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Two Types of Delayed Post-Traumatic Intracerebral Hematoma

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Two Types of Delayed Post-Traumatic Intracerebral Hematoma Two Types of Delayed Post-Traumatic Intracerebral Hematoma Takashi TSUBOKAWA Department of Neurological Surgery, Nihon University School of Medicine, Tokyo 173 Summary The findings of repeated CT scans, clinicalcourses and pathologicalstudies in 28 cases of delayed post-traumatic intracerebral hematoma were studied retrospectivelyto elucidate the mechanism of bleeding and to establish adequate treatment. Based on the results obtained, it became clear that there are two types of delayed hematoma. In 10 of the 28 cases, initial CT findings within 6 hours after head injury revealed cerebral contusion or hemorrhagic contusion, and spots of high density scattered in the low density zone gradually became confluent to form an irregularly shaped hematoma according to follow-up CT findings. This was termed "hematoma within a contusional area." In 15 of the 28 cases, initial CT findings within 6 hours after head injury revealed no abnormal density within the brain and the hematoma appeared suddenly 3 6 days after the injury. In eight of the 15 cases, emergency surgery was performed for the removal of epidural or subdural hematoma. This type of hematoma is termed "contusional hem atoma" and constitutes the second group. In three of the 28 cases, both types of hematoma were observed. Based on histological findings for the two types of delayed hematoma. The first group may be induced by an anoxic vasodilation mechanism (Evans et al.9)), while the second group may be derived from a different mechanism related to ishemic changes and the free radical reaction caused by the reflow phenomenon (Tsubokawa et al.14-16)1 It is important to establish correct diagnoses 1for delayed hematomas based on differences between follow-up findings of repeated CT and an initial CT performed within 6 hours after head injury since the operative indications and operative results for the two groups are different as indicated by our 28 cases. Key words: Head injury, repeated CT, contusion, delayed hematoma occurring immediately after trauma but with Introduction no typical posttraumatic apoplexy-like symp toms (Bollinger4), and has accounted for Delayed intracerebral hematoma following more than 50 % of traumatic intracerebral head injury is characterized by the appearance hematomas since CT was introduced in this of focal neurological signs or depression of particular field of diagnostics, computerized the level of consciousness, developing days or tomographic scanning (CT) is now the key weeks after the trauma. Prompt diagnosis diagnostic tool for this condition. However, and a decision concerning indication for even with CT it is difficult to make a correct surgery are necessary to minimize the harmful diagnosisof a delayed post-traumatic intracere effects that the hematoma may exert on the bral hematoma, to determine its exact patho already traumatized brain. genetic mechanism and to decide on the Because delayed traumatic intracerebral hem indication for surgery unless CT studies are atoma occurs in cases of severe head injury begun early after head injury and repeated is associated with focal neurological signs and until a hematoma of demonstrable size is depression of the level of consciousness formed (Tsubokawa et al. 14-16)) We reported previously that intracerebral after injury and diagnosis of delayed traumatic hematomas which, although not demonstrable intracerebral hematoma was ultimately estab in initial CT performed within 6 hours after lished by operation or autopsy were selected head injury, appear in repeated CT on 1 to 5 for the study (Table 1). days later can be classified into two types. One type includes those hematomas formed Results within a contused area which show evidence of cerebral contusion or hemorrhagic contusion in initial CT and are formed by the gradual I. Development and course of the two types of confluence of small hemorrhagic areas. The hematoma other type consists of those contusional hema In 10 of these 28 cases there was initial CT tomas which are not demonstrable, with no evidence of cerebral contusion or hemorrhagic evidence of contusion (Lanksch et al.101), in contusion, and a typical finding of multiple initial CT but appear within a normal brain punctiform or patchy areas of minor bleeding area later between 8 hours and 6 days after appearing in low density areas within 6 hours injury. after injury. These CT findings correspond The purpose of the present study was to respectively to Type I and Type II cerebral explore the possibility that these two types contusions according to the classification of of intracerebral hematomas are dissimilar Lanksch et al. Four of the 10 cases had an with respect to the mechanism of bleeding extracerebral hematoma, i.e., two with subdural and hence should be treated in a different way, hemorrhage and the other two with small based on CT findings, clinical courses and epidural hematomas at the fracture line. operative results obtained in our own