Delayed Hypersensitive Process in Subacute Subdural Hematoma

Abstract

The authors report 2 patients with subacute subdural hematoma (sASDH). An inflammatory process is known to be involved in the development of traumatic subdural effusion (TSE) evolving into chronic subdural hemorrhage (CSDH), but a similar event has not been previously described in acute subdural hematoma (ASDH) evolving into sASDH. In our cases, dexamethasone (DXM) and other conservative treatments were administered to our first patient with dramatic clinical outcome, and a postoperative pathologic examination of the neomembrane of the sASDH in the second patient was done, which showed marked inflammatory process with T-lymphocytes and neutrophils infiltration. The good response to DXM in the first patient and the definite laboratory result of the second patient and their radiologic presentations, as well as a review of relevant literature, suggest that a T-lymphocyte-mediated, delayed hypersensitive reaction triggered by undissolved blood clot may be the driving force of ASDH developing into sASDH, which starts after the seventh day, and peaked by the end of the second week of the clinical course.

Impact of Time Interval between Trauma Onset and Burr Hole Surgery on Recurrence of Late Subacute or Chronic Subdural Hematoma

“…Hemodynamically, two mechanisms have been suggest : invasion of cerebrospinal fluid by a difference in osmotic pressure and cerebral hyperperfusion that follows hypoperfusion of the acute phase 3 35 37) . Pathophysiologically, following an initial head injury, blood within the subdural space triggers an inflammatory response that leads to high concentrations of vascular endothelial growth factor, increasing the permeability of capillaries 38) . After approximately two weeks, neomembranes on the inner and outer surface are formed through dural collagen synthesis and fibroblast spread, followed by ingrowth of neocapillaries, enzymatic fibrinolysis, and hematoma liquefaction 8 9 34) .…”

A review of sub acute subdural hematoma (SASDH) with our institutional experience and its management by double barrel technique (DbT): A novel technique

“…[2] Not only in terms of duration or computed tomography (CT) scan findings but pathologically also neomembrane of SASDH differs from that of CSDH, showing marked inflammatory process with T lymphocytes and neutrophil infiltration. [7] Hence, we proceed for the epidemiological evaluation of all the cases of SASDH, admitted to our institution, in the period August 2013 to December 2015. The advantage of the “double barrel technique (DbT)” over the conventional burrhole drainage is presented, along with their clinical follow up.…”