J, ct al: Interhemispheric sul.idural hematoma. Surg '¥ curol 1978; 10.

119 122.

13) Ho SU, Spehlmann R, Ho HT: CT scan in interhemispheric sul.idural hematoma. ！可じurology1977; 27

1097 ・1098.

14) Iサort.¥ Angiographi,che Befunde beim Hamatom und Empyem in Intι-rhemispha renspalt. For he hr

Gel> Rontg Strahl 1967; 107: 127-130

15) Izawa :'II. Takahashi K, Scntoh S A ca'c of interhemispheric suudural hematoma "'sociated with throml.io・

cytopenia. Neurol Surg (Tokyo) 1982; 10・556560.

16) Jacol:

235 236

17) Kasdon DL, :'llagruder ¥JR. Stevens EA、刊 al Bilateral intnhcmispheric sul.idural hematom出 ＼eurosurg

1979; 5: 57-59

18) Kusunoki T, :-.iogaki H, :'llasumura :'II.υal: Traumatic (para) interhemi,pheric hem<1toma. Progrc出 In

CT (Tokyo) 1980; 2: 433-435.

19) :'<ew PFJ, Scott ¥VR. 凶・hnurJA. et al: Computed axial tomog山 phywith the E :'ll 1 "・anncr. Radiology

1974; 110: 109 123.

20) Ogsbury JS, Sc、hneck行A.Lehman PA ¥Y Asp引 bof interhemispheric subdural hematoma, including the falx

syndrome. J Neural '.'¥ eurosurg Psychiat 1978; 41: 72-75.

21) Pozzati E, Gai、tG. ¥'inci A じtal: Traumatic interhcmisphcric oubdur礼lhe!ll;1toma. J Trauma 1982; 22:

241-243.

22) Satoh T、Yamamoto¥'.Asari S. et al: Tr；《tumaticinterhemispheric subdural hematoma. Report of a case

and analysis of 7 cases. :-.ieurol Su rι （Tokyo) 1982; 10: 667 672

23) Shigemori :'II、K川、auaT, Shirahama !¥'!.ct al: Acute interhemispheric subdural hematoma. Report of 2

cases. ¥ eurol日urg(Tokyo) 1982; 10: 647-652.

24）出｜川yanRQ, Gurdjian ES. Thomas L:'II Intじrhemi•、pheric chronic sulidural hematoma. ( '.ase report.

~eurology 1970; 20: 1215-1218.

25) ＼＼・oimantF, Thurel C, Roux FX句 etal: 11 c・nMtom山 sous-durauxaigus intcrhemi,pheriques. Rev ¥eurol

(Paris) 1983; 139・299-303.26) ¥¥'ollschlaeger PB. ¥¥・ollschlaeger G: The interhemispheric suudural or falx hematoma. 人mJ Roentgenol

1964; 92 '. 1252-1254.

27) Zimmerman RA, Bilaniuk LJ, Bruce D, et al: Computed tomograドhvof cranion・rcural injury in the abu叫 d

child. Radiology 1979; 130: 687 690.

28) Zimmerman RD, Rus同 IIEJ Yuruerg E, et al: Faix and interhemispheric五＂ureon axial CT II. Recogni・

tion and differentiation of interhemispheric suuarachnoid and suudural hemorrhage. 主J¥ R 1982; 3: 635-642

76

和文抄録

日外定第56巻 第l号（昭和62年 1月）

大脳半球間急性硬膜下血腫

症例報告と文献的考察

京都大学脳神経外科教室

山上達人， 半田肇， 長津史朗，永田 村~－，鄭 光 珍

大脳半球間IC生ずる急性硬膜下血麗は稀な病態で，

血腫側と反対側の下肢の麻庫や下l伎に強い運動麻樺を

特徴とする．

例を経験した． この例は， 特徴的な falxsyndrome

を呈さず，また， folio¥¥-up CT Iζて血腫の増大ない

ため，関頭術を施行することなく， i河：(rf1’j』ζ加療する

ことができた． 文献的考察を加えて報告する．我守は，52設の久性で， 大脳半球間急性硬膜下血腫