Surgical Neurology 64 (2005) S2:113 – S2:114 www.surgicalneurology-online.com
Acute interhemispheric subdural hematoma due to hemodialysis: case report Goksin Sengul, MDT, Yusuf Tuzun, MD, Associate PhD, Hakan Hadi Kadioglu, MD, PhD, Ismail Hakki Aydin, MD, FCNS, FICA Department of Neurosurgery, Ataturk University Medical School, Erzurum 25070, Turkey
Abstract
Background: Acute interhemispheric subdural hematoma (AISH) is an extremely limited complication in patients on maintenance hemodialysis. Diagnostic difficulties result from a fact that symptoms of acute hematoma such as headache, nausea, vomiting, apathy, sleepiness, paresthesia and seizures may also suggest dysequilibrium syndrome, dialytic dementia as well as hypertensive encephalopathy. Case Description: A case of acute interhemispheric subdural hematoma during long-term dialysis is presented. Conclusion: AISH caused by hemodialysis is a very important complication. It is sometimes difficult to differentiate from dysequilibrium or dialysis dementia. Clinicians must pay closer attention on neurological examination of hemodialyzed patient. Surgical treatment must be as prompt as possible because of the possible sudden worsening of the patient’s clinical condition. D 2005 Elsevier Inc. All rights reserved.
Keywords:
Interhemispheric; Subdural; Hematoma; Hemodialysis
1. Case description A 26-year-old woman had undergone hemodialysis 3 times weekly for 2 years. In July 2004, she had headache, vomiting, right hemiparesis, and loss of consciousness during hemodialysis. The patient was admitted to our clinic within 1 hour from the onset of symptoms. On examination, her Glasgow Coma Scale was 13 of 15 (opening eyes to call, obeying commands, and confused). She had a right hemiparesis with grade 2 power. Deep tendon reflexes were exaggerated, and plantar reflex was up-going on the right side. Computed tomography scan revealed interhemispheric hyperdensity over the tentorium cerebelli and along the falx and a 0.5 cm in thickness hyperdensity along the left parietal region (Fig. 1). Her hematologic and biochemical studies were not in normal range. After correcting them over 24 hours, the patient underwent paramedian twist drill Abbreviations: AISH, acute interhemispheric subdural hematoma. T Corresponding author. Department of Neurosurgery, Aziziye Research Hospital, Yenisehir, Erzurum 25070, Turkey. Tel.: +90 442 316 63 33-2085; fax: +90 442 316 63 40. E-mail addresses:
[email protected],
[email protected] (G. Sengul). 0090-3019/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.surneu.2005.07.050
Fig. 1. Computed tomography scan demonstrating the hyperdensity along the falx, left parietal region, and over the tentorium cerebelli. R indicates right.
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2. Conclusion
Fig. 2. Computed tomography scan demonstrating normal brain without hematoma after surgery.
craniostomy, and the hematoma was removed. Left parietal hematoma was treated nonsurgically. Postoperatively, she gradually improved (Glasgow Coma Scale, 15) but developed epileptic seizures. During the postoperative period, hemodialysis sessions were performed without heparin. After 15 days, the paresis recovered completely. The computed tomography scan demonstrated normal brain without hematoma (Fig. 2). The patient was discharged without any neurological deficits.
In proportion to a rapid increase in dialysis patients, neurological complications are increasing annually among long-term hemodialyzed patients [2]. Acute interhemispheric subdural hematoma due to hemodialysis is very rare but carries a bad prognosis. In most cases with AISH, focal symptoms have been characterized by contralateral motor palsy with crural dominance, as has been observed in the bfalx syndrome.Q Other possible neurological manifestations of AISH are disturbances of consciousness, focal or generalized epileptic manifestations, gait ataxia, dementia, language disorders, and oculomotor nerve palsies [1,3]. The diagnosis of AISH is mainly based on computed tomography. Cerebral angiography is only used to identify the source of bleeding [2,3]. Treatment strategies are based on the individual neurological response of each case and on the risk-benefit ratio to decide on a medical or surgical approach. Prompt surgical evacuation of hematoma is mandatory in the presence of a worsening neurological condition.
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