Review Article

Management of Patients Presenting with Acute Subdural Hematoma due to Ruptured Intracranial Aneurysm

Table 2

Patient characteristics*.

Series/year of publicationCase no.Age/sexInitial clinical findingsInitial diagnosticsSAHICHSide of aSDHSize of aSDHMLSLocation of aneurysmSize of aneurysmManagement (hours from ictus)Outcome

Watanabe et al. [30]/1991151/mWFNS 5, GCS 4, decerebrate posture, bilaterally dilated fixed pupils ataxic breathCT scanNoNoLtLt Pcal (ACA)Emergency craniectomy and hematoma evacuation (1 h)Deceased, GOS 1, mRS 6

Watanabe et al. [30]/1991272/fWFNS 4, GCS 12, right hemiparesisCT scan, DSAYesNoLtRt Pcal (ACA)Clipping (on day 15)Returned to normal daily life, GOS 5, mRS 1

Watanabe et al. [30]/1991374/fWFNS 5, GCS 4, decerebrate posture, ataxic breath, dilation of the left pupilCT scan, DSA failedYesNoRtLt Pcal (ACA) (found at autopsy)InoperableDeceased (3 days after onset), GOS 1, mRS 6

Kamiya et al. [5]/1991467/fH&H IV, paresisCT scan, DSAYesNoMCA30 mmCraniotomy, hematoma evacuation, and immediate clippingVegetative state, GOS 2, mRS 5

Kamiya et al. [5]/1991550/fH&H IIICT scan, DSAYesYesICA28 mmInoperable because of rerupture on admissionDecubitus and pneumonia, deceased, GOS 1, mRs 6

Kamiya et al. [5]/1991667/fH&H V, paresisCT scan, DSAYesYesMCA4 mmInoperableDeceased (on arrival), GOS 1, mRs 6

Kamiya et al. [5]/1991752/fH&H VCT scan, DSAYesYesNot detectedInoperableDeceased (on arrival), GOS 1, mRs 6

Kamiya et al. [5]/1991869/fH&H IICT scan, DSAYesYesAcom27 mmInoperable because of severe spasm on admissionDeceased, GOS 1, mRs 6

Kamiya et al. [5]/1991963/fH&H IICT scan, DSAYesNoMCA4 mmCraniotomy, hematoma evacuation, and immediate clippingGood recovery, GOS 5, mRs 1

Kamiya et al. [5]/19911073/mH&H IV, paresisCT scan, DSAYesNoAcom7 mmClinical deterioration, no operation impossibleDeceased, GOS 1, mRs 6

Kamiya et al. [5]/19911164/mH&H V, preoperative rerupture, cardiac failureCT scan, DSA failedYesNoNot detectedInoperableDeceased (nonfilling state DSA), GOS 1, mRs 6

Kamiya et al. [5]/19911272/fH&H IV, paresisCT scan, DSAYesYesDistal ACA4 mmHematoma evacuation and immediate clippingGood recovery, GOS 5, mRs 1

Kamiya et al. [5]/19911370/mH&H IV, paresisCT scan, DSAYesYesMCA6 mmHematoma evacuation and immediate clippingGood recovery, GOS 5, mRs 1

Kamiya et al. [5]/19911472/fH&H VCT scan, DSAYesYesICA4 mmInoperableDeceased (day 1), GOS 1, mRs 6

Kamiya et al. [5]/19911559/mH&H VCT scan, DSAYesYesMCA22 mmInoperableDeceased (day 2), GOS 1, mRs 6

Kamiya et al. [5]/19911639/fWFNS 5, GCS 4, decerebrate posturing, dilation of the right pupilCT scan, DSAYesYesModerate to markedDistal ACA3 mmHematoma evacuation and immediate clippingGood recovery, GOS 5, mRs 1

Kamiya et al. [5]/19911771/fH&H IIICT scan, DSAYesYesAcom11 mmHematoma evacuation and immediate clippingGood recovery, GOS 5, mRs 1

Rusyniak et al. [12]/19921974/fWFNS 5, GCS 4, decerebrate posturing, bilaterally miotic pupilsCT scan, CTAYesYesRtRt ICA-PcomHematoma evacuation, immediate clippingComplete recovery, GOS 5, mRS 1

Ragland et al. [13]/19932027/mGCS 5 right pupil nonreactive left mydriasisCT scan, DSANonoRtModerate to markedAcom20 mmHematoma evacuation, Maximal medical treatmentDeceased, GOS 1, mRS 6

