Acta Medica Philippina

ACUTE SUBDURALHEMATOMA:
A FIVE-YEAR REVIEW
Ty Henry

ABSTRACT Eighty-three casesof acute subdural admiuedto the Philippine General hematoma Hospilal from 1983 to 1993 were reviewed. Theprofile, natwgementand outcomeof the casesare presented. The typical patient is a a or youngFilipino mnle,frequently pedestrian intoicated driver involvedin a trffic accident orfall iniury. avictimof assault andsecondarily headiniuries Forry-eight7oarrivedwith severe surgical decompression. requiring imrnediate procedure dependent is Thechoice ofdiagnostic on its availability. In thosewith severehead withan mortaliryis54.l Vo injuries,theoperative overall mortaliry of 5a.0%o.In all cases,the The age is overallm.ortality 30.I Vo. mean of nonsurvivorsis 33.5years. Themortaliryreaches n 40Vo thoseassociatedwith confusio and67Vo in iniuries. in thosewith systematic lrcmatona,ve hicular subdural : Keywords acute blunt traumn,carotidangiography. accident,

of reviewtheprofile,management outcome and patienswithacute hematomas subdural admised to the Philippine GeneralHospital (PG[I) in in if orderto determine improvement diagnosis management atlainable. is and

METHODOLOGY of Thisis a descriptive study.Therecords 83 patiens admittedto the PhilippineGeneral Hospitalfrom 1989to 1993for acutesuMural carotid hematoma, diagnosed eitherbyCT scan, angiography exploratorycraniotomy,were or rcvicwcd. Thcrcwcre335entries under general the for hcading "subdural hematoma" 1989to of Only 196 1993 thcPGHDivision Records. at of wereavailable review.Of these,96 for rccords were werechronic hematomas,4 acute subdural hygromasand weresubacute I3 suMunl suMural from the wereexcluded hematomas, hence and review. The cases headinjurieswhich were of roombutwerenotadmiued seen theemergency at givesan werealsoexcluded. This necessarily underestimate theotal numberofacuteSDH of for the lastfive years. Also, the datapresented did not include the functional outcome in limitations, Despite tlrese follow-ups. subsequent it is hopedthat the data will give a workable picture theproblem hand. of at

(SDH) are Acute subduralhematomas and operated uponwithin 24hours become those within48 to 72 hours.They clinicallymanifest present with a trighermortalitythanothcr often masslesionsresultingfrom headinjury. The course of the patientsis determinedby the of severity thebraininjury at thetimeof trauma and by the rapidity of the expansionof the and hompt diagnosis intervention hematoma. ofthis paperto areessential.It is theobjective

RESULTS yieldcd mostnumberof the Theyear1990 numbcr o[ cascsper year cascs.Thc avcrage thepatients was 16.6. Eighty-scvcnpercentof with a ratioto lcmalcs 6.5 to I as wcrcmalcs of in shown Table1.

Department of Division of Neurosurgery Surgery, UP-PGFI M edicalCenter

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Table 1. CaseDistribution of Acute SDH at ttvPGH

There were cases wounds 5 two ofgunshot and were These cases werefound cases unknown. 5 (Table3). sprawled thepavement on Table Meclanisms Injury inAcuteSDHat 3. of tlvPGH Mechanisms
Vehicularaccident pedestrians passengers drivers Blunt bauma assault Fall injury Gunshot wound Unknown Total

Year 1989 1990 1991

Cases

Male

Female

r9y2
1993 Total

l0 29 l6 l6 t2 83

10 22 14 l5 il 72

0 7
, I I ll

The agesrangedfrom 6 monthsto 72 years, The with 6 unknown cases. mean was age 28 averaging .4years and 33.4yean with females werein the males34.1years. In males,47.2Vo third and fourth decadeswhereasin females, 45.57o werebelow20 yean Cfable2). Fifty-four percentof admittedcases were involved in vehicularaccidents. Of these45 werepedestrians while26.77owaft cases, 57.87o driven. Blunt traumarepresents 2l.7%o whereas, with assaultusing hard 19% was associated objectslike leadpipes,woodblocks,bolo, and 15.77o cases. fists. Fdl injuriescomprised of Tahle2. AgeDistributionof AcuteSDH at the PGH
Age Total Male
Female

45(54.2?o) 26(3r.3%o) 12(14.57o) 7 (8.47o) 18Qr.77o) 16(L9.3Vo) 13(r5.7%o) 2Q.4Vo) 5 (6.0?o)

