- Email: [email protected]
Subdural Hematoma Mimickers: A Systematic Review
Accepted Manuscript Subdural Hematoma Mimickers: A Systematic Review Dragos Catana, MD, Alex Koziarz, BHSc, Aleksa Cenic, MD, Siddharth Nath, BSc, Sheila Singh, MD, Saleh A. Almenawer, MD, Edward Kachur, MD PII:
S1878-8750(16)30358-8
DOI:
10.1016/j.wneu.2016.05.084
Reference:
WNEU 4145
To appear in:
World Neurosurgery
Received Date: 25 March 2016 Revised Date:
24 May 2016
Accepted Date: 25 May 2016
Please cite this article as: Catana D, Koziarz A, Cenic A, Nath S, Singh S, Almenawer SA, Kachur E, Subdural Hematoma Mimickers: A Systematic Review, World Neurosurgery (2016), doi: 10.1016/ j.wneu.2016.05.084. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Subdural Hematoma Mimickers: A Systematic Review
Singh1, MD; Saleh A. Almenawer1, MD; Edward Kachur1, MD
RI PT
Dragos Catana1, MD; Alex Koziarz1, BHSc; Aleksa Cenic1, MD; Siddharth Nath1, BSc; Sheila
Correspondence to: Saleh A. Almenawer, MD Neurosurgeon, Division of Neurosurgery
M AN U
Running Title: Subdural hematoma mimickers
SC
From 1Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
TE D
Department of Clinical Epidemiology and Biostatistics McMaster University, 1280 Main Street West Hamilton, Ontario, Canada L8S 4L8
EP
Phone: + (905) 962 0098 Fax: + (905) 577 1481
AC C
Email: [email protected]
Key words: computed tomography; magnetic resonance imaging; mimic; subdural hematoma; subdural mass
ACCEPTED MANUSCRIPT
Abstract Background: A variety of subdural pathologies that may mimic hematomas are reported in the
subdural masses that may mimic subdural hematomas.
RI PT
literature. Therefore, we aimed to identify the atypical clinical and radiological presentations of
Methods: A systematic review of MEDLINE and EMBASE was conducted independently by two reviewers to identify articles describing subdural hematoma mimickers. We additionally
SC
present one patient from our institution with a subdural pathology mimicking a subdural
findings, and clinical outcomes.
M AN U
hematoma. We analyzed patient clinical presentations, underlying pathologies, radiological
Results: We included 43 articles totaling 48 patients. The mean age was 55.7 years (SD: 16.8 years). Of the 45 cases describing patient history, 13 (27%) individuals had history of trauma. The underlying pathologies of the 48 subdural collections were 10 (21%) metastasis, 14 (29%)
TE D
lymphoma, 7 (15%) sarcoma, 4 (8%) infectious, 4 (8%) autoimmune, and 9 (19%) miscellaneous. CT findings were 18 (41%) hyperdense, 11 (25%) hypodense, 9 (20%) isodense, 3 (7%) isodense/hyperdense, and 3 (7%) hypodense/isodense. Thirty-four (71%) patients were
EP
treated surgically. Of these patients, 65% had symptom resolution. Neither the pathology (p=0.337) nor the management strategy (p=0.671) correlated with improved functional
AC C
outcomes.
Conclusions: Identification of atypical history and radiological features should prompt further diagnostic tests including MRI to elucidate proper diagnosis given that certain pathologies may be managed non-surgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2 MRI, and a history of progressive headaches with no trauma may raise the suspicion of an atypical subdural pathology.
ACCEPTED MANUSCRIPT
Introduction: Subdural hematomas are among the most common entities requiring intervention in the field of neurosurgery.1 A crescent-shaped mass situated in the cranial vault can be associated
RI PT
with a spectrum of neurological deficits and is readily recognized with conventional unenhanced computed tomography (CT). In theory, any mass within the subdural space can attenuate x-rays and reproduce imaging associated with a hematoma. A mass with a high attenuation coefficient
SC
can mimic an acute blood clot, while a mass with a low coefficient can mimic a liquefied clot. We conducted a systematic review to identify pathologies that may mimic subdural
M AN U
hematomas. In addition, we included a patient from our center of subdural pathology that was initially diagnosed with hematoma. We aimed to examine the clinical presentation, radiological features, and outcomes of these mimickers in order to make a proper diagnosis, and
Methods:
TE D
subsequently, formulate an optimal management strategy.
This systematic review was performed in accordance to the PRISMA (Preferred
AC C
Search Strategy:
EP
Reporting Items for Systematic Reviews and Meta-Analyses) Statement.2
A search of EMBASE and MEDLINE was conducted independently by two authors
(D.C. and A.K.) through February 2016 to identify English studies reporting atypical presentations of subdural pathologies which may mimic subdural hematomas. The following search terms and Medical Subject Headings (MeSH) were used in a variety of combinations: ‘subdural’, ‘hematoma’, ‘mimicking’, ‘present’, or ‘simulate’. Furthermore, a manual search of
ACCEPTED MANUSCRIPT
the references of included abstracts was performed to identify articles not indexed by MEDLINE or EMBASE. Studies reporting cases where the subdural pathology was a hematoma were
RI PT
excluded. Conference abstracts not published in a full report were excluded.
Eligibility Criteria:
Two investigators (D.C. and A.K.) independently evaluated all potentially eligible
SC
articles. Eligibility criteria included studies of any design and any publication date. Selected studies were required to report the etiology that the subdural hematoma mimicked, and the age
M AN U
and gender of the patient. Additional outcomes consisted of the CT and magnetic resonance imaging (MRI) results, radiological appearance of the pathology, patient trauma history, presentation, treatment, clinical outcomes, and in-hospital mortality. Disagreements as to whether to include or exclude a study was decided by consensus amongst the two reviewers
TE D
(D.C. and A.K.), and a third reviewer (S.A.) was consulted if necessary.
Data Extraction and Synthesis:
EP
Two reviewers (D.C. and A.K.) independently extracted data from each article, which was verified by a third reviewer (S.A.). Data collection forms were used by two reviewers, which
AC C
included the following fields: study title, author, year of publication, sample size, patient age, gender, CT findings, MRI results, history of trauma, presentation, underlying pathology, clinical outcomes, and in-hospital mortality. The association between pathology and outcomes was examined statistically and calculated using SPSS version 11.5 (SPSS, Chicago, III). A p-value less than 0.05 was a criterion for statistical significance.
ACCEPTED MANUSCRIPT
Results:
Single Center Patient:
RI PT
Our case involves a 60-year-old male who presented with a left hemiparesis and decreased level of consciousness. A CT scan revealed a hypodense crescent-shaped collection in the right subdural space (figure 1), whereas a T1-weighted MRI revealed a hyperintense
SC
crescent-shaped collection (figure 2). A review of his history revealed that he was involved in a motor vehicle collision several months prior and was treated at a different health care center. The
M AN U
patient was initially thought to have a chronic subdural hematoma. Surgical evacuation revealed a purulent material, and a subdural empyema was diagnosed. Following surgical intervention the patient demonstrated left hemiparesis. A retrospective review of the imaging revealed small lytic
Systematic Review:
TE D
defects in the skull base and air-fluid levels in the sinuses suggestive of an infection.
Our initial literature search yielded 636 non-duplicate studies, of which 503 were
EP
excluded based on title and abstract review. Of the 133 full-text articles evaluated for eligibility, 88 were excluded (figure 3). A total of 43 studies totaling 48 patients including our single-center
AC C
subdural pathology were eligible (table 1).3-45 The mean age of all included patients was 55.7 years (SD: 16.8 years). Of these, there
were 19 (40%) female patients. Patients presented with the following symptoms: headache (52%), hemiparesis (21%), weakness/numbness of limb (15%), mental status changes (17%), decreased level of consciousness (17%), speech impairments (13%), seizures (6%), and diplopia (6%). Of the 45 cases describing patient history, 35 (78%) cases there was no history of trauma.
ACCEPTED MANUSCRIPT
Forty-four articles reported CT radiological findings: 18 (41%) were hyperdense, 11 (25%)
hypodense,
9
(20%)
isodense,
3
(7%)
isodense/hyperdense,
and
3
(7%)
hypodense/isodense. Twenty-five articles reported MRI radiologic findings. Of the 22 T1-
RI PT
weighted MRI results, there were 9 (41%) hypointense, 4 (18%) isointense, 7 (32%) hyperintense, 1 (5%) isointense/hyperintense and 1 (5%) hypointense/isointense. Whereas, of the 18 T2-weighted MRI results, there were 4 (22%) hypointense, 1 (6%) isointense, and 13 (72%)
SC
hyperintense. The underlying pathologies of the subdural collections of the 48 patients were: 10 (21%) metastasis, 14 (29%) lymphoma, 7 (15%) sarcoma, 4 (8%) infectious, 4 (8%)
M AN U
autoimmune, and 9 (19%) miscellaneous (table 2).
Thirty-four (71%) patients were treated surgically. The post-treatment results of 20 patients were reported, which included the following: symptom resolution (65%), symptom improvement (15%), fixed and dilated pupils (10%), and loss of brainstem function (10%).
were in-hospital mortality.
