Rapid spontaneous resolution of acute subdural hematoma associated with a contralateral arachnoid cyst: A case report and review of the literature

Aslam Perwez; Waleed Abdelfattah Azab; Suryapratap Singh

doi:10.4103/2230-7095.113832

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CASE REPORT

Year : 2013 | Volume : 3 | Issue : 1 | Page : 26-28

Rapid spontaneous resolution of acute subdural hematoma associated with a contralateral arachnoid cyst: A case report and review of the literature

Aslam Perwez¹, Waleed Abdelfattah Azab¹, Suryapratap Singh²
¹ Department of Neurosurgery, Ibn Sina Hospital, Kuwait
² Department of Trauma Surgery, Sehore, Bhopal, Madhya Pradesh, India

Date of Web Publication

21-Jun-2013

Correspondence Address:
Aslam Perwez
Department of Neurosurgery, Ibn Sina Hospital, P.O Box: 25427 Safat 13115
Kuwait

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2230-7095.113832

Abstract

Rapid resolution of post-traumatic acute subdural hematoma is infrequently reported. We report a case of rapid spontaneous disappearance of post-traumatic acute subdural hematoma in one patient who was discovered to have a contralateral middle cranial fossa arachnoid cyst. The previously reported mechanisms responsible for the rapid spontaneous disappearance of post-traumatic acute subdural hematoma are reviewed and the contribution of the middle cranial fossa arachnoid cyst to the disappearance of the pos-traumatic acute subdural hematoma that has taken place in our case is discussed. To the best of our knowledge the association between spontaneous disappearance of post-traumatic acute subdural hematoma and arachnoid cysts has not been previously reported.

Keywords: Arachnoid, cyst, hematoma, subdural

How to cite this article:
Perwez A, Azab WA, Singh S. Rapid spontaneous resolution of acute subdural hematoma associated with a contralateral arachnoid cyst: A case report and review of the literature. Int J Stud Res 2013;3:26-8

How to cite this URL:
Perwez A, Azab WA, Singh S. Rapid spontaneous resolution of acute subdural hematoma associated with a contralateral arachnoid cyst: A case report and review of the literature. Int J Stud Res [serial online] 2013 [cited 2023 Mar 29];3:26-8. Available from: http://www.ijsronline.net/text.asp?2013/3/1/26/113832

Introduction

Acute subdural hematoma is frequent among patients with closed head trauma and represents a challenging pathological condition in view of its high mortality rate and poor outcomes. ^[1]

Although infrequently reported, rapid spontaneous resolution of acute subdural hematomas may be underestimated. ^[2]

We report one patient with a middle cranial fossa arachnoid cyst in whom rapid spontaneous disappearance of a contralateral post-traumatic acute subdural hematoma occurred.

Case report

A 15-month-old female patient presented with head injury after a fall from downstairs. She immediately lost consciousness for a brief period and then generalized tonic-clonic epileptic fits started until she was transferred to the emergency room. After initial resuscitation and seizure control, the patient was sleepy with no focal neurological deficits noted on neurological examination. A CT scan of the brain revealed a left fronto-temporo-parietal acute subdural hematoma with no midline shift [Figure 1] and [Figure 2]. A right middle cranial fossa Type II arachnoid cyst was also noted in addition to moderate cerebral atrophy [Figure 2]. Conservative management with administration of dehydrating measures and close observation was decided based on the good clinical condition of the patient and the absence of focal neurological deficits and midline shift. A follow-up CT scan, done 12 h later [Figure 3], [Figure 4] and [Figure 5], revealed almost complete resolution of the hematoma. The patient was discharged 2 days later in a fit condition.

Figure 1: CT image obtained early after trauma reveals left frontotemporoparietal acute subdural hematoma. No midline shift is present. Note the low density band between hematoma and the inner wall of the skull bone

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Figure 2: A right middle cranial fossa Type II arachnoid cyst was found with moderate cerebral atrophy

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Figure 3: A follow-up CT scan 12 h post injury with almost complete resolution of the hematoma

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Figure 4: Early CT scan demonstrating acute subdural hematoma seen as hyperdensity at the level of the left middle cranial fossa skull base with contralateral arachnoid cyst

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Figure 5: Resolution of the hematoma as seen in the basal cuts at the level of the middle cranial fossa skull base

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Discussion

In addition to our case, several other reports of ASDH that diminished or disappeared spontaneously have been published. ^{[2],[3],[4],[5],[6],[7]} Several mechanisms of rapid spontaneous resolution of ASDH were hypothesized. Redistribution and dispersal of the hematoma is thought to be the underlying mechanism by many authors. ^{[3],[4],[5],[7]} A tear in the arachnoid membrane with CSF leaking into the subdural space is speculated to play an important role in washing out the hematoma. ^[8] Pulsatile flow of CSF through the tear results in redistribution and dispersal of the hematoma with subsequent retrograde flow into the subarachnoid space. Suzuki et al. described a characteristic low density band between the hematoma and the inner wall of the skull bone seen in early CT scan images that correlates with this process. ^[7] A similar finding was noted in our case [Figure 1]. However, redistribution of the blood rather than actual disappearance of the hematoma was demonstrated by magnetic resonance imaging despite apparent complete disappearance on CT scan images. ^[4],[6] The effect of dehydrating measures together with cerebral atrophy possibly contributes to dilution and redistribution of blood with hematoma disappearing in CT scans. ^[9]

In one report, AIDS-related cerebral atrophy was speculated to have favorably influenced the spontaneous resolution of an acute subdural hematoma. ^[10]

We think that dehydrating measures administered to our patient in addition to cerebral atrophy notable in her CT images were, at least partially, responsible for the rapid resolution of the subdural hematoma. Another proposed mechanism is acute cerebral swelling that is speculated by some authors to compress the haematoma leading to its redistribution. ^[11]

Matsuyama et al. however, considered acute cerebral swelling not a necessary condition for rapid disappearance of the hematoma. ^[5]

In our patient, a Type II right middle cranial fossa arachnoid cyst was found on CT imaging. Middle cranial fossa arachnoid cysts are classified into three types. Type I cysts are located in the sylvian fissure, posterior to the sphenoid ridge without any mass effect; these freely communicate with the subarachnoid space. Type II cysts are larger, rectangular, and localized in the proximal and middle parts of the sylvian fissure. These slowly communicate with the subarachnoid space. Type III cysts are the largest and lenticular shaped; they generally cause midline shift without communication to the subarachnoid space. ^{[12],[13],[14]} According to their relation to the subarachnoid space, arachnoid cysts are classified as communicating or non-communicating. ^{[15],[16],[17]} Marked fluid motion and jet flow between middle cranial fossa cysts and the cisterns are found in communicating cysts, while only slight fluid motion is found in isolated cysts. ^[18]

We speculate that CSF jet flow between arachnoid cyst and subarachnoid space might have contributed to the rapid disappearance of the hematoma in our patient through a more vigorous CSF motion resulting in a more effective dispersal and washout of the hematoma.

References

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