0-9 l0-19 20-29 30-39 4049 50-59 60-69 70-72

7 (8.4Vo) 5 (6.9E") 2 (r8.29o) 9 (10.87o) 6 (8.3Vo) 3 (nsEo)

l9 | (9.rVo) (26.4Vo) Q4.l%o) l6 l5 I prq") (r9.3Eo) (20.8Vo) 9 (l0.8Vo) 8 ( l l . l 7 o ) | (9.lVo) 9 (10.8%( 9 (12.5E") 0 5 $.AEo) 3 (4.2Co) 2 (r8.2Vo) 2(2.4Eo) 2(2.8qo) 0
20 5 (6.9q")

Among thoseinvolvedin vehicular weremales 15.6%o accidents, 84.4Vo were and females. themales, Of 605Vo pedestrians, were 2l.0%o passengers 18.47o drivers. were were and 4297owere pedestrians Of the females, and w 57.l%o etepassengers. percent blunttrauma Ninety-four victims of weremales; werefemales.Ninety-four 5.67o percent blunttrauma males in of weredueto no assaults whereas such involved females. assault percent males 9.I 7o females Twenty-four of and of had subdural hematoma secondary blunt to trauma. predom Males nawd(92.370) fall injuries in (7.7Vo). females over Among males fall the with injuries one had prior seizure, five were intoxicated, sixwere work. while at victims males ofwhom All gunshot were one wasasleep whenhe washit. Sixtypercent of with unknown those weremales etiology and (table4). 40Vo females werc

Unknown 6 (7.2E)

| (9.1E")

Average 33.4years 34.1years 28.4years Range

0.5to72 4 to72

0.5to 65

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PhiliPPina ActaMedica

4. Tab,Ie SexDistibutionandEtiologyof Acute SDHatthe PGH

percentof blunt trauma Seventy-seven in occurred the20 n 49 agegroups.Sixty-nine percent fall injurieswasfoundamongthe20 of to 39 yearsold. Table6. AgeD istributionof Etiologiesof Acute SDII at rhePGII

Mechanisms Vehicular accident pedestrians passengers driven Blunt trauma Assault Fall injury Gunshot wound Unknown

lvlale

Female

3E(52.87o) 7 (63.67o) 23 (3r.9%o) 8 (rr.IVo) 7 (9.7Vo) L7(23.@o\ 16(22.2Vo) 12(16.77o) 2 (2.8Vo) 3 (4.27o)

3 (27.3vo) 4 (36.4Vo) 0 L (97o) 0 | (9.r%o) 0 2 (I8.2Vo)

Age

Blunt Fall Gunshot Unknown Wound Trauma

percentof all vehicular Twenty-seven occurredin the 20 to 29 age group accidents whereasinjuries to pedesrianswere present acrossall age groups. Fifty percent of the passengers in thethird andfourthdecades, were patients fell off their who female those including in vehicles.Thedriverswereall males the20 to 60 agegroup(Table5). Table5. AgeD istibutio n of VehicularAccidents in AcuteSDH Driver Toul Passengers Age Pedestrians

0 1 2 3 4 5 6 7 U

0 0 0 0 0 0 0 n l

19 1 0 0 - 1 9 0 l l - 2 9 6 2 0 - 3 9 3 7 1 4 9 5 0 0 - 5 9 1 1 0 - 6 9 1 1 0 -1 70 20 0 n o w n 0 0 0

l 0 1 0 0 0 3

0-9 10-19 20-20 30-39 4G40 5e59 60-69 70-12

4 3 4 0 3 5 3 I

(l)*

0 0 4 2 0 t 0 0 0 1

5 6 2 4 4 7 3 1 3

All the patientsin this restrospective Room weretakento thePGHEmergency study of 24 hoursof injury,with a range 0.25 within percent the of hourLo23.5hours.Seventy-two immediate surgical patients required (48.2Vo) lhe of Forty patients decompression. headinjurieswith a total numhr had scvere (GCS)of lessthan8. Of ComaScale Glasgow thcsc,37 paticntsunderwent emergency hematoma. the On of evacuation thesubdural injuriesof had othcrhand,26patients moderate patients underweht GCS 8 to 12. Of tlrese,l3 (17 Twentypercent of evacuation hematoma. patients) had mild injurieswith l0 undergoing were All decompression. theoperations surgical (Table7). of donewithinfour hours diagnosis gical of Tabte7. Severity HeadI njuriesand Sur in AcuteSDHat thePGH Decompression Coma Glasgow Scale 3-7 8-rz l3-15 Toral Total Cases Total Operations

3(2F
4(l)* 2(l)* I

(1r
0 0 0

Unknown3

4O(48.2Vo) 37 (92.5Vo) 26 (31.3vo) 13(50.57o) t7 (2O.5Vo) l0 (58'57o) 83 (100.0olo) 60 (72.3o/o)

*Figures in parenthesis indicatethosefalling from vehicles.