TE D
Forty-two studies describing patient follow-up reported death in 12 (29%) patients, of which 8
Neither the pathology (p=0.337) nor the management strategy (p=0.671) correlated with
EP
improved functional outcomes. Moreover, the management strategy was not associated with
AC C
increased mortality (p=0.488).
Discussion:
This systematic review provides a comprehensive overview of subdural pathologies that
may mimic subdural hematomas. The most common mimicker was found in our systematic review to be lymphoma (29%), followed by metastasis (21%), sarcoma (15%), infectious (8%), and autoimmune (8%).
ACCEPTED MANUSCRIPT
Metastasis Among patients with a metastatic pathology, it is uncertain as to whether prostate cancers have a predilection for invading the subdural space, or whether the prevalence of its metastasis to
RI PT
the dura mirrors cancer epidemiology in the general population. Metastases to the dura may be the result of hematogenous spread via arterial circulation in the absence of skull invasion.46 Transmission via the lymphatic circulation has also been suggested.46 The reported incidence of
SC
subdural hematomas in the presence of dural metastases ranges from 15% to 40%, which may make the diagnosis even more challenging.46 Dural metastases have been reported to cause
M AN U
subdural hematomas via the rupture of tumor vessels or the dilation and rupture of superficial dural vessels from intracranial pressure.47 Treatment options for the metastasis subgroup of patients are usually directed by the overall prognosis of the underlying malignancy. Palliative surgery may be reasonable in candidates with high performance status or favorable survival
Lymphoma
TE D
prognosis.
Within the lymphoma category, pathologies generally exhibit an unusually homogeneous
EP
signal density in the subdural space. One report22 noted prolonged immunotherapy as a risk factor, while another17 noted a rapid resolution of symptoms after a short course of systemic
AC C
dexamethasone. Most patients had complaints of unrelenting and progressive headaches for weeks before initial assessment. Sarcoma
Myelodysplastic syndromes present de novo in up to one third of acute myeloid
leukemias; however, their diagnosis usually coincides with blast crisis in chronic myeloid leukemia (CML) and carries a poor prognosis.31 Four of our included patients with sarcoma were
ACCEPTED MANUSCRIPT
diagnosed with chronic myeloid leukemia, a type of CML. Intracranial seeding is exceedingly rare in CML, and the most striking feature among this group of mimickers is the clinical and radiological discrepancy. All patients complained of persistent and progressive headaches for
RI PT
weeks to months prior to CT imaging, which revealed mostly isodense to hyperdense mass. Infectious
Four instances of infection presented as isolated subdural collections, two of which were
SC
neurocysticercosis34,35 and two of which were bacterial empyemas, including our case.10 The former had elements of previous history of cysticercosis and multiple septations of subdural
M AN U
collection, which raised the possibility of an alternate diagnosis. The bacterial empyemas were unsuspected due to a lack of previous surgical intervention and resulted from contiguous spread by β-hemolytic streptococcus or Hemophilus influenza otorhinologic infections.6 Clinically, all bacterial infections were accompanied by headaches and overt febrile symptoms without
TE D
meningismus.6 Autoimmune
Autoimmune disorders causing inflammation of a leptomeningeal or pachymeningeal
EP
segment can also mimic a hyperdense subdural signal. Three patients with hyperdense signals were diagnosed with Wegener’s granulomatosis,37 Rosai-Dorfmann disease,38 and polyarteritis
AC C
nodosa.39 Clinical history of several months of low grade fevers, malaise and fatigue along with disease specific symptoms such as hematuria, ischemic digits and cranial nerve palsy were reported. Immunosuppressive therapy is the mainstay of treatment and surgery is reserved for decompressive or diagnostic purposes when other investigations are inconclusive. Along the autoimmune category, Rosai-Dorfman disease can also mimic an acute subdural hematoma, which is a benign
systemic histio-proliferative disorder characterized by massive
ACCEPTED MANUSCRIPT
lymphadenopathy in the head and neck region.48-51 It is often associated with extra-nodal lymphatic tissue hyperplasia in the peri-meningeal space. Concomitant massive cervical, auricular or occipital adenopathy should prompt suspicion for this rare disorder. Surgical
Unique Clinical and Radiological Features and Management
RI PT
intervention is indicated only in instances of clinical decompensation from mass effect.
Despite the overall heterogeneity of etiologies of subdural hematoma mimickers, 35
SC
(78%) of the 45 cases expectedly presented with no traumatic history or signs of head injury. This characteristic alone does not exclude pure acceleration-deceleration mechanisms but lowers
M AN U
suspicion of a subdural hematoma, especially when considering the absence of other commonly associated findings such as traumatic subarachnoid hemorrhage, subgaleal hematoma, cerebral contusions or bony fractures. Of the 44 cases reporting CT radiological appearances, 30 (68%) showed hyperdense, isodense or isodense/hyperdense signals in which concomitant injury would
TE D
be expected but presented as an isolated finding. Our results contained 44 patients in which a CT scan was administered and 25 patients in which MRI was used. Although CT scans are able to detect bony involvement in cranial lesions, contrast-enhanced MRI can differentiate pathologies
EP
by identifying dural lesions, their morphology as well as distinguishing leptomeningeal involvement.4 However, the availability and shorter imaging time in CT renders it the primary
AC C
imaging modality upon case presentation. We found the atraumatic history may raise the suspicion of an atypical subdural patholog
as most (78%) of our included patients had no history of trauma. A common presentation of these mimickers was the history of a progressive headache. This presentation along with atraumatic history should prompt further radiological examination of a non-subdural hematoma pathology. Moreover, on radiological presentation, most cases were hyperdense on CT scans,
ACCEPTED MANUSCRIPT
hypointense on T1-weighted MRI image, and hyperintense on T2-weighted MRI image. The type of management strategy was not found to be associated with improved functional outcomes. Strengths and Limitations
RI PT
The comprehensive search strategy, involving the use of a combination of various key words and exhaustive review of the references of all included articles to ensure that all nonindexed cases of subdural hematoma mimickers were included in this study, all by two
SC
independent authors, is a strength of our study. As well, two independent reviewers evaluated and extracted data from eligible studies to minimize any error. To our knowledge, this is the first
M AN U
systematic review investigating subdural pathologies that may mimic subdural hematomas. However, our systematic review is not without limitations. Fewer studies conducted radiological examinations with MRI. Therefore, an examination of preoperative MRI features was not possible. Additionally, our statistics should be interpreted with caution given the relatively small
TE D
overall number of patients. A larger study with prospectively collected data is warranted in order to formulate an optimal management strategy when dealing with subdural masses that may
Conclusion:
EP
mimic a subdural hematoma.
AC C
This systematic review of individual patients broadens the differential diagnosis of a
common intracranial radiological presentation. Identification of the atypical history and radiological features should prompt for further magnetic resonance diagnostic imaging whenever possible. Certain pathologies may favor non-surgical management, such as advanced metastases, or pathologies that do not possess mass effect of medically treated conditions; hence, the importance of proper diagnosis of the underlying subdural pathology. A history of progressive
ACCEPTED MANUSCRIPT
headaches without trauma that is hyperdense on CT scan, hypointense on T1 MRI and hyperintense on T2 MRI may raise the suspicion of an atypical subdural pathology.
RI PT
Disclosure: Conflict of interest: none
SC
References
1. Almenawer SA, Farrokhyar F, Hong C, et al. Chronic subdural hematoma management: a
M AN U
systematic review and meta-analysis of 34829 patients. Ann Surg. 2014;259:449-57. 2. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.
TE D
3. Barrett C, Rodrigues D, Bradey N, et al. Intracranial metastasis masquerading as acute subdural haematoma. Br J Neurosurg. 2008;22:444-6.
EP
4. Boukas A, Sunderland GJ, Ross N. Prostate dural metastasis presenting as chronic subdural hematoma. A case report and review of the literature. Surg Neurol Int. 2015;6:30.
AC C
5. Cheng YK, Wang TC, Yang JT, et al. Dural metastasis from prostatic adenocarcinoma mimicking chronic subdural hematoma. J Clin Neurosci. 2009;16:1084-6. 6. de Beer MH, van Gils AP, Koppen H. Mimics of subacute subdural hematoma in the ED. Am J Emerg Med. 2013;31:634.e1-3. 7. Nzokou A, Magro E, Guilbert F, et al. Subdural Metastasis of Prostate Cancer. J Neurol Surg Rep. 2015;76:e123-e127.
ACCEPTED MANUSCRIPT
8. Oktay K, Ozsoy KM, Cetinalp NE, et al. Dural Metastasis From Breast Carcinoma Mimicking Subdural Hematoma: Case Report. J Neurol Sci Turk. 2014;31:818-21.
