Delayed, catastrophic expansion of acute traumatic subdural hematomas: a case series

Incidences of catastrophic, life-threatening expansion of acute traumatic subdural hematomas (SDH) greater than 72-hours after injury are rare and limited to single case reports in the literature. Here we report the largest series of this rare subset of patients and evaluate the incidence and associated clinical factors.

We retrospectively reviewed all asymptomatic acute traumatic SDH admissions that were managed conservatively to a single large academic tertiary trauma center over a 5-year period. Inclusion criteria were diagnosis of non-operative acute SDH, Glasgow coma score (GCS) ≥14, and severe symptomatic expansion greater than 72 h after injury.

Nine patients met criteria for severe, symptomatic delayed expansion of asymptomatic acute SDH. The median age was 80.1 years. In all cases, the mechanism of injury was a low velocity, ground-level fall. The SDH size on initial imaging ranged from 3 mm to 16 mm at maximum diameter. All patients were admitted for observation with repeat imaging demonstrating stability of hemorrhage within 12 h. The median time to SDH expansion was 4.5 days. Repeat imaging demonstrated large, acute, operative SDHs, measuring 20.8 mm on average. Five patients underwent immediate surgical intervention, of which 4 were eventually discharged with GCS ≥14. The remaining 4 patients were transitioned to comfort measures without surgical intervention.

The risk of neurologic devastation and catastrophic event from SDH expansion >72 h from injury is exceedingly low, and head imaging should be performed at the first sign of symptoms despite length of time from injury.