Dating of subdural haematoma

The present study, unlike others, included only early cases of SDH and further differentiation of the haemorrhage according to age was attempted within this short post-traumatic interval. It is pertinent to note that these studies also do not mention the specific radiological methods applied in estimating the age of the subdural haematoma.

After about days of the clot formation, the density drops to about 30HU and becomes isodense with the adjacent cortex [ 4 ]. Since the cases in the present study were well within or close to 10 days, all the cases had a high attenuation, which is in concordance with all the above published data.

Correlation of attenuation of the haematoma and time interval between injury and computed tomography was found to be highly negative i. The determination of the post-traumatic interval of the subdural haemorrhage is a complex problem and has been worked out by a very few investigators. Hence a very limited number of studies with which the results of the present study could be compared.

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These findings accord with the results of other studies examining Intra-reader reliability of attenuation measurements [ 19 ]. Currently, the dating of subdural haemorrhage by measuring the CT number alone could lead to inaccuracies as it depends on measurement technique, object composition, and beam energy. Therefore with further research on this subject, the attenuation of subdural haemorrhages can be measured with more reliability and, thereby placing them accurately into particular post-traumatic interval groups.

However, the outcome of living patients may not be entirely transferable to post-mortem radiology. The application of the current methodology to post-mortem cases will be an oversimplification. Though, the few post-mortem radiological studies conducted previously have inferred minimal difference with the autopsy findings in cases of craniocerebral trauma, not much work has been done on decomposed bodies [ 23 , 24 ].

Further in these studies [ 23 , 24 ], the cases had a time interval of less than 24hours between the death and postmortem radiological examination. These studies concentrated mainly on the gross features rather than going into specifics like aging and the degree of the autolytic process if any. From the radiological point of view, the dating of early SDH remains limited, in the fact that all the SDH were hyper dense, but concurs with the already published data [ 4 , 25 , 26 ]. However, on a further classification of these HU numbers about post-traumatic intervals, information was obtained on the range of attenuation for a particular post-traumatic interval.

Though few studies suggest that dating of subdural haematoma cannot be done accurately using radiological methods [ 25 — 27 ], the present study, yet gives a reliable and a reproducible method for the estimation of the age of early subdural haemorrhage.

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Not many studies have been conducted recently on the radiological dating of SDH. Those studies which have dealt with the radiological dating of SDH have not specified the radiological methods and hence the comparison with different studies have been limited. The results from one of the recently conducted questionnaire based study showed that there was a considerable variation among the radiologists, regarding medico-legal opinions on the age of SDH and concluded it unsuitable to use in court because of non-uniformity [ 28 ].

The study was limited by the small sample of materials investigated.

Histological dating of subdural hematoma in infants.

The influence of hypothermia, shock, hypoxia, variations in the blood pressure, the effect of medications during emergency care, potential effects of associated injuries and failure of the internal organs were not evaluated. Repeat CT examinations of the same patient at various times were not done in our study. Also, a single CT scan machine was used in this study hence variations in attenuation between different CT Scanners could not be appreciated. Because of the difficulty in differentiation into antemortem and postmortem breakdown of cellular components, it is hard to predict the post-traumatic intervals in decomposing bodies.

Finally, the CT Scanner and protocol that have been used in this study is not the state of the art concerning its various parameters. Though single slice CT scanners are not used in state of the art head scans [ 29 ], the constraints on the availability of advanced scanners in a developing country like India, has compelled us to use the resources at hand.

Considering a few recent studies being done on the postmortem use of the radiological technologies in the interpretation of the cranio-cerebral traumatic injuries [ 23 , 24 ] one can with some confidence say that these methods hold a lot of stake for the future of radiological autopsy or may indeed replace few of the routinely conducted forensic autopsies of the present times.

Dating of Early Subdural Haematoma: A Correlative Clinico-Radiological Study

The present study has adopted one of the most objective and scientific methods in determining the attenuation of the subdural haematomas in contrast to the other previous studies where none has been applied or has not been mentioned. Though this study has been limited to the early post-traumatic intervals, it could still grasp some significant findings in the form of variations in the attenuation of the subdural haemorrhage with relation to time of the injury. The attenuation of the acute subdural haemorrhage decreased with increase in the post-traumatic interval.

On further classification of these HU numbers about post-traumatic intervals, information was obtained on the range of attenuation for a particular post-traumatic interval. The variations in the hospital care and treatment, the mode of injuries high velocity , have considerably changed over the years and hence could have contributed to the observed variations despite proper study design.

