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Title Acute Interhemispheric Subdural Hematoma : Case Report andReview of Literature
Author(s)YAMAGAMI, TATSUHITO; HANDA, HAJIME;NAGASAWA, SHIRO; NAGATA, HIROKAZU; CHUNG,KWANG JIN
Citation 日本外科宝函 (1987), 56(1): 69-76
Issue Date 1987-01-01
URL http://hdl.handle.net/2433/204004
Right
Type Departmental Bulletin Paper
Textversion publisher
Kyoto University
Arch Jpn Chir 56(1), 69~76, Jan., 1986
症例
Acute Interhemispheric Subdural Hematoma
Case Report and Review of Literature
TATSUHITO YAMAGAMI, HAJIME RANDA, SHIRO i'iAGASAWA,
HIROKAZU NAGATA and KWANG JIN CHUNG
Department of :¥curosurgery, Faculty of Medicine, Kyoto Univ旧日tyReceived for Publication, Sept. 22, 1986.
Summary
Acute interhemispheric subdural hematoma is an unusual condition, where hemiparesis, more
severe in the lower limb, or monoparesis of the lower limb can be fo山 1don the contralateral side
of the hematoma. This falx syndrome has been regarded as being pathognomonic for inter-
hemispheric subdural hematoma. We encountered a 52-year-old female who did not show falx
syndrome and recovered without a craniotomy and hence, accentuates the signi凸canceof a direc-
tion of head trauma, a careful neurological examination and serial follow-up CT (computed
tomography).
Introduction
Subdural hematoma localizing in the interhemispheric space is rare in adults and not mor巴
than thirty cases have been reported since ARING and Ev ANS described an autopsy case in 1940
(1-28).
Head trauma is the most frequent cause. '.¥linor head trauma in patierts with hemorrhagic
diasthesis or under anticoagulant therapy, as well as a rupture of an anterior cerebral artery
aneurysm, bring about acute interhemispheric subdural hematoma.
Removal of the hematoma has been proposed as valid therapy in this disorder, however、a
few patients have been successfully managed by conservative treatment9,is,叫 2s,25). In this
report we present a case of acute traumatic interhemispheric subdural hematoma (AIHSH) and
a review of the literature.
Key words: Head injury, Interhemispheric subdural hematoma, CT scan, Traumatic interhemispheric sul》duralhematoma, Faix syndrome. 索引語:頭部外傷,大脳半球間硬膜下血IN!.CTスキャン,外傷性大脳半球間硬膜下血腫,大脳鎌症候群.Reprint request: Tatsuhito Yamagami, Department of Neurosurgery, Ijinkaitakeda Hospital, 28-1 :¥loriminami-cho, Ishida. Fushimi-ku, Kyoto 601-13, Japan
70 日外宝 第56巻第1号 (昭和62年 1月)
Case Report
八ftera 52 year-old female wa~ involved in a traffic t叫lision司、hewa、transferredto a local
hospital and a skin laceration of the mandibular region ¥¥・a, sutured. 九 lo州 ofconsciousness
"> Fig. la. ('’l performed 1 hour after head trauma. 、、cmilun.1r high dcn,it\・ ar1・a along
the left anterior half of the falx
CT performed 6 hours刈ftnhead trauma. :-; n apparent incrl'ase in the size of the h仁m.11りn1;1
人CTTEIYfERlfE\ll~PHERIC ~UBDURAL IIEλIAT0¥1.-¥ 71
occurred, and [a,ted about one hour. メincethe (”r taken one hour after the accident (Fig. la)
revealed a semilunar high density area along the falx cerebri, she was referred to our department.
Upon admittance, seven hours after the accident, ,;he was alert and free from nuchal rigidity and
motor weakness. Contusions were found in the forehead, the right hypochondrium, and the
right upper quadrant of the abdomen. Laboratory findings did not reveal hematological
disorders. A plain skull film showed no fractures. Because the size of the hematoma was found
to be unchanged on the successive CT (Fig. lb), conservative therapy was chosen. The next day
two episodes of vomiting occurred but the level of consciou、nessdid not worsen. A neurological
examination showed no hemiparesis or motor weakness in the lower limb・ Follow-upCT
scanning confirmed a gradual decrease of the inter hemispheric subdural hematoma (Fig. 2). Two
weeks later she was discharged without any los、ofneurological functioning. A CT performed 38
days later showed the complete disappearance of AIHSH (Fig. 3).
