Background: An acute subdural hematoma (aSDH) is a rare presentation of a ruptured intracranial aneurysm with pathophysiology and prognosis poorly defined. According to literature, prognosis might be improved with prompt diagnosis, hematoma evacuation and aneurysm treatment. The objective is to specify pathophysiology, prognostic factors and management of this pathology.

Methods: We reported 23 cases of aSDH due to ruptured MCA aneurysm from literature revision and 2 cases from our center.

Results: Median age was 51 years and 48% (12/25) were females. At their arrival, 76% (19/25) presented decreased level of consciousness and 55.55% (10/18) neurological deficits. Aneurysmal location was left MCA in 57.14% (8/14) and MCA segments were M4 in 76.92% (10/13) and bifurcation in 23.07% (3/13), median aneurysmal size was 6 mm, median hematoma size was 10 mm, median midline shift was 9 mm, aneurysmal projection and MCA concavity were anterior in 100% (3/3), subarachnoid hemorrhage (SAH) was present in 52.17% (12/23). The treatment was surgery in 84% (21/25), endovascular in 12% (3/25) and in 20% (5/25) decompressive craniectomy (DC) was necessary. Glasgow Outcome Scale (GOS) was >3/favorable in 66.66% (16/24) and death in 16.66% (4/2).

Conclusions: Anterior MCA concavity and aneurysmal projection might be related with aSDH presentation in proximal MCA aneurysms. We should suspect aneurysm origin when there is no history or stigma of trauma, and CT shows disproportionately massive aSDH. Hematoma evacuation solves the compressive mechanism which is the main cause of neurological deterioration in pure aSDH cases, because of that, immediate hematoma evacuation could justify better outcome in these patients.

Keywords: Acute subdural hematoma; Aneurisma roto; Arteria cerebral media; Hematoma subdural agudo; Middle cerebral artery; Ruptured aneurysm.

Copyright © 2024 Sociedad Española de Neurocirugía. All rights reserved.

背景：

急性亚急性硬膜下血肿（aSDH）是颅内动脉瘤破裂的一种罕见表现，其发病机制和预后尚不明确。据文献报道，及时诊断、清除血肿以及治疗动脉瘤可以改善预后。本研究的目的是阐明这种病理的发病机制、预后因素及治疗方法。

方法：

我们通过文献回顾总结了23例因大脑中动脉（MCA）动脉瘤破裂导致急性亚急性硬膜下血肿的病例，并报告了来自我们中心的两例病例。

结果：

患者平均年龄为51岁，48% (12/25) 为女性。到达时，76% (19/25) 的患者意识水平下降，55.55% (10/18) 患者存在神经功能缺损。动脉瘤位于左侧MCA的占57.14%（8/14），MCA段为M4的占76.92% (10/13)，分支处的占23.07% (3/13)，平均动脉瘤大小为6毫米，平均血肿大小为10毫米，中线移位平均值为9毫米。所有病例（3/3）的动脉瘤投影和MCA凹陷均位于前方，蛛网膜下腔出血(SAH)出现在52.17% (12/23) 的患者中。治疗方法包括手术84% (21/25)，血管内治疗12% (3/25)，以及在20% (5/25) 的情况下需要进行去大骨瓣减压术(DC)。根据Glasgow结局量表(GOS)，66.66% (16/24) 患者预后良好，死亡率为16.66% (4/2)。

结论：

前侧MCA凹陷和动脉瘤投影可能与近端MCA动脉瘤导致的aSDH表现相关。当没有创伤史或证据时，CT显示不成比例的巨大aSDH，应怀疑为动脉瘤来源。血肿清除解决了纯aSDH病例主要由压迫机制引起的神经功能恶化的原因，因此，立即进行血肿清除可能会改善这些患者的预后。

关键词：

急性亚急性硬膜下血肿；破裂的动脉瘤；大脑中动脉；蛛网膜下腔出血；中间脑动脉；破裂动脉瘤。