RI PT
9. Patil S, Veron A, Hosseini P, et al. Metastatic prostate cancer mimicking chronic subdural hematoma: a case report and review of the literature. J La State Med Soc. 2010;162:203-5. 10. Tomlin JM, Alleyne CH. Transdural metastasis from adenocarcinoma of the prostate
SC
mimicking subdural hematoma: case report. Surg Neurol. 2002;58:329-31; discussion 331. 11. Villano JL. Ryan CW. Patients presenting with CNS lesions. Case 2. Subdural presentation
M AN U
of recurrent breast cancer. J Clin Oncol. 2003;21:4060-2.
12. Yu WL, Sitt CM, Cheung TC. Dural metastases from prostate cancer mimicking acute subdural hematoma. Emerg Radiol. 2012;19:549-52.
TE D
13. Azevedo R, Reis F, Brito A, et al. Dural lymphoma mimicking subdural haematoma on computerized tomography. Br J Haematol. 2015;169:156. 14. De Blay V, Misson N, Dardenne G, et al. Leptomeningeal myelomatosis mimicking a
EP
subdural haematoma. Neuroradiology. 2000;42:735-7.
AC C
15. Evliyaoglu C, Ilbay K, Ercin C, et al. Primary cranial vault lymphoma presenting as a traumatic subdural hematoma. Zentralbl Neurochir. 2006;67:26-9. 16. Gocmen S, Gamsizkan M, Onguru O, et al. Primary dural lymphoma mimicking a subdural hematoma. J Clin Neurosci. 2010;17:380-2.
ACCEPTED MANUSCRIPT
17. Goetz P, Lafuente J, Revesz T, et al. Primary low-grade B-cell lymphoma of mucosaassociated lymphoid tissue of the dura mimicking the presentation of an acute subdural
RI PT
hematoma. Case report and review of the literature. J Neurosurg. 2002;96:611-4. 18. Mathon B, Nouet A, Villa C, et al. Teaching NeuroImages: Burkitt dural lymphoma mimicking a subacute subdural hematoma. Neurology. 2013;81:e128-9.
subdural haematoma. Br J Neurosurg. 2004;18:647-9.
SC
19. Mitsos A, Georgakoulias N, Jenkins A. Intracranial plasmacytoma presenting as chronic
M AN U
20. Ramnarayan R, Anilkumar T, Nayar R. An unusual extra-axial hypodense lesion mimicking a chronic subdural haematoma. J Neurosci Rural Pract. 2013;4:216-9. 21. Reyes MG, Homsi MF, Mangkornkanong M, et al. Malignant lymphoma presenting as a
TE D
chronic subdural hematoma. Surg Neurol. 1990;33:35-6.
22. Sacho RH, Kogels M, du Plessis D, et al. Primary diffuse large B-cell central nervous system lymphoma presenting as an acute space-occupying subdural mass. J Neurosurg. 2010;
EP
113:384-7.
23. Yoon SH, Paek SH, Park SH, et al. Non-Hodgkin lymphoma of the cranial vault with
AC C
retrobulbar metastasis mimicking a subacute subdural hematoma: case report. J Neurosurg. 2008;108:1018-20.
24. Kambham N, Chang Y, Matsushima AY. Primary low-grade B-cell lymphoma of mucosaassociated lymphoid tissue (MALT) arising in dura. Clin Neuropathol. 1998;17:311-7. 25. Jesionek-Kupnicka D, Smolewski P, Kupnicki P, et al: Primary extranodal marginal zone Bcell lymphoma of the mucosa-associated lymphoid tissue type in the central nervous system
ACCEPTED MANUSCRIPT
(MZL CNS) presented as traumatic subdural hematoma and subarachnoid bleeding - case report. Clin Neuropathol. 2013;32:384-92.
RI PT
26. Shimizu K, Ochiai M. Primary diffuse large B-cell lymphoma presenting as a subdural tumor associated with calcified chronic subdural hematoma. Case report and review of the literature. Chirurgia. 2012;25:77-81.
SC
27. Catana D, Lach B, Cenic A. Myeloid Sarcoma “en plaque” disguised as Acute Subdural Hematoma. Can J Neurol Sci. 2016 [Epub ahead of print]
M AN U
28. Mallory GM, Van Gompel JJ, Rabinstein AA, et al. Wolf in sheep's clothing: acute chloroma disguised as a subdural hematoma. Neurocrit Care. 2012;16:148-50. 29. Natarajan M, Devi NS. Angiosarcoma presenting as subdural hematoma. Neurol India.
TE D
2012;60:132-3.
30. Nussbaum ES, Wen DY, Latchaw RE, et al. Meningeal sarcoma mimicking an acute subdural hematoma on CT. J Comput Assist Tomogr. 1995;19:643-5.
EP
31. O'Brien CE, Saratsis AM, Voyadzis JM. Granulocytic sarcoma in a patient with blast crisis
AC C
mimicking a chronic subdural hematoma. J Clin Oncol. 2011;29:e569-71. 32. Oertel MF, Korinth MC, Gilsbach JM. Recurrent intracranial sarcoma mimicking chronic subdural haematoma. Br J Neurosurg. 2003;17:257-60. 33. Smidt MH, de Bruin HG, van't Veer MB, et al. Intracranial granulocytic sarcoma (chloroma) may mimic a subdural hematoma. J Neurol. 2005;252:498-9.
ACCEPTED MANUSCRIPT
34. Feinberg WM, Valdivia FR. Cysticercosis presenting as a subdural hematoma. Neurology. 1984;34:1112-3.
hematoma. Case illustration. J Neurosurg. 2005;102:389.
RI PT
35. Im SH, Park SH, Oh DH, et al. Subdural cysticercosis mimicking a chronic subdural
36. de Tribolet N, Zander E. Intracranial sarcoidosis presenting angiographically as a sub-dural
SC
hematoma. Surg Neurol. 1978;9:169-71.
37. Kalra S, Yadav A, Agarwal S, et al. Wegener's granulomatosis with subdural hematoma as
M AN U
the initial manifestation. Int J Crit Illn Inj Sci. 2013;3:88-90.
38. Kumar KK, Menon G, Nair S, et al. Rosai-Dorfman disease mimicking chronic subdural hematoma. J Clin Neurosci. 2008;15:1293-5.
TE D
39. Song JS, Lim MK, Park BH, et al. Acute pachymeningitis mimicking subdural hematoma in a patient with polyarteritis nodosa. Rheumatol Int. 2005;25:637-40. 40. Chattopadhyay S, Srinisavan M, Thomas P. Postangiographic contrast enhancement
EP
mimicking acute subdural hemorrhage in a patient with severe occipital headache and
AC C
neurological symptoms: a case report. J Med Case Rep. 2008;2:119. 41. Destian S, Heier LA, Zimmerman RD, et al. Differentiation between meningeal fibrosis and chronic subdural hematoma after ventricular shunting: value of enhanced CT and MR scans. AJNR Am J Neuroradiol. 1989;10:1021-6. 42. Gungor S, Caglar K, Akdur D, et al. Infantile myofibromatosis in a three-year-old boy presented as subdural hematoma. Tumori. 2008;94:885-7.
ACCEPTED MANUSCRIPT
43. Kitaura K, Harima K, Inami N, et al. Prolonged dural enhancement by iodine contrast agent mimicking subdural haematoma in a patient with nephrogenic systemic fibrosis. Clin Kidney
RI PT
J. 2010;3:193-4. 44. Rennert J, Hamer OW. Large subdural effusions after angiography mimicking acute subdural hematoma. J Comput Assist Tomogr. 2010;34:249-50.
SC
45. Tun K, Kaptanoglu E, Celikmez RC, et al. Meningeal extramedullary haematopoiesis mimicking subdural hematoma. J Clin Neurosci. 2008;15:208-10.
M AN U
46. Laigle-Donadey F, Taillibert S, Mokhtari K, et al. Dural metastases. J Neurooncol. 2005;75:57-61.
47. George KJ, Lau A, Ellis Michael, et al. Metastatic coagulopathic subdural hematoma: A
TE D
dismal prognosis. Surg Neurol Int. 2012;3:60.
48. Kutlubay Z, Bairamov O, Sevim A, et al. Rosai-Dorfman disease: a case report with nodal and cutaneous involvement and review of the literature. Am J Dermapathol. 2014;36:353-7.
AC C
2013;32:341-6.
EP
49. McClellan SF, Ainbinder DJ. Orbital Rosai-Dorfman disease: a literature review. Orbit.
50. La Barge DV 3rd, Salzman KL, Harnsberger HR, et al. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): imaging manifestations in the head and neck. AJR Am J Roentgenol. 2008;191:W299-306. 51. Carbone A, Passannante A, Gloghini A, et al. Review of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) of head and neck. Ann Otol Rhinol Laryngol. 1999;108:1095-104.
ACCEPTED MANUSCRIPT
Figure Legends: Figure 1: CT scan displaying a hypodense crescent shaped collection in the right subdural space.
collection in the right subdural space.
AC C
EP
TE D
M AN U
SC
Figure 3: Process of study inclusion and exclusion.