O’Sullivan et al. [3]/19942132/mWFNS 5, GCS 4, bilaterally fixed pupils, hypertensive with bradycardiaCT scanYesLtLt ICA-Pcom12 mmMannitol, without effect on pupillary response (3 h), died before decompressionDeceased, GOS 1, mRS 6

O’Sullivan et al. [3]/19942248/fWFNS 5, GCS 4, dilated unreactive pupils, unstable cardiopulmonary situationCT scan, DSAYesYesRtRt ICA-Pcom15 mmManitol, without effect on pupillary response, hematoma evacuation, and clipping of the aneurysm (7 h)Deceased, GOS 1, mRS 6

O’Sullivan et al. [3]/19942336/fWFNS 5, GCS 3, bilaterally fixed pupilsCT scan, DSAYesYesRtRt MCA12 mmHematoma evacuation (4 h) and delayed clipping (day 4)Residual mild left hemiparesis, returned to work as a teacher, GOS 4, mRS 3

O’Sullivan et al. [3]/19942463/fWFNS 5, GCS 3, dilated unreactive pupilsCT scan, DSAYesRtRt ICA-Pcom20 mmHematoma evacuation (4 h) and delayed clipping (day 7)Full recovery, returned to normal lifestyle, GOS 5, mRS 1

O’Sullivan et al. [3]/19942562/fWFNS 3, GCS 14, mild left hemiparesisCT scan, DSAYesNoRt20 mmRt ICA-Pcom4 mmHematoma evacuation and immediate clippingUneventful recovery, returned to normal lifestyle, GOS 5, mRS 1

Nowak et al. [14]/19952652/fWFNS 5, GCS 3, dilated unreactive pupils, hypertensive crisis (systolic BP 280 mmHg)CT scanYesNoRtRt Pcal (ACA)Manitol, emergency hematoma evacuationDeceased, GOS 1, mRS 6

Nowak et al. [14]/19952745/fWFNS 1, GCS 15, disturbances of visionCT scan, DSAYesYesRt10 mmRt MCAHematoma evacuation and clipping (day 1)Full recovery, returned to normal lifestyle, GOS 5, mRS 1

Nowak et al. [14]/19952849/fWFNS 5, GCS 3, mild left-sided hemiparesisCT scanYesRtMarkedRt MCA>25 mmEmergency hematoma evacuation with gluing of the aneurysmDeceased, GOS 1, mRS 6 (rebleeding)

Nowak et al. [14]/19952963/mWFNS 5, GCS < 6, right dilated pupilCT scan, DSAYesRtRt MCA10 mmImmediate hematoma evacuation and delayed clipping (week 5)Full recovery, no serious neurological deficits, GOS 5, mRS 1

Ishibashi et al. [15]/19973054/fWFNS 1, GCS 15, no neurological deficitCT scan, DSANoNoLtLt ICA-PComCraniotomy, hematoma evacuation, and immediate clipping (<24 h)No neurological deficit, return to normal life, GOS 5, mRS 1

Nonaka et al. [16]/20003152/fGCS 4, decerebrate rigidity, and left oculomotor paresisCT scan, DSANoNoLtModerate to markedLt ICA-PCom10 mmCraniotomy, hematoma evacuation, and immediate clipping (>24 h)Full recovery, no neurological deficits, GOS 5, mRS 1

Inamasu et al. [17]/20023268/mWFNS 2, GCS 14, H&H II CT scan, DSA YesNo<25 cc<5 mmAcomCraniotomy, hematoma evacuation, and immediate clipping (6 h)Good recovery, GOS 5, mRs 1

Inamasu et al. [17]/20023361/fWFNS 4, GCS 10, H&H IV CT scan, DSA YesYes <25 cc <5 mmRt MCACraniotomy, hematoma evacuation, and immediate clipping (6 h)Good recovery, GOS 5, mRs 1

Inamasu et al. [17]/20023475/fWFNS 4, GCS 11, H&H IV CT scan, DSA YesYes <25 cc <5 mmLt MCACraniotomy, hematoma evacuation, and immediate clipping (6 h)Severe disability, GOS 3, mRS 5

Inamasu et al. [17]/20023528/fWFNS 5, GCS 5, H&H IV CT scan,No NoRt <25 cc>10 mmLt ICA-Pcom (autopsy)Craniectomy and hematoma evacuationDeceased (5 days after admission), GOS 1, mRS 6

