Acute subdural hematomas: atypical CT findings

Seventy-one patients with acute subdural hematomas were examined by CT within 72 hr of a documented head injury. Lesions often did not have the classical appearance of a homogeneous, high-density extracerebral collection of blood in a crescentic configuration. Specifically, 28 patients (39%) had mixed-density subdural hematomas (MDSDH) with various degrees of low-density blood within the subdural space. In 10 of these 28 patients, the hematoma had a relatively localized mass effect with a convex inner margin, occasionally mimicking the appearance of an epidural hematoma. The MDSDH group differed from the typical homogeneous high-density subdural hematomas in that they were larger (average maximal thickness was 18.1 mm versus 8.0 mm), had more midline shift, and had a higher mortality rate (50% versus 26%). Four patients with MDSDH demonstrated an unusual pattern of ventricular compression with trapping of cerebrospinal fluid in the body of the ipsilateral ventricle and compression of the body of the contralateral ventricle. This pattern has to our knowledge not been previously described. Possible causes of the low-density regions within the hematomas include unclotted blood in an early stage of hematoma development, serum extruded during the early phase of clot retraction, or cerebrospinal fluid within the subdural space due to an arachnoid tear.