Challenges in the diagnosis and management of patients with non-traumatic subdural hematomas

Non-traumatic subdural hematomas (NSDH) represent a rare but clinically significant pathology in the practice of neurologists and neurosurgeons. Establishing their non-traumatic origin often poses a challenge, especially in the absence of obvious risk factors, among which the leading ones are the use of antithrombotic therapy and advanced age of patients. Less common etiological factors include rupture of aneurysms, arteriovenous malformations and fistulas, as well as dural venous sinus thrombosis. Currently, there are no large case series dedicated to the management strategies of NSDH patients; therefore, indications for surgical treatment are based on recommendations for traumatic subdural hematomas. This article presents a literature review covering the period from 2000 to 2024, based on the Elibrary and PubMed databases, focusing on NSDH cases. Of the 119 publications screened, 36 met the inclusion criteria (strictly non-traumatic origin). The analysis allowed for the systematization of current data on the etiology, diagnosis, and treatment approaches for NSDH, emphasizing the importance of thorough angiographic examination to detect vascular anomalies, especially in young patients, and the necessity of correcting hemostatic disorders in the perioperative period. Furthermore, three original clinical cases are presented illustrating the course and outcomes of this condition in patients receiving dual antithrombotic therapy, where despite successful hematoma evacuation, a high risk of somatic complications was observed. Thus, the article summarizes contemporary understanding of the complex issue of NSDH, which holds significant practical value for improving diagnosis and treatment of this pathology.

1. Potapov AA, Krylov VV, Gavrilov AG, et al. Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options). Burdenko’s Journal of Neurosurgery. 2016;80(2):93–101. (In Russ.). https://doi.org/10.17116/neiro201680293-101

2. Garbossa D, Altieri R, Calamo Specchia FM, et al. Are acute subdural hematomas possible without head trauma? Asian journal of neurosurgery. 2014;9(4):218–222. https://doi.org/10.4103/1793-5482.146612

3. Depreitere B, Van Calenbergh F, van Loon J. A clinical comparison of non-traumatic acute subdural haematomas either related to coagulopathy or of arterial origin without coagulopathy. Acta neurochirurgica. 2003;145(7):541–546. https://doi.org/10.1007/s00701-003-0020-7

4. Orde MM. Non-traumatic acute subdural hemorrhage due to cranial venous hypertension. Academic Forensic Pathology. 2019;9(1–2):33–43. https://doi.org/10.1177/1925362119851114

5. Adhiyaman V, Asghar M, Ganeshram KN, Bhowmick BK. Chronic subdural haematoma in the elderly. Postgraduate medical journal. 2002;78(916):71–75. https://doi.org/10.1136/pmj.78.916.71

6. Aspegren OP, Astrand R, Lundgren MI, et al. Anticoagulation therapy a risk factor for the development of chronic subdural hematoma. Clinical neurology and neurosurgery. 2013;115(7):981–984. https://doi.org/10.1016/j.clineuro.2012.10.008

7. Lee KS. Chronic subdural hematoma in the aged, trauma or degeneration? Journal of Korean Neurosurgical Society. 2016;59(1):1–5. https://doi.org/10.3340/jkns.2016.59.1.1

8. De Carvalho D, Almenawer S, Lozej M, et al. Spontaneous chronic subdural hematoma in a 22-year-old healthy woman. World neurosurgery. 2013;80(5):654.e9–11. https://doi.org/10.1016/j.wneu.2012.11.065

9. Patnaik А, Sharma A, Sahu RN, et al. Spontaneous recurrent chronic subdural hematoma in a young woman. Indian Journal of Neurosurgery. 2019;08(02):142–144. https://doi.org/10.1055/s-0039-1694852

10. Shylova MA, Druk IV, Globa IV. Changes in the brain vascular bed associated with sudden death of young subjects. Forensic Medical Expertise. 2018;61(1):55–59. (In Russ.). https://doi.org/10.17116/sudmed201861155-59

11. Boujemâa H, Góngora-Rivera F, BarragánCampos H, et al. Bilateral acute subdural hematoma from ruptured posterior communicating artery aneurysm. A case report. Interventional Neuroradiology. 2006;12(1):37–40. https://doi.org/10.1177/159101990601200107

12. Hesselbrock RR. Bi-lateral non-traumatic subdural hematoma. Aviation, Space, and Environmental Medicine. 2012;83(12):1186–1187. https://doi.org/10.3357/asem.3551.2012

13. Caton MT Jr, Wiggins WF, Nuñez D. Non-traumatic subdural hemorrhage: beware of ruptured intracranial aneurysm. Emergency Radiology. 2019;26(5):567–571. https://doi.org/10.1007/s10140-019-01691-2

14. Kulwin C, Bohnstedt BN, Payner TD, et al. Aneurysmal acute subdural hemorrhage: prognostic factors associated with treatment. Journal of Clinical Neuroscience. 2014;21(8):1333–1336. https://doi.org/10.1016/j.jocn.2013.12.010

15. Shotar E, Sourour NA, Premat K, et al. Acute subdural hematomas in ruptured brain arteriovenous malformations: association with distal flow-related aneurysms. Clinical Neuroradiology. 2020;30(2):305–312. https://doi.org/10.1007/s00062-019-00771-7