Inamasu et al. [17]/20023653/fWFNS 5, GCS 4, H&H V, bilaterally dilated pupilsCT scan, DSAYesNoRt<25 cc>10 mmRt ICA-PcomCraniotomy, hematoma evacuation, and clippingDeceased (3 days after admission due to severe postoperative brain swelling), GOS 1, mRS 6

Inamasu et al. [17]/20023772/f WFNS 5, GCS 4, H&H V CT scan, Yes No<25 cc >10 mmLt ICA-Pcom (autopsy)Infusions of manitol, burr holeDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20023853/m WFNS 5, GCS 5, H&H V CT scan Yes No<25 cc>10 mmUnknownInfusions of manitol, burr holeDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20023947/f WFNS 5, GCS 4, H&H V CT scan Yes No<25 cc>10 mmUnknownInfusions of manitol, burr holeDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20024070/fWFNS 5, GCS 4, H&H VCT scanYesYes<25 cc>10 mmUnknownNo response to manitol infusion, conservative treatmentDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20024181/fWFNS 5, GCS 4, H&H VCT scan Yes No<25 cc>10 mmUnknownNo response to manitol infusion, conservative treatmentDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20024255/mWFNS 5, GCS 3, H&H VCT scan Yes No<25 cc>10 mmUnknownNo response to manitol infusion, conservative treatmentDeceased, GOS 1, mRS 6

Inamasu et al. [17]/20024349/mWFNS 5, GCS 3, H&H VCT scan Yes No<25 cc>10 mmUnknownNo response to manitol infusion, conservative treatmentDeceased, GOS 1, mRS 6

Gelabert-Gonzalez et al. [18]/20044468/fWFNS 5, GCS 4, fixed pupilsCT scan, DSAYesNoLtLt ICA-PcomHematoma evacuation and immediate clipping (4 h)Mild right-sided hemiparesis, GOS 4, mRS 2

Gelabert-Gonzalez et al. [18]/20044564/fWFNS 4, GCS 9, dilation of the right pupilCT scan, CTAYesRtMarkedLt ICA-PcomHematoma evacuation and immediate clipping (28 h)Full recovery, neurologically intact, GOS 5, mRS 1

Gelabert-Gonzalez et al. [18]/20044641/fWFNS 5, GCS 4, right oculomotor paresisCT scan, DSAYesYesLtMarkedLt ICA-PcomHematoma evacuation and immediate clipping (5 h)Deceased, GOS 1, mRS 6

Gelabert-Gonzalez et al. [18]/20044759/fWFNS 5, GCS 6, bilaterally fixed pupilsCT scan, DSAYesNoRtRt ICA3 mmHematoma evacuation and immediate clipping (9 h)Deceased, GOS 1, mRS 6

Krishnaney et al. [19]/20044842/fWFNS 2, GCS 14CT scan, MRI, MRA, DSANoNoBilateralAcom10 mmCraniotomy, hematoma evacuation and clipping, (6 days)Uneventful recovery, no neurological deficits, GOS 5, mRS 1

Kim et al. [20]/20054972/fWFNS 2, GCS 14CT scan, DSAYesYesRt6 mm8 mmLt distal ACAHematoma evacuation and immediate clipping (48 h)Dysphasia, right hemiparesis, GOS 3, mRS 4

Kim et al. [20]/20055042/mWFNS 5, GCS 3, bilaterally fixed pupilsCT scan, DSAYesLt6.5 mm10 mmLt ICA-PcomHematoma evacuation and immediate clipping (3 h)Mild left-sided arm paresis, GOS 4 mRS 3

Marinelli et al. [21]/20055162/fWFNS 1, GCS 15, complete left third nerve palsyCT scan, MRI, MRA, DSANoNoLtLt ICA-Pcom10 mmEndovascular embolizationFull recovery of left third nerve palsy, GOS 5, mRS 1

Hori et al. [22]/20055257/mWFNS 2, GCS 13-14, incomplete right oculomotor palsyCT scan, DSANoNoRtModerate to markedRt MCA1.5 mmHematoma evacuation and immediate clippingFull recovery, GOS 5, mRS 1

Koerbel et al. [23]/20055362/fWFNS 4, GCS 10-11, rapid neurological deteriorationCT scan, DSANoNoLtModerate to markedLt ICA-Pcom5 mmHematoma evacuation followed by coilingReturned to normal lifestyle, GOS 5, mRS 1

