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Acute SDH

Fresh coagulated blood between the arachnoid and dura mater is characteristic of acute SDH and can be diagnosed by clinicians or pathologists in the first

3 days following the traumatic event (Figs. 7.14, 7.15). The loosely coagulated blood drains off at autopsy, leaving no - or only minimal - visible residues on the inner surface of the dura and brain after formalin fixation. An SAH and/or displacement of the cerebrum with unilateral flattening of the hemispheres are present in most cases. A rapidly developing SDH becomes life threatening in adults once its volume has attained 50 ml (Di Maio and Di Maio 2001). If the SDH develops slowly, a considerably larger volume can be tolerated. Most cases of SDH are accompanied by laceration and/or contusion injuries of the cerebral cortex (Maxeiner 1998: 42 versus 30 of 166 cases investigated).

The ruptured vessel can be detected in some cases of acute, or even subacute SDH (Krauland 1982; Maxeiner 1997). On removal of the brain, an operating microscope and contrasting agents or dye may be applied for demonstration of the rupture (Maxeiner 1997). The site of a venous (or arterial) rupture often exhibits small focal SAH, which should be examined microscopically to confirm (or exclude) primary vascular disease, especially if non-accidental injury is suspected.

A concomitant old SDH is often found, especially if the victim was an alcoholic (or in shaken baby syndrome - see p. 502). Spontaneous or mechanically induced rebleeding into an old SDH is not uncommon. The bleeding has its source in the sinusoidal vessels of the granulation tissue organizing the preexisting hematoma. The presence of hemosiderin-containing macrophages or of macrophages of different ages in different layers of the bleeding are an indication that multiple bleeds have occurred at different times. A

Fig. 7.14a-d. Acute subdural hemorrhage at autopsy. a Beneath the dura mater the left-sided hemorrhage is translucent as a blue-colored alteration; b after removal of parts of the dura the hemorrhage is exposed while the right hemisphere is character

ized by an extreme flattening of the gyri as an indication of brain compression and swelling as well as c mass shifting; d the hemorrhage may extend to the basal subdural space of the cerebrum

Fig. 7.15a-e. The cerebral sequelae of an acute subdural hemorrhage after formalin fixation. a, b The brain hemispheres are marked by a left-sided (L) parenchymal compression (caused by the already removed SDH) associated with left-sided minor cortical hemorrhages at the temporal pole and right-sided (R), more distinct cortical (frontoabasal) hemorrhages; c (left-sided) uncal herniation (arrows) with bleeding associated with (central and right-sided) midbrain hemorrhage (arrowheads); d on the frontal section: multiple hemorrhages (right-sided) because of the shifting process, especially in the left part of corpus callosum, the right gyrus cingulus as well as a (ischemic induced) dark-colored right putamen; e hemorrhages within the white matter of the first frontal gyrus which gives evidence of gliding contusions as the result of acceleration

Fig. 7.15a-e. The cerebral sequelae of an acute subdural hemorrhage after formalin fixation. a, b The brain hemispheres are marked by a left-sided (L) parenchymal compression (caused by the already removed SDH) associated with left-sided minor cortical hemorrhages at the temporal pole and right-sided (R), more distinct cortical (frontoabasal) hemorrhages; c (left-sided) uncal herniation (arrows) with bleeding associated with (central and right-sided) midbrain hemorrhage (arrowheads); d on the frontal section: multiple hemorrhages (right-sided) because of the shifting process, especially in the left part of corpus callosum, the right gyrus cingulus as well as a (ischemic induced) dark-colored right putamen; e hemorrhages within the white matter of the first frontal gyrus which gives evidence of gliding contusions as the result of acceleration

Prussian blue reaction for stainable Fe should be carried out even on an apparently fresh SDH (for details see Oehmichen et al. 1981).

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