These are also in part due to the dynamic character of such injuries and the various manner in which trauma victims react to an injury. National Center for Biotechnology Information , U. J Clin Diagn Res. Published online Apr 1. Find articles by Murali Gundu Rao. Find articles by Dalbir Singh. Find articles by Niranjan Khandelwal. Find articles by Suresh Kumar Sharma. Author information Article notes Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Introduction Determination of post-traumatic interval remains one of the foremost important goals of any forensic investigation related to human crimes.

Materials and Methods The study included a total of cases of closed head injury with subdural haemorrhage. Results Statistically significant results were obtained between the HU measurements of the SDH and the post-traumatic intervals and were found to be statistically significant. Conclusion The density of the subdural haematoma decreases with increase in the post-traumatic interval that concurs with the limited number of studies being conducted in the past. Attenuation coefficient, Computed tomography, Post-traumatic interval, Subdural haemorrhage, Volume. Introduction Subdural Haemorrhage SDH is a form of brain haemorrhage in which there is a collection of blood between the dura and the arachnoid layers of the meninges.

Radiological Procedure Non-contrast computed tomography of the head was done using single slice hi-speed GE machine scanner with a tube current of mA, tube voltage of kVp and a slice thickness of 10 mm Window Width HU, Window centre HU. Results A total of cases in the age group of years were studied.

Open in a separate window. Frequency distribution of cases according to the post-traumatic interval. Kolmogorov Smirnov test for testing normality of data.

Time Observer 1 1 st reading Observer 1 2 nd reading Observer 1 3 rd reading Observer 2 1 st reading Observer 2 2 nd reading Observer 2 3 rd reading Kolmogorov Smirnov- Z 1. The cut value is. Variables in the Equation B S. Exp B Odds Ratio Variable s entered on step 1: Discussion The timing of a traumatic event by post-mortem findings carries immense significance for the forensic experts.

Limitations of The Study The study was limited by the small sample of materials investigated. Future Prospects A long-term study involving more number of cases helps in the better understanding of the attenuation variations of the SDH with relation to time. Further this study could be extended to cases below 18 years of age that hold a lot of medico-legal significances.

More innovative research can be done by the application of HU measurements on different organs in determining the time since death. Conclusion The present study has adopted one of the most objective and scientific methods in determining the attenuation of the subdural haematomas in contrast to the other previous studies where none has been applied or has not been mentioned.

Forensic Neuropathology and associated neurology. Berlin Heidelberg New York: Fundamentals of Diagnostic Radiology. CT-number variability in thoracic geometry. Surgical management of acute subdural haematomas. Use of drains versus no drains after burr-hole evacuation of chronic subdural haematoma: Bedside twist drill craniostomy for chronic subdural haematoma: Preliminary results of a prospective randomized study. Overview, Computed Tomography [Internet]. MRI of the central nervous system.

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Gas embolism following intraosseous medication application proven by postmortem multislice computed tomography and autopsy. The Computer tomographic attenuation and the age of subdural haematomas. Evaluation of the age of subdural haematomas by computerized tomography. Computed tomography of cranial subdural and epidural haematomas: J Comput Assist Tomogr. Rarely, acute SDHs may be nearly isodense with the adjacent cerebral cortex. Patients with a deficient coagulation can also demonstrate a hematocrit fluid-fluid level as the blood does not form a clot and red cells have time to drift dependently 4.

In patients with underlying low hemoglobin and platelets conditions such as sickle cell anemia , acute subdural hemorrhage may be hypodense even in the acute phase As the clot ages and protein degradation occurs, the density starts to drop.


The key to identification is visualizing a number of indirect signs, including:. Rarely, the periphery of the SDH may calcify, see calcified chronic subdural hematoma for an in-depth discussion regarding the CT appearance of this entity. Acute on chronic subdural hematomas refers to a second episode of acute hemorrhage into a pre-existing chronic subdural hematoma.

It typically appears as a hypodense collection with a hematocrit level located posteriorly. A similar appearance can be seen in patients with clotting disorders or on anticoagulants 4. The appearance of a hematoma varies with the biochemical state of hemoglobin which varies with the age of the hematoma. It may appear biconvex-shaped on the coronal plane rather than crescent-shaped which is a typical appearance on the axial plane.

Histological dating of subdural hematoma in infants.

Treatment depends primarily on the amount of mass-effect and neurological impairment caused by the collection, and thus correlates with the size of the subdural hemorrhage. Small collections — so-called 'smear subdurals' — especially those which are chronic and are not causing symptoms can be observed with serial CT scans.

Symptomatic collections need to be surgically evacuated. In the acute setting, this should be performed rapidly within 4 hours 3 and usually requires a craniotomy as the clot is not easily evacuated via burr holes. The compressed brain can take some time to re-expand, and subdural collections may re-accumulate. To quiz yourself on this article, log in to see multiple choice questions. You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Unable to process the form. Check for errors and try again.

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