Fig. 2. Upper: ・℃T24 hours after the head trauma.人 decreasein the si日 ofthe hema-toma along the anterior half of the falx "・as con凸rmed. .¥ slight hematoma along
the posterior half of the falx """'' found. Lm\'t•r: CT 4 days after head trauma. .¥ belt-like high densit,・ area along the falx cerebri decreased in size
72 日外宝 引56巻第1号(ll?l自162年 1月)
Fig. 3. CT performed 38 d‘り、 afterthe head trauma. The intcrhemispheric >ul>dural
hematoma disappeared.
Discussion
A traumatic episode i,, the most frequent cau同 ofAJH:-;H えnotherinducing factor i、anticoagulant therapy13,2s> 'dinor head tr札umacomplicated by bleeding diasthesis, for ex
ample, hemophilia or thrombocytopenia give rise to AIHSH•·15,2a> h:.ASDO:¥ reported a case of
mild head trauma with a ventriculoperitoneal shunt17>. Ruptures of a callosomarginal aneurysm
were also de;-cribed 7・削. Z1 ~1MERMA:\ published 15 c<1:,C;, of child λbu刈 andshowed that A lHSH
in children is frequent in the parietooccipital region27,2s> A!HSH is not uncommon in
children2>
{‘a,、
inducing factor are汎immarizedin Tabl巴 1. Impaぐtfrom the median direction, i.e. fτontal,
parietal, and occipital region are frequent. Our case mげ han・ had an impact in a median direc-
tion since the mandibular skin was lacer孔ted. This impact 111ay ha v・cproduced a rotational
injury, which stretched and disrupted the parasagittal bridging veins.
Interhemispheric subdural hematoma due to head trauma in adults (Table 1).
1) Age and sex
The yoはngestpatient w山 23year~ old and the oldest 78. 九Ialepreponder辻neewa, found
(male 15, female 7).
2) Clinical manifestation,
Almost all ca;,c, are symptomatic within the third day3,19>. Hemiparesis, more prominent
in the leg. or monoparesis of the kg, that is, folx syndrome is characteristic. ¥lotor wealくness
I nterllt'mispht•n c su l》dur'd ltematorna d uじ tohead trauma in adult札Table I.
-/〔,戸、『甲山同Z叶開閉山国開ピ『∞-uZ岡山知-『.
ef戸U]由ご〔Mh〉戸
ZHW/『〉吋。一r--J
Re,
recovert'd
di引 l
Cl'l'OVt'rl'd
r('covcred
rれ O¥'Cfl'd
died
Trealllll'lll
burr holl's
burr holes
burr hole~
burr holes
Cr<.1111りtom、era niotorn ,,
¥'l‘S
ぐれ1niotom、
Study
autops''
CA<;
ぐA<;
CAC
PE(人ぐA<;
CJ¥(;
CT, CAじ
(‘A<;
( lth .. r Symptoms
I t'COVぐr"d
recovげ t・d
I('(、<lVt'Cl、d
ret‘ll¥'t'I引 i
rcco、•t·r"d
d札、d
ret'llV('rt d
reuwer1・d
died
hurr holes
(I ‘l 111otomv
lT、1niotom、l'0l1S('rV日ti、’r
er:‘1ni《》tom、’
ぐ《》nscrvat1vc
l'<.lllSνrvはltVl'
|川rrholes
(、l
(‘I
(_"(
CT,ぐAC
CT. CAじ
c’l
CT, CA<;
t’l
¥'I I
elem t・Illta
lwadac he
hea《lach《白
hcacl‘tell<' vomiti H日
討eizure
head‘achc M'lZUr('
?ミt・1χure
hcmq川 l'l'Sl式
hcnd‘tChl' decl'n・brall' l川 sture. I I l
seizure
Faix 長;yndrome
¥'('S
¥'t'S
、vピ持VぜS
yes
、'('気
、t'気、’じ日
Loss of L、onsιiousness
Vt'S
Ill’ V<'S
、’l'S
H'S
n《》
?