RI PT
Figure 2: T1-weighted MRI with gadolinium displaying a hyperintense crescent shaped
ACCEPTED MANUSCRIPT
Table 1: Individual Patient Data Author, Year
Age (years), Gender
Mimicker Pathology
History of Trauma
Azevedo et al., 2015
69, male
Lymphoma
Barrett et al., 2008 Boukas et al., 2015
59, male 75 male
Metastasis Metastasis
Traumatic Traumatic
Hyperdense Hypodense
Surgical Surgical
Medical
Sarcoma
Atraumatic
Hyperdense
Surgical
57, female
Atraumatic
Hyperdense
Medical
72, male
contrast extravasation post angiography Metastasis
Atraumatic
Isodense
Surgical
de Beer et al., 2013
66, female
Metastasis
Atraumatic
Isodense
Medical
31, male
Infectious
De Blay et al., 2000
79, female
Lymphoma
de Tribolet N, Zander E, 1978 Destian et al., 1989
72, female
Autoimmune
77, female
RI PT
37, male
Chattopadhyay et al., 2008 Cheng et al., 2009
Isodense
Surgical
Hypodense/Isodense
Surgical
Atraumatic
Not Reported
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Traumatic
Hyperdense
Surgical
SC
Atraumatic
Atraumatic
M AN U
Catana et al., 2016
Management
Atraumatic
Radiological Appearance on CT Hyperdense
78, female
Feinberg WM, Valdivia FR, 1984 Gocmen et al., 2010
35, male
Infectious
Atraumatic
Hypodense
Surgical
45, female
Lymphoma
Atraumatic
Isodense
Surgical
Goetz et al., 2002
64, female
Lymphoma
45, female
Gungor et al., 2008
3, male
Im et al., 2005
85, male
Kalra et al., 2013
42, male
Kitaura et al., 2010
65, female
Kumar et al., 2008
45, male
Atraumatic
Hyperdense
Surgical
infantile myofibromatosis
Atraumatic
Hyperdense
Surgical
Infectious
Atraumatic
Hypodense
Surgical
Autoimmune
Atraumatic
Isodense/Hyperdense
Surgical
nephrogenic systemic fibrosis and iodine administration Autoimmune
Atraumatic
Hyperdense
Medical
Atraumatic
Hyperdense
Surgical
EP
23, female
AC C
20, male
TE D
Evliyaoglu et al., 2006
shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis Lymphoma
ACCEPTED MANUSCRIPT
45, female
Sarcoma
Atraumatic
Isodense/Hyperdense
Surgical
Mathon et al., 2013
59, female
Lymphoma
Atraumatic
Isodense
Surgical
Mitsos et al., 2004
62, male
Lymphoma
Traumatic
Isodense
Surgical
Natarajan M, Devi NS, 2012 Nussbaum et al., 1995
41, male
Sarcoma
Not Reported
Isodense
Surgical
76, male
Sarcoma
Not Reported
Hyperdense
Surgical
Nzokou et al., 2015
65, male
Metastasis
Atraumatic
Hyperdense
Surgical
O’Brien et al., 2011
34, male
Sarcoma
Atraumatic
Hypodense
Surgical
Oertel et al., 2003
62, male
Sarcoma
Atraumatic
Hypodense/Isodense
Surgical
Oktay et al., 2014 Patil et al., 2010 Ramnarayan et al., 2013 Rennert et al., 2010
62, male 71, male 59, male 63, female
Atraumatic Traumatic Traumatic Atraumatic
Isodense/Hyperdense Hypodense/Isodense Hypodense Hyperdense
Medical Surgical Surgical Medical
Reyes et al., 1990 Sacho et al., 2010 Smidt et al., 2005 Song et al., 2005 Tomlin JM, Alleyne CH, 2002 Tun et al., 2008
56, male 46, female 45, male 45, male 61, male
Metastasis Metastasis Lymphoma contrast extravasation post angiography Lymphoma Lymphoma Sarcoma Autoimmune Metastasis
Atraumatic Atraumatic Atraumatic Atraumatic Traumatic
Hypodense Hyperdense Not Reported Hyperdense Isodense
Surgical Surgical Medical Medical Surgical
SC
M AN U
TE D
Hyperdense
Surgical
Atraumatic
Hyperdense
Surgical
53, male 62, male 62, female 56, male
Lymphoma Metastasis Lymphoma Lymphoma
Atraumatic Atraumatic Not Reported Atraumatic
Hyperdense Hyperdense Not Reported Isodense
Surgical Medical Surgical Surgical
Lymphoma
Traumatic
Not Reported
Surgical
Infectious
Traumatic
Hypodense
Surgical
60, female 60, male
EP
Traumatic
73, female
meningeal extramedullary hematopoiesis Metastasis
AC C
Villano JL, Ryan CW, 2003 Yoon et al., 2008 Yu et al., 2012 Kambham et al., 1998 Shimizu K, Ochiai M, 2012 Jesionek-Kupnicka et al., 2013 Single Center Case
51, female
RI PT
Mallory et al., 2012
ACCEPTED MANUSCRIPT
Table 2: Subdural Hematoma Mimicker Pathologies and Management
4,10,18-25
66.6 (5.7)
6 Atraumatic (60%)
13-26
Lymphoma (14 patients) • B-cell lymphoma (21%) • B-cell lymphoma of MALT (29%) • Meningeal Lymphoma (7%) • Non-hodgkin’s lymphoma (21%) • Plasmocytoma (14%) • Burkitt Lymphoma (1%)
59.3 (10.7)
9/13 (69%) Atraumatic
6,34,35
Infectious (4 patients) • Cysticercosis (50%) • Empyema (50%)
36-39
Autoimmune (4 patients) • Neurosarcoidosis (25%) • Wegener’s Granulomatosis (25%) • Rosai-Dorfman (25%) • Acute Pachymeningitis (25%)
5/5 (100%) Atraumatic
3/4 (75%) Atraumatic
AC C
52.8 (25.0)
51 (14.1)
1 hypodense (13%) 1 isodene (13%) 2 hyperdense (25%) 1 hypodense/isodense (13%) 1 isodense/hyperdense (13%) 3 hypodense (75%) 1 isodense (25%)
EP
48.6 (15.1)
4/4 (100%) Atraumatic
MRI Results T1-weighted
1 hypodense (10%) 3 isodense (30%) 4 hyperdense (40%) 1 hypodense/isodense (10%) 1 isodense/hyperdense (10%) 3 hypodense (23%) 4 isodense (31%) 5 hyperdense (38%) 1 hypodense/isodense (8%)
TE D
27-33
Sarcoma (7 patients) • Myeloid Sarcoma (14%) • Chloroma (43%) • Angiosarcoma (14%) • Meningeal Sarcoma (14%) • Recurrent Spindle Cell Sarcoma (14%)
CT Results
RI PT
Metastases (10 patients) • Prostate (70%) • Lung (10%) • Breast (20%)
Trauma History
3 hyperintense (100%)
2 hyperdense (67%) 1 isodense/hyperdense (13%)
T2-weighted
Management Strategy
1 hyperintense (100%)
7 operative (70%) 3 non-operative (30%)
1 hypointense (14%) 2 isointense (29%) 2 hyperintense (29%) 1 hypointense/isointense (14%) 1 isointense/hyperintense (14%)
3 hypointense (38%) 1 isointense (13%) 4 hyperintense (50%)
13 operative (93% operative) 1 non-operative (7% operative)
1 hypointense (50%) 1 isointense (50%)
1 hyperintense (100%)
6 operation (86% operative) 1 non-operative (14%)
1 hypointense (50%) 1 hyperintense (50%)
1 hyperintense (100%)
4 operative (100%)
1 hypointense (33%) 1 isointense (33%) 1 hyperintense (33%)
1 hypointense (33%) 2 hyperintense (67%)
2 operative (50%) 2 non-operative (50%)
SC
Mean Age in years (SD)
M AN U
Mimicker Pathology
ACCEPTED MANUSCRIPT
40-45
4 hypodense (44%) 5 hyperdense (56%)
RI PT
8/9 (89%) Atraumatic
5 hypointense (100%)
EP
TE D
M AN U
SC
44.9 (24.5)
AC C
Miscellaneous (9 patients) • Shunt-associated Meningeal Fibrosis (44%) • Contrast Extravasation Post Angiography (22%) • Infantile Myofibromatosis (11%) • Meningeal Extramedullary Hematopoiesis (11%) • Nephrogenic Systemic Fibrosis & Iodine Administration (11%) SD; standard deviation
4 hyperintense (100%)
2 operative (22%) 7 non-operative (78%)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Highlights Intracranial subdural masses that mimic subdural hematomas exist
•
It is important to properly diagnose these pathologies as the management plan can differ
•
We evaluate the clinical presentation, radiological features, and outcomes of these
RI PT
•
pathologies
A subdural collection that is hyperdense on CT scan and hyperintense on T2 MRI, and a
SC
history of progressive headaches with no trauma may raise the suspicion of an atypical
EP
TE D
M AN U
subdural pathology.
AC C
•
ACCEPTED MANUSCRIPT
Abbreviations: CML: chronic myeloid leukemia
RI PT
CT: computed tomography MeSH: medical subject headings
AC C
EP
TE D
M AN U
SC
MRI: magnetic resonance imaging
ACCEPTED MANUSCRIPT
Conflict of interest statement:
AC C
EP
TE D
M AN U
SC
RI PT
We declare that we have no financial or other conflicts of interest.