Westermaier et al. [4]/075455/fWFNS 5, GCS 6, anisocoria rightCT scan, DSAYesYesRtRt AcomEVD coiling and hematoma evacuation (24 h)No formal deficits, mobile for short distance, GOS 4, Barthel 70

Westermaier et al. [4]/075556/fWFNS 5, GCS 3, MI, bilaterally fixed pupils, cardiopulmonary unstableCT scan, DSAYesYesRtRt MCALargeRepeated infusions of manitol, hematoma evacuation, and immediate clipping (24 h)Simple communication, left hemiparesis, permanent care, GOS 3, Barthel 20

Westermaier et al. [4]/075655/fWFNS 5, GCS 3, dilation of the right pupilCT scan, DSAYesNoRtRt ICA-PcomImmediate hematoma evacuation, EVD and delayed coiling (24 h)Mild left hemiparesis, GOS 4, Barthel 70

Westermaier et al. [4]/075755/fWFNS 5, GCS < 6, anisocoria rightCT scan, DSAYesNoRtRt AcomImmediate hematoma evacuation, EVD, and delayed coiling (24 h)Full recovery, return to work, GOS 5, mRS 1

Westermaier et al. [4]/075843/fWFNS 5, bilaterally fixed and dilated pupilsCT scanYesNoLtLt ICA-PcomHematoma evacuation followed by coilingRt hemiparesis using a wheelchair for longer distances, GOS 3, Barthel 70

Westermaier et al. [4]/075954/fWFNS 5, GCS 3, dilation of the right pupil, cardiac instabilityCT scan, DSAYesRtRt AcomEVD, delayed coiling (24 h), hematoma evacuation three weeks later (burr hole)Not able to walk, dependent on permanent care, GOS 3, Barthel 0

Westermaier et al. [4]/076042/fWFNS 5, dilation of the right pupilCT scan, DSAYesRtRt ICA-PcomEVD, hematoma evacuation, and immediate clippingReturned to normal lifestyle, GOS 5, Barthel 100

Westermaier et al. [4]/076155/fWFNS 5, bilaterally fixed pupils, cyanotic and hypoxicCT scanYesYesRt5 mm4 mmRt MCA14 mmNo therapy as a result of prolonged hypoxia before admissionDeceased, GOS 1, mRS 6

Gilad et al. [24]/20076247/mWFNS 1, GCS 15, partial left sixth cranial nerve palsyCT scan, MRI, MRA, DSANoNoTentorium midlineIntrasellar Acom13 mmCoil embolization aloneUneventful, no neurological deficits, GOS 5, mRS 1

Suhara et al. [25]/20086327/fWFNS 4, GCS 8CT scan, DSANoNoRtLt Pcal (ACA)7 mmCraniectomy, immediate hematoma evacuation, and delayed clipping (5 days)Uneventful recovery, no neurological deficits, GOS 5, mRS 1

Nishikawa et al. [26]/20096445/mWFNS 5, GCS 5, dilated slowly reacting pupilsCT scan, MRI, MRANoYesBilateralModerate to markedLt ICAEmergency hematoma evacuation, and clippingDeceased (cerebral herniation 6 days after admission), GOS 1, mRS 6

Kocak et al. [27]/096568/fWFNS 5, GCS 6CT scan, DSA Yes NoRt ICA bifurcationPatient died during resuscitationDeceased, GOS 1, mRS 6

Kocak et al. [27]/096653/m WFNS 2, GCS 14 CT scan, DSA Yes NoLt PcomCraniotomy, hematoma evacuation, and immediate clippingGood recovery, GOS 5, mRs 1

Kocak et al. [27]/096748/f WFNS 3, GCS 10CT scan, DSA (after hematoma evacuation)YesNoModerate to markedRt PcomCraniotomy and immediate hematoma evacuation, delayed clipping (6 days)Severe disability, GOS 3, mRS 5

Kocak et al. [27]/096863/fWFNS 1, GCS 15CT scan, DSAYesNoLt MCACraniotomy, hematoma evacuation, and immediate clippingGood recovery, GOS 5, mRs 1

Kocak et al. [27]/096951/fWFNS 2, GCS 14CT scan, DSAYes NoAcomCraniotomy, SDH evacuation, clippingGood recovery, GOS 5, mRs 1

Kocak et al. [27]/097072/fWFNS 4, GCS 8CT scan, DSAYesYesModerate to markedRt MCACraniotomy, hematoma evacuation (aSDH + ICH) and immediate clippingDeceased, GOS 1, mRS 6