Skull Fract urt•
no
?
応、
eJ
J
?
?
t
H{
札引
〉
〉
・
、.、-I
Sex
M
M
M
M
M
M
'VI
人目ゼ
に3
9d」E
A斗
0
4
2
1
8
2
8
0
・hvqU44にJ
丹
r
Sitt• of Trauma
ocnp1tal
not given
not耳ivt・n
not givcn
pan eta I
not given
not日IVl'n
occipital
A11thor,, ¥'c.ir
Aring. 1940
Jacobsen, 1955
Cannon, 1961
lsfort, 1967
Clein, 1969
メ1bavan,1970
N,・". 197.:1
()日入la日、、 1978 nt》no
、,,‘ l
\'(‘s
、,.,ミ
Jl()
、じ3ミ
no
no
n<》
、.,‘S
¥'CS
no
II《》
!HJ
?
¥'('S
no
M
M
M
M
V
F
M
M
4.J
7・4守
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づ
】
パ
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】
ハ
U
F口氏U
A
HZ
「
D
not宮IVl'll
occ1p1t日l
front‘l I
not E』vcn
pariet日l
occipitnl
frontal
not日ivcn
(;Jj,t;、'・ 1978
Fcarnsidl', 1979
K u州 noki,1980
Ful川 machi,198'.Zl
Shi日enwri,1982
氏1tnh,1982
Po日 ‘ati.1982
9
0
12345ιV
1izA
可
i
1ム
唱
止
2A3A
rccovercJ
re cm’ercd
l' I
( .. ,
、esll(J
no
?
no
110
F
;vi
54
59
\\’内imant 1983
Fruin, 1984
17
18
、3w
recovered
tonst・rv‘illlVL'
< nns.・rvativl'
、t・%、.,、封
、’l'S
'unserv:‘lltVl'
ぐA<;,Sl‘
CAC, SC.
CA<;, S(‘
(、l
l】山IU川 hl'vomttin日
hcmipan・"s
《il'llll'llt川
。』nI
I
l
l
-
-- E
向
、
、《・'、’,.~、
¥'l''ミ
no
no
、’t'S
SClllltgr‘llll
no
no
no
I¥町、
19
20
21
22 ¥'amは宮川ni,1985
?: unknown, VII: i川 ialparesis, l I I 叫culomotorl川 lsv,~づ(
* γlderlv, M: male, F: frmale
ド
M
ド
ド
。6d
ι
T
O
D
け
4
nU巧4
巧’’
弓υ
not gtVl'n
OC《iμital
unkno、、11
l>r;'1hek. 1984
74 日外宝第56巻:Jq号(ll{if1l62'1-1月)
i式 u,;uallv contralateral to the hematom礼、butip、ilateralor bilateral motor weakness has been
reprted s, 11, 10, 11, 19>. I psilateral monoparesis or hemiparesis j, due to the compression of the
contralateral cerebral \•ascuLitur <.白
Other s戸nptomsare headache. vomiting川idseizure'’l (‘!carド011刈、:iousnesswas retained
in manv cases. In our case a loss of consciousness continuing for about one hour occurred. Faix
syndrome which has been regarded as being pathognomonic for diagno叶sdid not appear during
the clinical course.
