PMC8720441_01
Axial computed tomography scans performed on the day of presentation (a-c) and the next day (d-f) showing a subtly compressive, the left subdural hematoma apparently in acute phase that underwent slight regression in 1 day.
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F1
It was 15 mm in thickness without displacement of midline structures and showed a regression in 1 day with resolution of the headache [Figure 1].
Three-dimensional computed tomography angiography, anteroposterior (a) and the left lateral view (b), showing intact intracranial dural sinuses and the major cortical veins distributed in the left cerebral hemisphere.
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F2
CT angiography showed no vascular lesions in the intracranial dural sinuses or major cortical veins [Figure 2]. Cerebral magnetic resonance imaging (MRI) performed on post hospitalization day (PHD) 6 revealed a non-enhancing, nodular lesion in the subdural hematoma, and adjacent to the left parietal cortex [Figure 3].
Non-contrast axial T1- (a), T2-weighted- (b), fluid attenuated inversion recovery-(c), and post-contrast axial T1-weighted magnetic resonance imaging (d), performed on post hospitalization day 6, showing a non-enhancing, nodular lesion in the subdural hematoma, adjacent to the left parietal cortex (a-d, arrow).
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F3
CT angiography showed no vascular lesions in the intracranial dural sinuses or major cortical veins [Figure 2]. Cerebral magnetic resonance imaging (MRI) performed on post hospitalization day (PHD) 6 revealed a non-enhancing, nodular lesion in the subdural hematoma, and adjacent to the left parietal cortex [Figure 3].
Axial computed tomography scans (a and b) and T2-weighted magnetic resonance imaging (c), performed on post hospitalization day 14, showing a considerable enlargement of the subdural hematoma with the nodular lesion better circumscribed from the surrounding hematoma (c, arrow).
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F4
T2-weighted sequence [Figure 4]. Catheter angiography performed on PHD 14 did not reveal any intracranial vascular lesions.
Intraoperative photos showing, on reflection of the dura mater, a bi-layered subdural hematoma comprising a thick outer membrane and inner semisolid clots (a), intact cortical surface exposed after hematoma evacuation (b), nodular lesion adhering to the outer membrane of the hematoma and the arachnoids (c), and nodular lesion separate from the arachnoids with intact cortical vessels coursing underneath (d). A: anterior; Art: cortical artery; D: dura mater; I: inferior; NL: nodular lesion; OM: outer membrane of hematoma; P: posterior; S: superior; SH: semisolid hematoma; V: cortical vein; and Asterisk: cortical surface.
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F5
The nodular lesion identified previously on MRI, possessed a fibrous capsule, included clots, and adhered to the outer membrane of the hematoma and arachnoids. These attachments were bluntly dissected without injuring the cortical vessels coursing underneath [Figure 5].
Photomicrographs of the resected outer membrane (a and b) and nodular lesion (c and d) showing microvascular proliferation present in the outer membrane, adjacent to the hematoma cavity, and within the nodular lesion. (b and d) represent magnified views of the square areas in (a and c), respectively. (a-d) Hematoxylin and eosin stain. HC: Hematoma cavity; *Fibrous connective tissue; **Microvascular proliferation.
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F6
Microscopically, the resected outer membrane of the CSDH and the nodular lesion revealed areas of microvascular proliferation [Figure 6].
Axial computed tomography scans performed on postoperative day 1 (a and b) and day 35 (c and d) showing resolution of the residual subdural hematoma.
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F7
On postoperative day 35, CT showed a remarkable resolution of the residual hematoma [Figure 7].