S1878-8750(16)30358-8
DOI:
10.1016/j.wneu.2016.05.084
Reference:
WNEU 4145
To appear in:
World Neurosurgery
Received Date: 25 March 2016 Revised Date:
24 May 2016
Accepted Date: 25 May 2016
Please cite this article as: Catana D, Koziarz A, Cenic A, Nath S, Singh S, Almenawer SA, Kachur E, Subdural Hematoma Mimickers: A Systematic Review, World Neurosurgery (2016), doi: 10.1016/ j.wneu.2016.05.084. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Subdural Hematoma Mimickers: A Systematic Review
Singh1, MD; Saleh A. Almenawer1, MD; Edward Kachur1, MD
RI PT
Dragos Catana1, MD; Alex Koziarz1, BHSc; Aleksa Cenic1, MD; Siddharth Nath1, BSc; Sheila
Correspondence to: Saleh A. Almenawer, MD Neurosurgeon, Division of Neurosurgery
M AN U
Running Title: Subdural hematoma mimickers
SC
From 1Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
TE D
Department of Clinical Epidemiology and Biostatistics McMaster University, 1280 Main Street West Hamilton, Ontario, Canada L8S 4L8
EP
Phone: + (905) 962 0098 Fax: + (905) 577 1481
AC C
Email: [email protected]
Key words: computed tomography; magnetic resonance imaging; mimic; subdural hematoma; subdural mass
ACCEPTED MANUSCRIPT
Abstract Background: A variety of subdural pathologies that may mimic hematomas are reported in the
subdural masses that may mimic subdural hematomas.
RI PT
literature. Therefore, we aimed to identify the atypical clinical and radiological presentations of
Methods: A systematic review of MEDLINE and EMBASE was conducted independently by two reviewers to identify articles describing subdural hematoma mimickers. We additionally
SC
present one patient from our institution with a subdural pathology mimicking a subdural
findings, and clinical outcomes.
M AN U
hematoma. We analyzed patient clinical presentations, underlying pathologies, radiological
Results: We included 43 articles totaling 48 patients. The mean age was 55.7 years (SD: 16.8 years). Of the 45 cases describing patient history, 13 (27%) individuals had history of trauma. The underlying pathologies of the 48 subdural collections were 10 (21%) metastasis, 14 (29%)
TE D
lymphoma, 7 (15%) sarcoma, 4 (8%) infectious, 4 (8%) autoimmune, and 9 (19%) miscellaneous. CT findings were 18 (41%) hyperdense, 11 (25%) hypodense, 9 (20%) isodense, 3 (7%) isodense/hyperdense, and 3 (7%) hypodense/isodense. Thirty-four (71%) patients were
EP
treated surgically. Of these patients, 65% had symptom resolution. Neither the pathology (p=0.337) nor the management strategy (p=0.671) correlated with improved functional
AC C
outcomes.
Conclusions: Identification of atypical history and radiological features should prompt further diagnostic tests including MRI to elucidate proper diagnosis given that certain pathologies may be managed non-surgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2 MRI, and a history of progressive headaches with no trauma may raise the suspicion of an atypical subdural pathology.
ACCEPTED MANUSCRIPT
Introduction: Subdural hematomas are among the most common entities requiring intervention in the field of neurosurgery.1 A crescent-shaped mass situated in the cranial vault can be associated
RI PT
with a spectrum of neurological deficits and is readily recognized with conventional unenhanced computed tomography (CT). In theory, any mass within the subdural space can attenuate x-rays and reproduce imaging associated with a hematoma. A mass with a high attenuation coefficient
SC
can mimic an acute blood clot, while a mass with a low coefficient can mimic a liquefied clot. We conducted a systematic review to identify pathologies that may mimic subdural
M AN U
hematomas. In addition, we included a patient from our center of subdural pathology that was initially diagnosed with hematoma. We aimed to examine the clinical presentation, radiological features, and outcomes of these mimickers in order to make a proper diagnosis, and
Methods:
TE D
subsequently, formulate an optimal management strategy.
This systematic review was performed in accordance to the PRISMA (Preferred
AC C
Search Strategy:
EP
Reporting Items for Systematic Reviews and Meta-Analyses) Statement.2
A search of EMBASE and MEDLINE was conducted independently by two authors
(D.C. and A.K.) through February 2016 to identify English studies reporting atypical presentations of subdural pathologies which may mimic subdural hematomas. The following search terms and Medical Subject Headings (MeSH) were used in a variety of combinations: ‘subdural’, ‘hematoma’, ‘mimicking’, ‘present’, or ‘simulate’. Furthermore, a manual search of
ACCEPTED MANUSCRIPT
the references of included abstracts was performed to identify articles not indexed by MEDLINE or EMBASE. Studies reporting cases where the subdural pathology was a hematoma were
RI PT
excluded. Conference abstracts not published in a full report were excluded.
Eligibility Criteria:
Two investigators (D.C. and A.K.) independently evaluated all potentially eligible
SC
articles. Eligibility criteria included studies of any design and any publication date. Selected studies were required to report the etiology that the subdural hematoma mimicked, and the age
M AN U
and gender of the patient. Additional outcomes consisted of the CT and magnetic resonance imaging (MRI) results, radiological appearance of the pathology, patient trauma history, presentation, treatment, clinical outcomes, and in-hospital mortality. Disagreements as to whether to include or exclude a study was decided by consensus amongst the two reviewers
TE D
(D.C. and A.K.), and a third reviewer (S.A.) was consulted if necessary.
Data Extraction and Synthesis:
EP
Two reviewers (D.C. and A.K.) independently extracted data from each article, which was verified by a third reviewer (S.A.). Data collection forms were used by two reviewers, which
AC C
included the following fields: study title, author, year of publication, sample size, patient age, gender, CT findings, MRI results, history of trauma, presentation, underlying pathology, clinical outcomes, and in-hospital mortality. The association between pathology and outcomes was examined statistically and calculated using SPSS version 11.5 (SPSS, Chicago, III). A p-value less than 0.05 was a criterion for statistical significance.
ACCEPTED MANUSCRIPT
Results:
Single Center Patient:
RI PT
Our case involves a 60-year-old male who presented with a left hemiparesis and decreased level of consciousness. A CT scan revealed a hypodense crescent-shaped collection in the right subdural space (figure 1), whereas a T1-weighted MRI revealed a hyperintense
SC
crescent-shaped collection (figure 2). A review of his history revealed that he was involved in a motor vehicle collision several months prior and was treated at a different health care center. The
M AN U
patient was initially thought to have a chronic subdural hematoma. Surgical evacuation revealed a purulent material, and a subdural empyema was diagnosed. Following surgical intervention the patient demonstrated left hemiparesis. A retrospective review of the imaging revealed small lytic
Systematic Review:
TE D
defects in the skull base and air-fluid levels in the sinuses suggestive of an infection.
Our initial literature search yielded 636 non-duplicate studies, of which 503 were
EP
excluded based on title and abstract review. Of the 133 full-text articles evaluated for eligibility, 88 were excluded (figure 3). A total of 43 studies totaling 48 patients including our single-center
AC C
subdural pathology were eligible (table 1).3-45 The mean age of all included patients was 55.7 years (SD: 16.8 years). Of these, there
were 19 (40%) female patients. Patients presented with the following symptoms: headache (52%), hemiparesis (21%), weakness/numbness of limb (15%), mental status changes (17%), decreased level of consciousness (17%), speech impairments (13%), seizures (6%), and diplopia (6%). Of the 45 cases describing patient history, 35 (78%) cases there was no history of trauma.
ACCEPTED MANUSCRIPT
Forty-four articles reported CT radiological findings: 18 (41%) were hyperdense, 11 (25%)
hypodense,
9
(20%)
isodense,
3
(7%)
isodense/hyperdense,
and
3
(7%)
hypodense/isodense. Twenty-five articles reported MRI radiologic findings. Of the 22 T1-
RI PT
weighted MRI results, there were 9 (41%) hypointense, 4 (18%) isointense, 7 (32%) hyperintense, 1 (5%) isointense/hyperintense and 1 (5%) hypointense/isointense. Whereas, of the 18 T2-weighted MRI results, there were 4 (22%) hypointense, 1 (6%) isointense, and 13 (72%)
SC
hyperintense. The underlying pathologies of the subdural collections of the 48 patients were: 10 (21%) metastasis, 14 (29%) lymphoma, 7 (15%) sarcoma, 4 (8%) infectious, 4 (8%)
M AN U
autoimmune, and 9 (19%) miscellaneous (table 2).
Thirty-four (71%) patients were treated surgically. The post-treatment results of 20 patients were reported, which included the following: symptom resolution (65%), symptom improvement (15%), fixed and dilated pupils (10%), and loss of brainstem function (10%).
were in-hospital mortality.
TE D
Forty-two studies describing patient follow-up reported death in 12 (29%) patients, of which 8
Neither the pathology (p=0.337) nor the management strategy (p=0.671) correlated with
EP
improved functional outcomes. Moreover, the management strategy was not associated with
AC C
increased mortality (p=0.488).
