Spontaneous chronic subdural hematoma (CSH) is rare and is mostly seen in elderly
persons. Only a few case reports have reported it in young individuals. We report
an interesting rare case of spontaneous CSH in a young woman and the problems faced
in its management. This case report also highlights the occasional but important role
of magnetic resonance imaging (MRI) in managing multiseptated CSH.
A 23-year-old woman, laborer by profession, presented with complaints of headache
for past 30 days with intermittent vomiting for past 5 days. The patient was fully
conscious and oriented, with no neurologic deficits. Computed tomographic (CT) scan
of the head showed left side frontoparietal iso- to hypodense collection in subdural
location with mass effect and midline shift, suggestive of CSH ([Fig. 1]). There was no history of any trauma to the head, bleeding disorder, or intake of
any anticoagulants. There was history of right-sided CSH 6 years earlier, which was
drained by a burr hole in another hospital. The patient was completely normal in intervening
period. Her coagulation parameters were within normal range. The hematoma was drained
by frontal and parietal double burr hole technique evacuating nearly 100 cc of motor
oil colored fluid and clots. Her symptoms rapidly relieved, and she was discharged
on postoperative day 3. Twenty days after discharge, she presented with similar symptoms
of headache, vomiting, and a new-onset right-sided hemiparesis. CT scan showed a large
subdural collection in left frontoparietal region ([Fig. 2]). MRI of the brain showed presence of multiple septae within the hematoma that was
not apparent in CT scan ([Fig. 3]). A formal frontoparietal craniotomy was done with excision of capsule and evacuation
of hematoma ([Fig. 4]). Postoperative CT scan showed complete removal of the hematoma ([Fig. 5]). On follow-up of the patient after 6 months, there were no fresh complaints and
the CT scan was absolutely normal ([Fig. 6]).
Fig. 1 Axial CT scan showing left-sided frontoparietal isodense collection with midline
shift.
Fig. 2 Post 20 days of discharge, patient's CT scan showing hypodense collection in the
same region with moderate mass effect and midline shift.
Fig. 3 T2-weighted MRI showing characteristic septae (white arrows) within the subdural
collection.
Fig. 4 Fully expanded, pulsatile brain after craniotomy and membranectomy.
Fig. 5 Post second operation, CT scan showing complete removal of subdural hematoma.
Fig. 6 CT scan after 8 months of operation.
Chronic subdural hematoma is basically a disease of the elderly, and most of them
are caused by trivial trauma. Spontaneous onset CSH in young persons is very rare.[1]
[2]
[3]
[4]
[5]
[6] Because of its rarity in young population and the nonspecific nature of symptoms,
CSH is often diagnosed late and sometimes undertreated and neglected. Even in young
population group, trauma remains the most common cause of such hematoma; however,
some other causes have been reported. Coagulopathy,[1] arteriovenous malformation, and aneurysm[7] have been reported to cause spontaneous CSH. Intracranial hypotension[8] and middle fossa arachnoid cyst[9] have also been implicated as the predisposing factors for CSH. This case did not
have any coagulation abnormality or any vascular pathology. Aneurysms can cause acute
subdural hematoma due to their previous arachnoid adhesions and subsequent rupture
into the subdural space, which gradually converts into a chronic collection. Wang
et al[6] reported an interesting case of spontaneous CSH in a flute trainer, which they thought
to be caused by increased intravenous pressure induced by repeated blowing of air
(Valsalva's maneuver). Similar role of repeated Valsalva's maneuver in causing subdural
hematoma has been reported by Brennan et al[10] in a marathon runner and Jacome and Yanez[11] in a heavyweight lifter. Intracranial hypotension secondary to systemic hypotension
or exercise can cause spontaneous subdural hematoma.
The investigation of choice in subdural hematomas is CT scan. However, rarely, as
in this case, the cause of recurrent subdural hematoma could only be elicited by MRI
of the brain, which showed multiseptated nature of the collection. CT scan did not
show any internal septae within the collection.
The exact cause of CSH could not be revealed in this case. Multiple factors such as
intracranial hypotension and straining due to labor work (Valsalva's factor) could
have played a role in pathogenesis of such rare hematoma. This case is also exclusive
in that it stresses the rare but important role of MRI in knowing the internal architecture
of hematoma, which plays an important role in further management. Overall, the CSH
should be considered in the differential diagnosis of headache in young healthy persons
without any history of trauma, as a rare but easily treatable cause.
