J Korean Neurosurg Soc.  2016 Jan;59(1):1-5. 10.3340/jkns.2016.59.1.1.

Chronic Subdural Hematoma in the Aged, Trauma or Degeneration?

• Lee KS

• KMID: 2152911
• DOI: http://doi.org/10.3340/jkns.2016.59.1.1

Abstract

Chronic subdural hematomas (CSHs) are generally regarded to be a traumatic lesion. It was regarded as a stroke in 17th century, an inflammatory disease in 19th century. From 20th century, it became a traumatic lesion. CSH frequently occur after a trauma, however, it cannot occur when there is no enough subdural space even after a severe head injury. CSH may occur without trauma, when there is sufficient subdural space. The author tried to investigate trends in the causation of CSH. By a review of literature, the author suggested a different view on the causation of CSH. CSH usually originated from either a subdural hygroma or an acute subdural hematoma. Development of CSH starts from the separation of the dural border cell (DBC) layer, which induces proliferation of DBCs with production of neomembrane. Capillaries will follow along the neomembrane. Hemorrhage would occur into the subdural fluid either by tearing of bridge veins or repeated microhemorrhage from the neomembrane. That is the mechanism of hematoma enlargement. Trauma or bleeding tendency may precipitate development of CSH, however, it cannot lead CSH, if there is no sufficient subdural space. The key determinant for development of CSH is a sufficient subdural space, in other words, brain atrophy. The most common and universal cause of brain atrophy is the aging. Modifying Virchow's description, CSH is sometimes traumatic, but most often caused by degeneration of the brain. Now, it is reasonable that degeneration of brain might play pivotal role in development of CSH in the aged persons.

Keyword

Hematoma subdural chronic; Causality; Classification; Aging; Intracranial pressure; Craniocerebral trauma

MeSH Terms

Aging
Atrophy
Brain
Capillaries
Classification
Craniocerebral Trauma
Hematoma
Hematoma, Subdural, Acute
Hematoma, Subdural, Chronic*
Hemorrhage
Humans
Intracranial Pressure
Stroke
Subdural Effusion
Subdural Space
Tears
Veins

Figure

• 

  Fig. 1 Schematic representation of the web of causation model for causation of chronic subdural hematoma. Development of CSH starts from the separation of the dural border cell (DBC) layer. Trauma or bleeding tendency may precipitate hematoma formation, however, it cannot produce chronic subdural hematoma, when there is no potential subdural space. The real lines mean direct causal relationships, while the dotted lines represent precipitations. Adopted from Lee KS et al.34), with permission from Br J Neurosurg.

• 

  Fig. 2 Schematic explanation for the difference in the incidence of chronic subdural hematoma. Anatomical difference of the cranium may influence the left and male prevalence of chronic subdural hematoma. The length and degree of atrophy in this figure are not actual data.

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