Discussion:
This systematic review provides a comprehensive overview of subdural pathologies that
may mimic subdural hematomas. The most common mimicker was found in our systematic review to be lymphoma (29%), followed by metastasis (21%), sarcoma (15%), infectious (8%), and autoimmune (8%).
ACCEPTED MANUSCRIPT
Metastasis Among patients with a metastatic pathology, it is uncertain as to whether prostate cancers have a predilection for invading the subdural space, or whether the prevalence of its metastasis to
RI PT
the dura mirrors cancer epidemiology in the general population. Metastases to the dura may be the result of hematogenous spread via arterial circulation in the absence of skull invasion.46 Transmission via the lymphatic circulation has also been suggested.46 The reported incidence of
SC
subdural hematomas in the presence of dural metastases ranges from 15% to 40%, which may make the diagnosis even more challenging.46 Dural metastases have been reported to cause
M AN U
subdural hematomas via the rupture of tumor vessels or the dilation and rupture of superficial dural vessels from intracranial pressure.47 Treatment options for the metastasis subgroup of patients are usually directed by the overall prognosis of the underlying malignancy. Palliative surgery may be reasonable in candidates with high performance status or favorable survival
Lymphoma
TE D
prognosis.
Within the lymphoma category, pathologies generally exhibit an unusually homogeneous
EP
signal density in the subdural space. One report22 noted prolonged immunotherapy as a risk factor, while another17 noted a rapid resolution of symptoms after a short course of systemic
AC C
dexamethasone. Most patients had complaints of unrelenting and progressive headaches for weeks before initial assessment. Sarcoma
Myelodysplastic syndromes present de novo in up to one third of acute myeloid
leukemias; however, their diagnosis usually coincides with blast crisis in chronic myeloid leukemia (CML) and carries a poor prognosis.31 Four of our included patients with sarcoma were
ACCEPTED MANUSCRIPT
diagnosed with chronic myeloid leukemia, a type of CML. Intracranial seeding is exceedingly rare in CML, and the most striking feature among this group of mimickers is the clinical and radiological discrepancy. All patients complained of persistent and progressive headaches for
RI PT
weeks to months prior to CT imaging, which revealed mostly isodense to hyperdense mass. Infectious
Four instances of infection presented as isolated subdural collections, two of which were
SC
neurocysticercosis34,35 and two of which were bacterial empyemas, including our case.10 The former had elements of previous history of cysticercosis and multiple septations of subdural
M AN U
collection, which raised the possibility of an alternate diagnosis. The bacterial empyemas were unsuspected due to a lack of previous surgical intervention and resulted from contiguous spread by β-hemolytic streptococcus or Hemophilus influenza otorhinologic infections.6 Clinically, all bacterial infections were accompanied by headaches and overt febrile symptoms without
TE D
meningismus.6 Autoimmune
Autoimmune disorders causing inflammation of a leptomeningeal or pachymeningeal
EP
segment can also mimic a hyperdense subdural signal. Three patients with hyperdense signals were diagnosed with Wegener’s granulomatosis,37 Rosai-Dorfmann disease,38 and polyarteritis
AC C
nodosa.39 Clinical history of several months of low grade fevers, malaise and fatigue along with disease specific symptoms such as hematuria, ischemic digits and cranial nerve palsy were reported. Immunosuppressive therapy is the mainstay of treatment and surgery is reserved for decompressive or diagnostic purposes when other investigations are inconclusive. Along the autoimmune category, Rosai-Dorfman disease can also mimic an acute subdural hematoma, which is a benign
systemic histio-proliferative disorder characterized by massive
ACCEPTED MANUSCRIPT
lymphadenopathy in the head and neck region.48-51 It is often associated with extra-nodal lymphatic tissue hyperplasia in the peri-meningeal space. Concomitant massive cervical, auricular or occipital adenopathy should prompt suspicion for this rare disorder. Surgical
Unique Clinical and Radiological Features and Management
RI PT
intervention is indicated only in instances of clinical decompensation from mass effect.
Despite the overall heterogeneity of etiologies of subdural hematoma mimickers, 35
SC
(78%) of the 45 cases expectedly presented with no traumatic history or signs of head injury. This characteristic alone does not exclude pure acceleration-deceleration mechanisms but lowers
M AN U
suspicion of a subdural hematoma, especially when considering the absence of other commonly associated findings such as traumatic subarachnoid hemorrhage, subgaleal hematoma, cerebral contusions or bony fractures. Of the 44 cases reporting CT radiological appearances, 30 (68%) showed hyperdense, isodense or isodense/hyperdense signals in which concomitant injury would
TE D
be expected but presented as an isolated finding. Our results contained 44 patients in which a CT scan was administered and 25 patients in which MRI was used. Although CT scans are able to detect bony involvement in cranial lesions, contrast-enhanced MRI can differentiate pathologies
EP
by identifying dural lesions, their morphology as well as distinguishing leptomeningeal involvement.4 However, the availability and shorter imaging time in CT renders it the primary
AC C
imaging modality upon case presentation. We found the atraumatic history may raise the suspicion of an atypical subdural patholog
as most (78%) of our included patients had no history of trauma. A common presentation of these mimickers was the history of a progressive headache. This presentation along with atraumatic history should prompt further radiological examination of a non-subdural hematoma pathology. Moreover, on radiological presentation, most cases were hyperdense on CT scans,
ACCEPTED MANUSCRIPT
hypointense on T1-weighted MRI image, and hyperintense on T2-weighted MRI image. The type of management strategy was not found to be associated with improved functional outcomes. Strengths and Limitations
RI PT
The comprehensive search strategy, involving the use of a combination of various key words and exhaustive review of the references of all included articles to ensure that all nonindexed cases of subdural hematoma mimickers were included in this study, all by two
SC
independent authors, is a strength of our study. As well, two independent reviewers evaluated and extracted data from eligible studies to minimize any error. To our knowledge, this is the first
M AN U
systematic review investigating subdural pathologies that may mimic subdural hematomas. However, our systematic review is not without limitations. Fewer studies conducted radiological examinations with MRI. Therefore, an examination of preoperative MRI features was not possible. Additionally, our statistics should be interpreted with caution given the relatively small
TE D
overall number of patients. A larger study with prospectively collected data is warranted in order to formulate an optimal management strategy when dealing with subdural masses that may
Conclusion:
EP
mimic a subdural hematoma.
AC C
This systematic review of individual patients broadens the differential diagnosis of a
common intracranial radiological presentation. Identification of the atypical history and radiological features should prompt for further magnetic resonance diagnostic imaging whenever possible. Certain pathologies may favor non-surgical management, such as advanced metastases, or pathologies that do not possess mass effect of medically treated conditions; hence, the importance of proper diagnosis of the underlying subdural pathology. A history of progressive
ACCEPTED MANUSCRIPT
headaches without trauma that is hyperdense on CT scan, hypointense on T1 MRI and hyperintense on T2 MRI may raise the suspicion of an atypical subdural pathology.
RI PT
Disclosure: Conflict of interest: none
SC
References
1. Almenawer SA, Farrokhyar F, Hong C, et al. Chronic subdural hematoma management: a
M AN U
systematic review and meta-analysis of 34829 patients. Ann Surg. 2014;259:449-57. 2. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339:b2700.
TE D
3. Barrett C, Rodrigues D, Bradey N, et al. Intracranial metastasis masquerading as acute subdural haematoma. Br J Neurosurg. 2008;22:444-6.
EP
4. Boukas A, Sunderland GJ, Ross N. Prostate dural metastasis presenting as chronic subdural hematoma. A case report and review of the literature. Surg Neurol Int. 2015;6:30.
AC C
5. Cheng YK, Wang TC, Yang JT, et al. Dural metastasis from prostatic adenocarcinoma mimicking chronic subdural hematoma. J Clin Neurosci. 2009;16:1084-6. 6. de Beer MH, van Gils AP, Koppen H. Mimics of subacute subdural hematoma in the ED. Am J Emerg Med. 2013;31:634.e1-3. 7. Nzokou A, Magro E, Guilbert F, et al. Subdural Metastasis of Prostate Cancer. J Neurol Surg Rep. 2015;76:e123-e127.
ACCEPTED MANUSCRIPT
8. Oktay K, Ozsoy KM, Cetinalp NE, et al. Dural Metastasis From Breast Carcinoma Mimicking Subdural Hematoma: Case Report. J Neurol Sci Turk. 2014;31:818-21.
RI PT
9. Patil S, Veron A, Hosseini P, et al. Metastatic prostate cancer mimicking chronic subdural hematoma: a case report and review of the literature. J La State Med Soc. 2010;162:203-5. 10. Tomlin JM, Alleyne CH. Transdural metastasis from adenocarcinoma of the prostate
SC
mimicking subdural hematoma: case report. Surg Neurol. 2002;58:329-31; discussion 331. 11. Villano JL. Ryan CW. Patients presenting with CNS lesions. Case 2. Subdural presentation
M AN U
of recurrent breast cancer. J Clin Oncol. 2003;21:4060-2.