3) :-¥ euroradiologicけlfindings
川、ullfractures are rarely found on a plain slくullx-r<1y. In our c川 rskull fractures were not
recognized. ¥¥-oLLSCH L主EGERdescribed the significant findings on仁AG:(1) midline situated
pericallosal artery、(2)d turning away from the midline of anterior川 dmiddle internal cerebral
branches of the pericallosal artery. (3) ava刈 ular-;pace・betweenpericallosal and callosomarginal
arteries. ( 4) no deviation of internal cerebral veins、and(5)九opositive findings in the lateral
view26' A decrease or disappearance of alpha出、ti¥-ity、deltafrequency‘and phase reversal were
shown on EEG3>. Unfortunately, neithei (‘A<; nor EEG叫,ι1.sperformed in our【、白討E DRλBEi (
showed that ζl S(、intigram叫・asal、‘
ト'incethe advent of (‘,r、、 thisneuroradiological technique has at、quiredthe main role. ,¥
semilunar high densitv area along the midline, bounded medially by fo Ix cerebri, and laterally
by the convex border, are the common findings on CT13,2s>_ Even mild AIHSH出 our九 canbe
diagnosed lη・CT.
4) Therapv
< :raniotomy or burr hole formation with removal of th<.‘ hematoma have been performed
routinely. Rt泊代、nt句ヘconservative therapy has Ii引、nemployed.
’!'he prognc川、 isgood when the prim礼n・ head trauma is not fo ta I and appropriate diagnosis
is obtained. A craniotomy with removal of the hematoma may be recommended. In the case of
a small hematoma, without aggr川はtingclinical、igns.con叱 rvativetherapy with repeated CT
monitoring is also a刊叩table. Our case was treated con同 Ivatively because major neurological
deficits did not occur and size of hematoma did not incre川 rby sequential CTιラ;amination.
References
1) .-¥ring CD, E、an'JP: .-¥uerrant location of sulidural hematoma. .¥rch ¥<'urol Psychiat 1940; 44 1296 1306.
2) Brill <B. Jar川 h¥' Black P: (〕ccipitalinterhemispheri仁 川utcsuLdural hematoma treated l凡 lambdoidsuture tap. ~eurosurg 1985; 16: 247-251
3) Clein LJ, Bolton (ト Interhe・"'"phni.-sulidural hematoma. (・a><・ report. J "ieurol :-.; eur<>'urg Psy・ chiat 1969: 32: 389-392.
41 I>r:1bek P, Kulm J, ¥Volny E: Interhemi,feralni叩 bduralnihcmatom. Kliniぐk_\-、angiogra凸ckya scinti・ gra自ck)'ol•raz. Cesk '¥eurol :"l!eurochir 1984; 47: 268-272
5) Esposito I JI' lJn・ kりい ],(九mmalTl-:_ et al: Interhemisphericsuしduralhemat<>ni:i. ~outh ¥lじdJ 1984; 77: 379一381.
6) Fearnside ¥I Iえ‘ HallL町(、or¥,y( ( Interhヒrr】isphericsul.dur;巴tit】em.itomaf,【)llc》wir、ghead injur、Surg 1979; 49: 678-680.
7)卜t・in };¥I, Rovit RL. Interh<'111i.,ph1γM suLdural hemat川i1.1secondary tり hemorrhagefrom ,, calloso・
人CUTEI¥TERHE:'II I~l'HERI<:‘ SUBDU R人LHE:'II人TO¥!.¥ 75
marginal aneurysm. ¥ euroradiology 1966; 1: 183-186.
8) Friedman :'II B, Brant-Zawadzki :'II Interhemi,pheric ,ul.idural hemat<汀】1a from ruptured ,111cury,m.
Com put Radio! 1983; 7・129-134.9) Fruin Al I、JuhlGI.、T:iylけrC: Intcrhemispheric subdural hematoma. Case report. J \じurosurg1984;
60:・ 1300-1302.
10) Fukamachi A, Wakao T, Kawafuchi J: Lim山 tionof admi引 ionCT in a山 tehead injury.-Report of three
autopsy case,- ヌピurolSurg (Tokyo) 1981; 9:・ 349355.
11) Cannon ¥¥'E Interhemispheric sul.idural hematoma: Case report. _J '.'J eurosurg 1961; 18: 829 830.
12) Glista c;c, Reichm川 1OH, Brumlik J, ct al: Interhemispheric sul.idural hematoma. Surg '¥ curol 1978; 10.