series In all cases of Type I cerebral contusion of 28 cases of delayed traumatic intracerebral showing low density only in initial CT, the hematoma, and thereby to assess the clinical lesion developed into a hemorrhagic contusion value of the above classification. (Lanksch Type II10)) within 24 hours. By the third day of injury, these spots of bleeding Subjects gradually became confluent to form an ir regularly shaped hematoma (diameter of high From among the head injury cases seen at our density area exceeding 3 cm) which occupied hospital after the introduction of CT, 28 cases part of the initial low density area (Fig. 1). in which initial CT was nerformed 6 hours These hematomas are termed hematomas Table 1 Twenty-eight cases of traumatic delayed intracerebral hematoma classified into 2 groups based on CT findings, clinical courses and pathological findings. was performed within 24 hours after injury and four of them underwent additional decom pressive craniectomy. Among seven cases not undergoing emer gency evacuation surgery (three with subdural hematoma and four without extracerebral hematoma), an intracerebral hematoma became demonstrable in repeated CT scans within 24 hours after injury in two cases, within 48 hours in another two cases, and 3 to 5 days after injury in the remaining three cases. Fig. 1 CT scans illustrating the time course of Among eight cases in which an intracerebral delayed posttraumatic intracerebral hematoma hematoma developed after surgical removal (hematoma within a contusional area). A : Initial CT 5 hours after head injury. r of an extracerebral hematoma, the intracerebral subdural hemorrhage and 1-temporal contusion hematoma was formed within 4 hours after (Lanksch Type II) are observed. the operation in one case, 1 to 2 days after the B: CT findings 3 days after head injury. An operation in six cases and on the 5th postopera irregularly shaped intracerebral hematoma is tive day in one case. Intracerebral hematomas present in the contusion observed by the initial occurring after surgery for subdural or epidural CT. hematomas were ipsilateral to the preceding extracerebral hematoma in six cases and con within a contusional area since they are formed tralateral in the other two cases. from bleeding spots within a contused brain There were also three cases in the present area as reflected in the findings of repeated series where both a contusional hematoma and CT scans (Tsubokawa et al.14-16)) a hematoma within a contusional area were At the time when the diameter of the hema formed. In these cases, however, there was no toma exceeded 3 cm, shifting of the median concurrent extracerebral hematoma formation. structure was noted in eight of the 10 cases. In these two types of delayed traumatic In the other two cases where a hematoma intracerebral hematoma, impairment of con appeared at the frontal tip bilaterally or in the frontal lobe, no shifting of the median structure was seen. Fifteen of the remaining cases of delayed traumatic intracerebral hematoma had no abnormalities or only showed evidence of subarachnoid or sub or epidural hematoma in CT performed within 8 hours after injury. The appearance of an intracerebral hematoma was recognized in repeated CT performed between 8 hours and 6 days after injury. This type of hematoma differed from hematomas within the contused area in that it did not show any contusion or high density spots in Fig. 2 CT scans illustrating the time course of the brain in initial CT (Fig. 2). It was arbitrarily delayed posttraumatic intracerebral hematoma termed a contusional hematoma (Tsubokawa (contusional hematoma). et al.14-16)) A: Initial CT 8 hours after head injury. There are no visible pathological findings apart from Initial CT scan findings were negative in r-subdural hematoma. This hematoma was re cases of contusional hematoma within 8 hours moved by emergency surgery just after the CT. after injury except in nine cases with concurrent B : CT findings 4 days after emergency cra subdural hematoma and two cases with con niotomy. There is no remaining r-subdural comitant epidural hematoma. In eight out of hematoma, but intracerebral hematoma is 11 case of extracerebral hematoma, evacuation observed in the 1-front-temporal area. sciousness ranging from confusion to a coma, returned to their premorbid life. Of the two anisocoria or impaired light reaction was noted patients treated nonsurgically, one had a in about 20% of the cases and hemiplegia was disability necessitating assistance in daily life present in 30% of the cases. However, no and the other successfully returned to a normal gross alterations of neurological symptoms life (Table 2). were seen to occur coincidentally with the Of the 15 cases of contusional hematoma, development of delayed intracerebral hema two presented brain stem symptoms immedia toma, nor were these instances in which late tely after sustaining injury, while in another apoplectic symptoms according to Bollinger there was confusion at the time of hospitaliza manifested themselves at the time of hematoma tion and a hematoma later developed in the formation.
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