12. Yu WL, Sitt CM, Cheung TC. Dural metastases from prostate cancer mimicking acute subdural hematoma. Emerg Radiol. 2012;19:549-52.
TE D
13. Azevedo R, Reis F, Brito A, et al. Dural lymphoma mimicking subdural haematoma on computerized tomography. Br J Haematol. 2015;169:156. 14. De Blay V, Misson N, Dardenne G, et al. Leptomeningeal myelomatosis mimicking a
EP
subdural haematoma. Neuroradiology. 2000;42:735-7.
AC C
15. Evliyaoglu C, Ilbay K, Ercin C, et al. Primary cranial vault lymphoma presenting as a traumatic subdural hematoma. Zentralbl Neurochir. 2006;67:26-9. 16. Gocmen S, Gamsizkan M, Onguru O, et al. Primary dural lymphoma mimicking a subdural hematoma. J Clin Neurosci. 2010;17:380-2.
ACCEPTED MANUSCRIPT
17. Goetz P, Lafuente J, Revesz T, et al. Primary low-grade B-cell lymphoma of mucosaassociated lymphoid tissue of the dura mimicking the presentation of an acute subdural
RI PT
hematoma. Case report and review of the literature. J Neurosurg. 2002;96:611-4. 18. Mathon B, Nouet A, Villa C, et al. Teaching NeuroImages: Burkitt dural lymphoma mimicking a subacute subdural hematoma. Neurology. 2013;81:e128-9.
subdural haematoma. Br J Neurosurg. 2004;18:647-9.
SC
19. Mitsos A, Georgakoulias N, Jenkins A. Intracranial plasmacytoma presenting as chronic
M AN U
20. Ramnarayan R, Anilkumar T, Nayar R. An unusual extra-axial hypodense lesion mimicking a chronic subdural haematoma. J Neurosci Rural Pract. 2013;4:216-9. 21. Reyes MG, Homsi MF, Mangkornkanong M, et al. Malignant lymphoma presenting as a
TE D
chronic subdural hematoma. Surg Neurol. 1990;33:35-6.
22. Sacho RH, Kogels M, du Plessis D, et al. Primary diffuse large B-cell central nervous system lymphoma presenting as an acute space-occupying subdural mass. J Neurosurg. 2010;
EP
113:384-7.
23. Yoon SH, Paek SH, Park SH, et al. Non-Hodgkin lymphoma of the cranial vault with
AC C
retrobulbar metastasis mimicking a subacute subdural hematoma: case report. J Neurosurg. 2008;108:1018-20.
24. Kambham N, Chang Y, Matsushima AY. Primary low-grade B-cell lymphoma of mucosaassociated lymphoid tissue (MALT) arising in dura. Clin Neuropathol. 1998;17:311-7. 25. Jesionek-Kupnicka D, Smolewski P, Kupnicki P, et al: Primary extranodal marginal zone Bcell lymphoma of the mucosa-associated lymphoid tissue type in the central nervous system
ACCEPTED MANUSCRIPT
(MZL CNS) presented as traumatic subdural hematoma and subarachnoid bleeding - case report. Clin Neuropathol. 2013;32:384-92.
RI PT
26. Shimizu K, Ochiai M. Primary diffuse large B-cell lymphoma presenting as a subdural tumor associated with calcified chronic subdural hematoma. Case report and review of the literature. Chirurgia. 2012;25:77-81.
SC
27. Catana D, Lach B, Cenic A. Myeloid Sarcoma “en plaque” disguised as Acute Subdural Hematoma. Can J Neurol Sci. 2016 [Epub ahead of print]
M AN U
28. Mallory GM, Van Gompel JJ, Rabinstein AA, et al. Wolf in sheep's clothing: acute chloroma disguised as a subdural hematoma. Neurocrit Care. 2012;16:148-50. 29. Natarajan M, Devi NS. Angiosarcoma presenting as subdural hematoma. Neurol India.
TE D
2012;60:132-3.
30. Nussbaum ES, Wen DY, Latchaw RE, et al. Meningeal sarcoma mimicking an acute subdural hematoma on CT. J Comput Assist Tomogr. 1995;19:643-5.
EP
31. O'Brien CE, Saratsis AM, Voyadzis JM. Granulocytic sarcoma in a patient with blast crisis
AC C
mimicking a chronic subdural hematoma. J Clin Oncol. 2011;29:e569-71. 32. Oertel MF, Korinth MC, Gilsbach JM. Recurrent intracranial sarcoma mimicking chronic subdural haematoma. Br J Neurosurg. 2003;17:257-60. 33. Smidt MH, de Bruin HG, van't Veer MB, et al. Intracranial granulocytic sarcoma (chloroma) may mimic a subdural hematoma. J Neurol. 2005;252:498-9.
ACCEPTED MANUSCRIPT
34. Feinberg WM, Valdivia FR. Cysticercosis presenting as a subdural hematoma. Neurology. 1984;34:1112-3.
hematoma. Case illustration. J Neurosurg. 2005;102:389.
RI PT
35. Im SH, Park SH, Oh DH, et al. Subdural cysticercosis mimicking a chronic subdural
36. de Tribolet N, Zander E. Intracranial sarcoidosis presenting angiographically as a sub-dural
SC
hematoma. Surg Neurol. 1978;9:169-71.
37. Kalra S, Yadav A, Agarwal S, et al. Wegener's granulomatosis with subdural hematoma as
M AN U
the initial manifestation. Int J Crit Illn Inj Sci. 2013;3:88-90.
38. Kumar KK, Menon G, Nair S, et al. Rosai-Dorfman disease mimicking chronic subdural hematoma. J Clin Neurosci. 2008;15:1293-5.
TE D
39. Song JS, Lim MK, Park BH, et al. Acute pachymeningitis mimicking subdural hematoma in a patient with polyarteritis nodosa. Rheumatol Int. 2005;25:637-40. 40. Chattopadhyay S, Srinisavan M, Thomas P. Postangiographic contrast enhancement
EP
mimicking acute subdural hemorrhage in a patient with severe occipital headache and
AC C
neurological symptoms: a case report. J Med Case Rep. 2008;2:119. 41. Destian S, Heier LA, Zimmerman RD, et al. Differentiation between meningeal fibrosis and chronic subdural hematoma after ventricular shunting: value of enhanced CT and MR scans. AJNR Am J Neuroradiol. 1989;10:1021-6. 42. Gungor S, Caglar K, Akdur D, et al. Infantile myofibromatosis in a three-year-old boy presented as subdural hematoma. Tumori. 2008;94:885-7.
ACCEPTED MANUSCRIPT
43. Kitaura K, Harima K, Inami N, et al. Prolonged dural enhancement by iodine contrast agent mimicking subdural haematoma in a patient with nephrogenic systemic fibrosis. Clin Kidney
RI PT
J. 2010;3:193-4. 44. Rennert J, Hamer OW. Large subdural effusions after angiography mimicking acute subdural hematoma. J Comput Assist Tomogr. 2010;34:249-50.
SC
45. Tun K, Kaptanoglu E, Celikmez RC, et al. Meningeal extramedullary haematopoiesis mimicking subdural hematoma. J Clin Neurosci. 2008;15:208-10.
M AN U
46. Laigle-Donadey F, Taillibert S, Mokhtari K, et al. Dural metastases. J Neurooncol. 2005;75:57-61.
47. George KJ, Lau A, Ellis Michael, et al. Metastatic coagulopathic subdural hematoma: A
TE D
dismal prognosis. Surg Neurol Int. 2012;3:60.
48. Kutlubay Z, Bairamov O, Sevim A, et al. Rosai-Dorfman disease: a case report with nodal and cutaneous involvement and review of the literature. Am J Dermapathol. 2014;36:353-7.
AC C
2013;32:341-6.
EP
49. McClellan SF, Ainbinder DJ. Orbital Rosai-Dorfman disease: a literature review. Orbit.
50. La Barge DV 3rd, Salzman KL, Harnsberger HR, et al. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): imaging manifestations in the head and neck. AJR Am J Roentgenol. 2008;191:W299-306. 51. Carbone A, Passannante A, Gloghini A, et al. Review of sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) of head and neck. Ann Otol Rhinol Laryngol. 1999;108:1095-104.
ACCEPTED MANUSCRIPT
Figure Legends: Figure 1: CT scan displaying a hypodense crescent shaped collection in the right subdural space.
collection in the right subdural space.
AC C
EP
TE D
M AN U
SC
Figure 3: Process of study inclusion and exclusion.
