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Post-traumatic acute subdural haematoma (ASDH) is a life threatening condition. The traditional approach is urgent surgery in haematomas with a mass effect. We report a case with a large post-traumatic ASDH whose haematoma disappeared markedly within 2 hours.
A 19 year old man sustained a head trauma at 22:30 and presented with Glasgow Coma Scale (GCS) score of 9 to the state hospital. CT scan showed a right hemispheric ASDH and a marked midline shift (panel A). He was transferred to our hospital for urgent surgery. In our hospital his GCS score was 12. A repeat CT scan at 00:30 showed substantial decrease of ASDH and oedema (panel B). Six hours later CT revealed total resolution of ASDH and the appearance of subarachnoidal haemorrhage (panel C). On the third day he was completely alert with a GCS of 15. MRI on the fifth day showed mild subarachnoidal haemorrhage (panel D). He was discharged on the tenth day with excellent neurological condition.
Although infrequently reported, rapid spontaneous resolution of an ASDH may be underestimated.1–5 Two possible hypotheses for spontaneous resolution have been proposed: (1) the haematoma is diluted by cerebrospinal fluid and is washed out; (2) the haematoma is compressed by the pressure produced by acute cerebral swelling and redistributed.2 Some authors have demonstrated redistribution and dispersal of blood in the subdural space with MRI.4,5
We think that a tear in the arachnoid membrane and connection between the subdural and subarachnoidal spaces results in dilution of haematoma. Thus not only redistribution and dispersal but also washing out of haematoma by retrograde flow into the subarachnoidal space may be the causes of ultra fast spontaneous resolution of an ASDH. In cases showing rapid improvement of neurological status a subsequent control CT is indicated before surgery.