16. Choi HJ, Lee JI, Nam KH, et al. Acute Spontaneous Subdural Hematoma due to Rupture of a Tiny Cortical Arteriovenous Malformation. Journal of Korean Neurosurgical Society. 2015;58(6):547–549. https://doi.org/10.3340/jkns.2015.58.6.547

17. Fukushima Y, Matsuda K, Yoshino Sh, et al. A pure acute subdural hematoma presenting with a diploic arteriovenous fistula: case report and literature review. Journal of Neuroendovascular Therapy. 2022;16(2):123–126. https://doi.org/10.5797/jnet.cr.2020-0206

18. Thapa A, Bidur K, Shakya B. Pure acute-onchronic subdural hematoma due to ruptured posterior communicating artery aneurysm: unsuspecting entity. World Neurosurgery. 2018;114:335–338. https://doi.org/10.1016/j.wneu.2018.03.211

19. Okholm SH, Nagy D, Farkas DK, et al. Non-traumatic subdural hematoma and cancer: a cohort study. Clinical Epidemiology. 2023;8(15):629–633. https://doi.org/10.2147/CLEP.S408667

20. Liu X, Gao C, Yuan J, et al. Subdural haematomas drain into the extracranial lymphatic system through the meningeal lymphatic vessels. Acta Neuropathologica Communications. 2020;8(1):16. https://doi.org/10.1186/s40478-020-0888-y

21. Irfan M, Kurakula S, Singh H, et al. Non-traumatic chronic subdural hematoma with myelodysplastic syndrome: a case report. Cureus. 2023;15(3):e36–110. https://doi.org/10.7759/cureus.36110

22. Shi X-Y, Zhang J-X, Tang Z-X, et al. Severe spontaneous acute arterial subdural hematoma as an initial symptom of chronic myeloid leukemia. British Journal of Neurosurgery. 2023;37(6):1721–1724. https://doi.org/10.1080/02688697.2021.1885625

23. Zheng JX, Tan TK, Kumar DS, et al. Subdural haematoma due to dural metastases from bronchogenic carcinoma in a previously well patient: an unusual cause of non-traumatic recurrent intracranial haematomata. Singapore Med J. 2011;52(4):e66–69.

24. Ledić D, Girotto D, Pal S, et al. Risk factors for subdural bleeding in elderly population. Collegium antropologicum. 2014;38(4):1195–1198.

25. Seo JG, Yang J, Lee JH, et al. Comparisons of radiological and clinical characteristics between traumatic and non-traumatic subdural hematoma patients. Korean Journal of Neurotrauma. 2021;17(1):34–40. https://doi.org/10.13004/kjnt.2021.17.e9

26. Yeon JY, Kong DS, Hong S-C. Safety of early warfarin resumption following burr hole drainage for warfarin-associated subacute or chronic subdural hemorrhage. Journal of neurotrauma. 2012;1;29(7):1334– 1341. https://doi.org/10.1089/neu.2011.2074

27. Roguski M, Wu K, Riesenburger RI, et al. Mild elevations of international normalized ratio at hospital Day 1 and risk of expansion in warfarin-associated subdural hematomas. Journal of Neurosurgery. 2013;119(4):1050–1057. https://doi.org/10.3171/2013.3.JNS121946

28. Mousa А, Hassan A, Oudah B, et al. Acute spontaneous subdural hematoma in a patient with an end-stage renal disease after starting dual antiplatelet therapy post drug-eluting stent insertion: a case report. Cureus. 2023;15(7):e41761. https://doi.org/10.7759/cureus.41761

29. Lin YT, Cheng YK, Lin CL, et al. Increased risk of subdural hematoma in patients with liver. QJM: An International Journal of Medicine. 2017;110(12):815–820. https://doi.org/10.1093/qjmed/hcx167

30. Ishii T, Sawauchi S, Taya K, et al. Acute spontaneous subdural hematoma of arterial origin. No shinkei geka. Neurological surgery. 2004;32(12):1239–1244.

31. Naama O, Belhachmi A, Ziadi T, et al. Acute spontaneous subdural hematoma: an unusual form of cerebrovacular accident. Journal of neurosurgical sciences. 2009;53(4):157–159.

32. Chakkera P, Gupta M, Marasakatla S, et al. Cerebral venous sinus thrombosis associated subdural hematoma: a case series on clinical presentation and management. Annals of Indian Academy of Neurology. 2023;26(5):778– 781. https://doi.org/10.4103/aian.aian_346_23

33. Wang IK, Chen HJ, Cheng YK, et al. Subdural hematoma in diabetic patients. European Journal of Neurology. 2015;22(1):99–105. https://doi.org/10.1111/ene.12538

34. Power A, Hamady M, Singh S, et al. High but stable incidence of subdural haematoma in haemodialysis-a single-centre study. Nephrology Dialysis Transplantation. 2010;25(7):2272–2275. https://doi.org/10.1093/ndt/gfq013

35. Missori P, Fenga L, Maraglino C, et al. Spontaneous acute subdural hematomas. A clinical comparison with traumatic acute subdural hematomas. Acta neurochirurgica. 2000;142(6):697–701. https://doi.org/10.1007/s007010070115

36. Murthy SB, Wu X, Diaz I, et al. Non-traumatic subdural hemorrhage and risk of arterial ischemic events. Stroke. 2020;51(5):1464–1469. https://doi.org/10.1161/STROKEAHA.119.028510