Contralateral Acute Subdural Hematoma Developing Intraoperatively following Evacuation of an Ipsilateral Spontaneous Acute Subdural Hematoma in an Elderly Patient

A 73-year-old male patient presented in an unconscious state with weakness of the right side of the body, 8 hours after a fall. On examination, he had no eye opening, no verbal response, and on pain was localizing with the left hand. He was flexing weakly with the right upper limb on pain. There was no history of antiplatelet or anticoagulant intake and he had no other preexisting medical illnesses. Computed tomography (CT) scan showed a left-sided acute subdural hematoma (SDH) with significant mass effect, effacement of cisterns, and midline shift ([Fig. 1A-C]). There was no contralateral intracranial bleed or injury. He underwent left-sided temporoparietal craniotomy, durotomy, and clot evacuation. Intraoperatively, an arterial bleeding point was noted in the left frontal lobe and was cauterized. The brain was extremely lax and hence after duraplasty, the bone flap was replaced. Postoperatively, he was reversed from anesthesia but not extubated and was noted to have left-sided focal seizures. A CT scan was done that showed contralateral acute SDH with a small interhemispheric SDH with no parenchymal contusion ([Fig. 2A–E]). However, as this was not causing any significant midline shift or cisternal effacement conservative treatment was continued. A magnetic resonance imaging (MRI) study was done later too that showed only an acute subdural hematoma on the right side with no cerebral injury ([Fig. 3A–D]). His seizures were managed with anticonvulsants and serial CT scans showed resolution of the contralateral SDH over time ([Fig. 3E–H]). He was discharged uneventfully after 3 weeks with a full recovery.

Fig. 1 Preoperative computed tomography (CT) scan images (A–C) showing left-sided acute subdural hematoma with significant mass effect and midline shift with no contralateral contusion or acute subdural hematoma seen.

Fig. 2 Postoperative computed tomography (CT) scan images (A–C) showing complete evacuation of the subdural hematoma on the left side and a fresh subdural hematoma on the right side with no obvious contusion; (D) reconstructed three-dimensional image showing replaced bone flap on the left side and (E) coronal CT image showing a convexity acute subdural hematoma on the right side.

Fig. 3 Postoperative MRI (A) FLAIR images showing a hyperintense collection over the right cerebral convexity and an interhemispheric collection; (B, C) T2-weighted images and (D) T1-weighted images showing blood over the right cerebral convexity with no evidence of any parenchymal injury; postoperative CT scan images after 4 weeks (E–H) showing complete resolution of the right-sided acute subdural hematoma. CT, computed tomography; MRI, magnetic resonance imaging.

Publication History

Article published online:
29 July 2021

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