RI PT
Figure 2: T1-weighted MRI with gadolinium displaying a hyperintense crescent shaped
ACCEPTED MANUSCRIPT
Table 1: Individual Patient Data Author, Year
Age (years), Gender
Mimicker Pathology
History of Trauma
Azevedo et al., 2015
69, male
Lymphoma
Barrett et al., 2008 Boukas et al., 2015
59, male 75 male
Metastasis Metastasis
Traumatic Traumatic
Hyperdense Hypodense
Surgical Surgical
Medical
Sarcoma
Atraumatic
Hyperdense
Surgical
57, female
Atraumatic
Hyperdense
Medical
72, male
contrast extravasation post angiography Metastasis
Atraumatic
Isodense
Surgical
de Beer et al., 2013
66, female
Metastasis
Atraumatic
Isodense
Medical
31, male
Infectious
De Blay et al., 2000
79, female
Lymphoma
de Tribolet N, Zander E, 1978 Destian et al., 1989
72, female
Autoimmune
77, female
RI PT
37, male
Chattopadhyay et al., 2008 Cheng et al., 2009
Isodense
Surgical
Hypodense/Isodense
Surgical
Atraumatic
Not Reported
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Atraumatic
Hypodense
Medical
Traumatic
Hyperdense
Surgical
SC
Atraumatic
Atraumatic
M AN U
Catana et al., 2016
Management
Atraumatic
Radiological Appearance on CT Hyperdense
78, female
Feinberg WM, Valdivia FR, 1984 Gocmen et al., 2010
35, male
Infectious
Atraumatic
Hypodense
Surgical
45, female
Lymphoma
Atraumatic
Isodense
Surgical
Goetz et al., 2002
64, female
Lymphoma
45, female
Gungor et al., 2008
3, male
Im et al., 2005
85, male
Kalra et al., 2013
42, male
Kitaura et al., 2010
65, female
Kumar et al., 2008
45, male
Atraumatic
Hyperdense
Surgical
infantile myofibromatosis
Atraumatic
Hyperdense
Surgical
Infectious
Atraumatic
Hypodense
Surgical
Autoimmune
Atraumatic
Isodense/Hyperdense
Surgical
nephrogenic systemic fibrosis and iodine administration Autoimmune
Atraumatic
Hyperdense
Medical
Atraumatic
Hyperdense
Surgical
EP
23, female
AC C
20, male
TE D
Evliyaoglu et al., 2006
shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis shunt-associated meningeal fibrosis Lymphoma
ACCEPTED MANUSCRIPT
45, female
Sarcoma
Atraumatic
Isodense/Hyperdense
Surgical
Mathon et al., 2013
59, female
Lymphoma
Atraumatic
Isodense
Surgical
Mitsos et al., 2004
62, male
Lymphoma
Traumatic
Isodense
Surgical
Natarajan M, Devi NS, 2012 Nussbaum et al., 1995
41, male
Sarcoma
Not Reported
Isodense
Surgical
76, male
Sarcoma
Not Reported
Hyperdense
Surgical
Nzokou et al., 2015
65, male
Metastasis
Atraumatic
Hyperdense
Surgical
O’Brien et al., 2011
34, male
Sarcoma
Atraumatic
Hypodense
Surgical
Oertel et al., 2003
62, male
Sarcoma
Atraumatic
Hypodense/Isodense
Surgical
Oktay et al., 2014 Patil et al., 2010 Ramnarayan et al., 2013 Rennert et al., 2010
62, male 71, male 59, male 63, female
Atraumatic Traumatic Traumatic Atraumatic
Isodense/Hyperdense Hypodense/Isodense Hypodense Hyperdense
Medical Surgical Surgical Medical
Reyes et al., 1990 Sacho et al., 2010 Smidt et al., 2005 Song et al., 2005 Tomlin JM, Alleyne CH, 2002 Tun et al., 2008
56, male 46, female 45, male 45, male 61, male
Metastasis Metastasis Lymphoma contrast extravasation post angiography Lymphoma Lymphoma Sarcoma Autoimmune Metastasis
Atraumatic Atraumatic Atraumatic Atraumatic Traumatic
Hypodense Hyperdense Not Reported Hyperdense Isodense
Surgical Surgical Medical Medical Surgical
SC
M AN U
TE D
Hyperdense
Surgical
Atraumatic
Hyperdense
Surgical
53, male 62, male 62, female 56, male
Lymphoma Metastasis Lymphoma Lymphoma
Atraumatic Atraumatic Not Reported Atraumatic
Hyperdense Hyperdense Not Reported Isodense
Surgical Medical Surgical Surgical
Lymphoma
Traumatic
Not Reported
Surgical
Infectious
Traumatic
Hypodense
Surgical
60, female 60, male
EP
Traumatic
73, female
meningeal extramedullary hematopoiesis Metastasis
AC C
Villano JL, Ryan CW, 2003 Yoon et al., 2008 Yu et al., 2012 Kambham et al., 1998 Shimizu K, Ochiai M, 2012 Jesionek-Kupnicka et al., 2013 Single Center Case
51, female
RI PT
Mallory et al., 2012
ACCEPTED MANUSCRIPT
Table 2: Subdural Hematoma Mimicker Pathologies and Management
4,10,18-25
66.6 (5.7)
6 Atraumatic (60%)
13-26
Lymphoma (14 patients) • B-cell lymphoma (21%) • B-cell lymphoma of MALT (29%) • Meningeal Lymphoma (7%) • Non-hodgkin’s lymphoma (21%) • Plasmocytoma (14%) • Burkitt Lymphoma (1%)
59.3 (10.7)
9/13 (69%) Atraumatic
6,34,35
Infectious (4 patients) • Cysticercosis (50%) • Empyema (50%)
36-39
Autoimmune (4 patients) • Neurosarcoidosis (25%) • Wegener’s Granulomatosis (25%) • Rosai-Dorfman (25%) • Acute Pachymeningitis (25%)
5/5 (100%) Atraumatic
3/4 (75%) Atraumatic
AC C
52.8 (25.0)
51 (14.1)
1 hypodense (13%) 1 isodene (13%) 2 hyperdense (25%) 1 hypodense/isodense (13%) 1 isodense/hyperdense (13%) 3 hypodense (75%) 1 isodense (25%)
EP
48.6 (15.1)
4/4 (100%) Atraumatic
MRI Results T1-weighted
1 hypodense (10%) 3 isodense (30%) 4 hyperdense (40%) 1 hypodense/isodense (10%) 1 isodense/hyperdense (10%) 3 hypodense (23%) 4 isodense (31%) 5 hyperdense (38%) 1 hypodense/isodense (8%)
TE D
27-33
Sarcoma (7 patients) • Myeloid Sarcoma (14%) • Chloroma (43%) • Angiosarcoma (14%) • Meningeal Sarcoma (14%) • Recurrent Spindle Cell Sarcoma (14%)
CT Results
RI PT
Metastases (10 patients) • Prostate (70%) • Lung (10%) • Breast (20%)
Trauma History
3 hyperintense (100%)
2 hyperdense (67%) 1 isodense/hyperdense (13%)
T2-weighted
Management Strategy
1 hyperintense (100%)
7 operative (70%) 3 non-operative (30%)
1 hypointense (14%) 2 isointense (29%) 2 hyperintense (29%) 1 hypointense/isointense (14%) 1 isointense/hyperintense (14%)
3 hypointense (38%) 1 isointense (13%) 4 hyperintense (50%)
13 operative (93% operative) 1 non-operative (7% operative)
1 hypointense (50%) 1 isointense (50%)
1 hyperintense (100%)
6 operation (86% operative) 1 non-operative (14%)
1 hypointense (50%) 1 hyperintense (50%)
1 hyperintense (100%)
4 operative (100%)
1 hypointense (33%) 1 isointense (33%) 1 hyperintense (33%)
1 hypointense (33%) 2 hyperintense (67%)
2 operative (50%) 2 non-operative (50%)
SC
Mean Age in years (SD)
M AN U
Mimicker Pathology
ACCEPTED MANUSCRIPT
40-45
4 hypodense (44%) 5 hyperdense (56%)
RI PT
8/9 (89%) Atraumatic
5 hypointense (100%)
EP
TE D
M AN U
SC
44.9 (24.5)
AC C
Miscellaneous (9 patients) • Shunt-associated Meningeal Fibrosis (44%) • Contrast Extravasation Post Angiography (22%) • Infantile Myofibromatosis (11%) • Meningeal Extramedullary Hematopoiesis (11%) • Nephrogenic Systemic Fibrosis & Iodine Administration (11%) SD; standard deviation
4 hyperintense (100%)
2 operative (22%) 7 non-operative (78%)
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
Highlights Intracranial subdural masses that mimic subdural hematomas exist
•
It is important to properly diagnose these pathologies as the management plan can differ
•
We evaluate the clinical presentation, radiological features, and outcomes of these
RI PT
•
pathologies
A subdural collection that is hyperdense on CT scan and hyperintense on T2 MRI, and a
SC
history of progressive headaches with no trauma may raise the suspicion of an atypical
EP
TE D
M AN U
subdural pathology.
AC C
•
ACCEPTED MANUSCRIPT
Abbreviations: CML: chronic myeloid leukemia
RI PT
CT: computed tomography MeSH: medical subject headings
AC C
EP
TE D
M AN U
SC
MRI: magnetic resonance imaging
ACCEPTED MANUSCRIPT
Conflict of interest statement:
AC C
EP
TE D
M AN U
SC
RI PT
We declare that we have no financial or other conflicts of interest.