119 122.
13) Ho SU, Spehlmann R, Ho HT: CT scan in interhemispheric sul.idural hematoma. !可じurology1977; 27
1097 ・1098.
14) Iサort.¥ Angiographi,che Befunde beim Hamatom und Empyem in Intι-rhemispha renspalt. For he hr
Gel> Rontg Strahl 1967; 107: 127-130
15) Izawa :'II. Takahashi K, Scntoh S A ca'c of interhemispheric suudural hematoma "'sociated with throml.io・
cytopenia. Neurol Surg (Tokyo) 1982; 10・556560.
16) Jacol:
235 236
17) Kasdon DL, :'llagruder ¥JR. Stevens EA、刊 al Bilateral intnhcmispheric sul.idural hematom出 \eurosurg
1979; 5: 57-59
18) Kusunoki T, :-.iogaki H, :'llasumura :'II.υal: Traumatic (para) interhemi,pheric hem<1toma. Progrc出 In
CT (Tokyo) 1980; 2: 433-435.
19) :'<ew PFJ, Scott ¥VR. 凶・hnurJA. et al: Computed axial tomog山 phywith the E :'ll 1 "・anncr. Radiology
1974; 110: 109 123.
20) Ogsbury JS, Sc、hneck行A.Lehman PA ¥Y Asp引 bof interhemispheric subdural hematoma, including the falx
syndrome. J Neural '.'¥ eurosurg Psychiat 1978; 41: 72-75.
21) Pozzati E, Gai、tG. ¥'inci A じtal: Traumatic interhcmisphcric oubdur礼lhe!ll;1toma. J Trauma 1982; 22:
241-243.
22) Satoh T、Yamamoto¥'.Asari S. et al: Tr;《tumaticinterhemispheric subdural hematoma. Report of a case
and analysis of 7 cases. :-.ieurol Su rι (Tokyo) 1982; 10: 667 672
23) Shigemori :'II、K川、auaT, Shirahama !¥'!.ct al: Acute interhemispheric subdural hematoma. Report of 2
cases. ¥ eurol日urg(Tokyo) 1982; 10: 647-652.
24)出|川yanRQ, Gurdjian ES. Thomas L:'II Intじrhemi•、pheric chronic sulidural hematoma. ( '.ase report.
~eurology 1970; 20: 1215-1218.
25) \\・oimantF, Thurel C, Roux FX句 etal: 11 c・nMtom山 sous-durauxaigus intcrhemi,pheriques. Rev ¥eurol
(Paris) 1983; 139・299-303.26) ¥¥'ollschlaeger PB. ¥¥・ollschlaeger G: The interhemispheric suudural or falx hematoma. 人mJ Roentgenol
1964; 92 '. 1252-1254.
27) Zimmerman RA, Bilaniuk LJ, Bruce D, et al: Computed tomograドhvof cranion・rcural injury in the abu叫 d
child. Radiology 1979; 130: 687 690.
28) Zimmerman RD, Rus同 IIEJ Yuruerg E, et al: Faix and interhemispheric五"ureon axial CT II. Recogni・
tion and differentiation of interhemispheric suuarachnoid and suudural hemorrhage. 主J¥ R 1982; 3: 635-642
76
和文抄録
日外定第56巻 第l号(昭和62年 1月)
大脳半球間急性硬膜下血腫
症例報告と文献的考察
京都大学脳神経外科教室
山上達人, 半田肇, 長津史朗,永田 村~-,鄭 光 珍
大脳半球間IC生ずる急性硬膜下血麗は稀な病態で,
血腫側と反対側の下肢の麻庫や下l伎に強い運動麻樺を
特徴とする.
例を経験した. この例は, 特徴的な falxsyndrome
を呈さず,また, folio¥¥-up CT Iζて血腫の増大ない
ため,関頭術を施行することなく, i河:(rf1’j』ζ加療する
ことができた. 文献的考察を加えて報告する.我守は,52設の久性で, 大脳半球間急性硬膜下血腫