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Acta Medica Philip'pina

surgery, who underwent Of thosepatients by 45Vowere diagnosed carotid angiography, 3AVoby CT scan and l5%o by exploratory craniotomy. Two cases(3.37o)were depressed fungalinfectionof fractuesandfow (6.7%o)lad the brain. Thesewere operatedon after skull films were taken. In severehead injuries that had 56.87o bilateralcarotid operation, underwent (BCA), 25Vohad CI scan,8.37o angiography were explored and l.1Vo had cerebralfungal infection. In moderateheadinjuries that were had 30.8Vo eitherBCA or CT scan, ope,ratedon, had 23.17o were exploredud L5.4Vo cerebral fungal infection. In mild head injuries that had had requiredoperation,40Vo CT scan,20Vo fracnres and llVo each depressed BCA,20Vo hadfungusandexploration Clable8). Table 8. DiagnosticModalities in Operated with AcuteSDH at thePGH Patients GCS C'f Fungus BCA ExploreDepressed

in 1007o thoseassociated but these cases reached with systemicinjuries. Overall, the mortality in was23.5%o thosewith multipleinjuries,407o in in those with contusion only and66.77o those injuries (table 9). with systemic Table 9. AssociatedIniuries and Operative Mortality in Acwe SDHat thePGH InjuriesTotal Oprated 0RMorulity Muulity m

There were 23 mortalities, 22 of them operative. Two patients were bought home postoperatively. these If medical advice against Total 18 27 the wereregardedasmortalities, overall twocases mortalityis30.LVo. Of the 23 patientswho did not undergo In the group with severehead injury, by 22were diagnosed CT scan. surgery, overall mortality was 50Voand operative Overall, the diagnosiswas arrived at mortality reached 54.lVo. One patient was and broughthomeagainst based on CT scanin 40 cases(48.2Vo') advice. All the survivors (33.77o). Nine in carotidangiography 28 cases hadGCSgreater than4. The meanageof nonpatients (10.87o)underwent exploratory survivors percent died was36.1years. Seventy craniotomy, four patients @.\Vo) underwent within oneweekpostoperatively. threefemale All for debridement brain fungusand two (2.4V0) mortalitiesbelongto this group. fracture with underwentelevationof depressed In the group with moderateheadinjury, noteof SDH. incidental overall mortality was ll.87o and operative Nine percent of the acute subdural mortality was 107o. One succumbedto casesoccurredwithout associated myocardial infarction and the other hematoma with a wereassociated 18.17o injurieswhereas pre-operative. Both diedwithin decompensated combination of intracranial lesions such as was 5 days. The meanageof non-survivors 40 contusion-hematomas, years. epidural hematomas, intracerebral hematoma,skull fractures, or The meanagefor mortality in maleswas (SAII). Sixtypercent 35.3years, in females, years.The mean hemorrhage subarachnoid 15 and had who underwentoperations multiple of those was agefor all non-survivors 33.5yearsClable morfalitywas3lVoin cranialinjuries.Operative l0).

3-7 10 21 8-124 4 1 3 - 1

5 3 5 4

0 0 2 1

I 2 2 1

37.5% 3 Qs.0%) 40.0% 14Q3.3%') 6 15 Conusion (42.e%) (18.1%) 2(33%l 0 0 Epidural 3(3.6%1 hematoma 23.5% Multiple 36(60.%) ll 51 (30.6%) 6t.4% 6.7% Systemic 2%)4(6.7%) 4 6(7 (lm%) 36.7% 44 40(6]%) 5 Fracrre (53.0%) Q1.s%)
4(61%\ None 8(9.6%)