Kocak et al. [27]/097156/f WFNS 4, GCS 7 CT scan, DSA YesYesModerate to markedRt MCACraniotomy, hematoma evacuation (aSDH + ICH), and immediate clipping (6 h)Deceased, GOS 1, mRS 6

Kocak et al. [27]/097267/mWFNS 5, GCS 5CT scan, DSA (after hematoma evacuation) YesNoModerate to markedRt PcomCraniotomy and immediate hematoma evacuation, delayed clipping (8 days)Severe disability, GOS 3, mRS 5

Kocak et al. [27]/097347/fWFNS 1, GCS 15CT scan, CTA, DSANoNoAcomCraniotomy, hematoma evacuation, and immediate clippingGood recovery, GOS 5, mRs 1

Kocak et al. [27]/097457/fWFNS 3, GCS 13CT scan, CTA, DSAYes NoLt PcomCraniotomy, hematoma evacuation, and immediate clippingGood recovery, GOS 5, mRs 1

Kocak et al. [27]/097546/f WFNS 4, GCS 12 CT scan, CTA, DSAYes NoRt PcomCraniotomy, hematoma evacuation, and immediate clippingSevere disability, GOS 3, mRS 5

Marbacher et al. [2]/107644/fWFNS 5, GCS 3, bilaterally fixed pupilsCT scan, DSAYesNoRt15 mm10 mmRt Pcal (ACA)5 mmCraniectomy, hematoma evacuation (4 h), and delayed clippingFull recovery, mild cognitive deficits, GOS 5, mRS 1

Marbacher et al. [2]/107750/fWFNS 3, GCS 13, mild left-sided hemiparesisCT scan, CTAYesYesRt9 mm23 mmRt MCA11 mmCraniectomy, hematoma evacuation (12 h), and delayed coilingMild left-sided arm paresis, GOS 4, mRS 2

Marbacher et al. [2]/107839/mWFNS 5, GCS 4, bilaterally fixed pupilsCT scan, CTAYesNoRt10 mm14 mmRt ICA-Pcom5 mmEVD, craniectomy, hematoma evacuation, and immediate clipping (18 h)Residual left-sided hemiparesis, GOS 4, mRS 2

Marbacher et al. [2]/107958/fWFNS 5, GCS 5, dilation of the right pupilCT scan, CTAYesYesRt5 mm4 mmRt MCA14 mmCraniectomy, hematoma evacuation, and immediate clipping (3 h)Full recovery, mild cognitive deficits, GOS 5, mRS 1

Marbacher et al. [2]/108045/fWFNS 5, GCS 4, dilation of the right pupilCT scan, DSAYesNoRt20 mm18 mmRt ICA-Pcom7 mmCraniectomy, hematoma evacuation, and immediate clipping (2 h)Gait ataxia, GOS 4, mRS 3

Marbacher et al. [2]/108168/fWFNS 1, GCS 15, right oculomotor paresisCT scan, CTAYesNoRt10 mm6 mmRt Distal ICA-Pcom2 mmCraniotomy, hematoma evacuation, and immediate clipping (6 h)Full recovery, no symptoms at all, GOS 5, mRS 0

Marbacher et al. [2]/108227/fWFNS 5, GCS 3, bilaterally fixed mydriasis, unstable cardiopulmonary conditionCT scan, DSAYesNoRt10 mm7 mmRt Pcal (ACA)12 mmCraniectomy, hematoma evacuation (1 h)Deceased, GOS 1, mRS 6

*Summary (characteristics) of 82 cases from 20 clinical case series or case reports of aneurysmal acute subdural hematomas. Abbreviations: SAH = subarachnoid hemorrhage; ICH = intracerebral hemorrhage; aSDH = acute subdural hematoma; MLS = midline shift; mm = millimeter; f = female; m = male; WFNS = World Federation of Neurological Surgeons; GCS = Glasgow Coma Scale; CT = computed tomography; Rt = right; Lt = left; mRS = modified Rankin Score; GOS = Glasgow Outcome Scale; FU = followup; NOS = not otherwise specified; Barthel = Barthel Index; DSA = digital subtraction angiography; MRI = magnetic resonance imaging; MRA = magnetic resonance angiography; MCA = middle cerebral artery; CTA = CT angiography; ICA = internal carotid artery; Pcom = posterior communicating artery; Acom = anterior communicating artery; ACA = anterior cerebral artery; Pcal = pericallosal artery; EVD = external ventricular drainage; MI = myocardial infarction.