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Acta MedicaPhilippina

passengers werecaused vehicularfalls. This by maydueto a lact of properpassenger restraintin patients a movingvehicle.Some actuallyfell off while sleeping atopcargotruckswhile somefell Overall GCS Total* Operative Mortality from thebackof nicycles. Mortality Aserious wasthecommon finding concem (50.0Vo) of i ntoxication(86Vo). was Driving motorbikes 19(l) 5r.47o 47.57o 3-7 (1lVo).Bikesafford (54.r%o) alsoa common accident of (ll.57o) less protection to the drivers than enclosed r5.4%o 7.77o 2 (l\ 8-12 vehicles. 23.lVo) Blunt traumawasthenextcommonwith 10.070 ll,8Vo 13-15 I (l) with themajorityassociated assault.While half (30.l%o) of thefall injuriesoccurred work,theotherhalf at 22(3\ Total 36.74o 265Vo (40.0E0) involvcdinloxicatcd malcs. Thcsefindingscompare differentlywittt *Include one case each for the severe and forcign data which indicate that subdural hematoma was more likely due to falls and moderate head injury group who went home against in adviceandonecase themild headinjurywhodidnot assaults vehicular than accidents. undergo surgical operation. victims Tha majorityof male accident victims whilefemale wereinjuredaspcdestrians hematoma were involved equally either as pedestrians foracute subdural Theyearlymortality or to ranged from 16.7%o 43.7Vo. Overall, the passengers. theinjureddriversweremales. All mortality is30.IVo(Table1l). All assaults involvedmalesandmajorityof fall injuriesinvolvedmales. Table 11. Annual Mortality in Acute SDH in The majorityof cases weremaleswithin PGH the 20 to 60 age groups. It appearedthat passengers cargo trucks, drivers of motor of patients bikes,victimsof assault intoxicated or Rate(7o) Mortality Year from injurieswere mostlymales. who suffered predominance This explains overwhelming the 40.0Vo 4 of malevictims. 1989 The mean age of the PGH patient is (24.rEo) 20.7Vo 1990 6(l) youngcr reported foreignliterature, in thanthose (43.7Vo) 37.5Vo r99I 6(l) was a 6 which was4l-42 ycus; the youngest 3l.2%o 1992 5 was months girl witha fall injury.Theoldest old injury. The 2 l6.7Vo a72-ycu-oldmalewith a mauling 1993 injurcdpcdesuians bclonged almostall age to (30.l%o) groups lc passcngers drivcrs mostly 27.7o/o whi were 23(2) and Total bclow 40 years. Blunt traumaaffectedthose bclow 50 yearsandfall injuriesmostlyaffected thoscbclow 40 years. Overall,the patients DISCUSSION bclonged a productive groupof l0 to 60 tn age yea$. The most frequent etiology of acute Most of the casesthat were brought in hematoma amongpatients thePGH at subdural alreadyhad severeheadinjuries. Thesewere is vehicularaccidents.More thanhalf of these Injuries also the patientsrequiring immediatesurgical to involvedinjuries thepedesrians. cases with undergoing surgery. followed decompression 92.5Vo common are topassengers thenextmost Amongthosebroughtin severe head injuries, with by injuries [o ttre driver. Why a majority of morudity was507o. overall to callsattention affectedpedestrians accidents The rest were broughtin with mild to practices. Half of the injuries to road traffic
Table 10. Mortality inAcute SDH at the PGH

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Acta Medica Philippina

moderatehead injuries. About half of these patients surgery.Therewasa higher underwent mortalityin those with moderate injuries operative (23.l%o) compared thosewith mild injuries to (l}Eo). But overal mortality appro I 12Vo in ached both groups. represents Theoverallmortalityof 30.17o with thosein foreign a good figure compared however, literature.The Filipino non-survivor, youngerthan his foreign counterpafl. This is might be due !o thepreponderance vehicular of which affectsthe younger groups age accidents in the local setting. with head injurics Mostof thecases severe werediagnosed means carotid by of angiography. Thiswasmostprobably to lackof financial due resources to unavailabiltyof the CT scair or provided machine.In these cases, angiography a fast and affordablealternative diagnose to a subdural mass lesion requiring emergency with mild to moderate head surgery. In cases injuries,CT scanwasmorecommonly usedasa means diagnosis.This wasprobablydue to of availability of time to producethe necessary fundsandto transport patients institutions the to with the CT scanmachine Among equipped thosenot operated CT scanwas donein all on, except case. one The associated injuries determinethe of Those with contusions outcome thepatients. havea mortality 407o whilethose multiple with of injurieshavea 2t.57omortality.Patients with injurieshada 66.1 mortality. 7o systemic

The overall mortality for those having severe head injuries was50Vo. lhose For having multiple injuries, the operativemortality was 24Vo.Thosewith contusions only have42.9Vo ve ity. operati and40Vo erallmortal Those ov with systemic uries inj haveI 007o operativ and66.7 e Vo overallmortality.Themean of non-survivors age is 33.5. Vehicular was accident theleading cause hematoma thelocalsetting. in of acute subdural Preventive measures public through appropriate education trafficrcgulation and enforcement are incidents.Efforts in esscntial dccrease to these maybeof muchhelpin addressing thisdircction problcms. Lhcse

REFERENCES l. 2. Headlnjury.3rded.Williams CooperPR. & Wilkins. 1993. Wilberger JE et al. Acute subdural hematoma: Morbidity, mortality and operative timing. J Neurosurgl99l;74 (20):212-218. WilbergerJE et al. Acute subdural hematoma: Morbidity and mortality related timingof operative to intervention. J Trauma 1990;30(6): 733-736.

3.

CONCLUSION The typicalpatientwith acutesubdural hematoma broughtto thePGH for management is a youngFilipino male,frequently pedestrian a or intoxicated driverinvolved accidens, in and secondarily victim of assault fall injury. a and patiensarrivedwith About{}Voof these head injuries severe requiring immediate surgical The choice of diagnostic decompression. procedure depends uponis availabilityandthe needfor sucha diagnosis. urgencyof the

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