Chronic subdural hematoma

Two days ago, Clara had 3 routine appointments scheduled with her orthopedist, ENT and neurosurgery assistant doctors.

She had a MRI done on September 10th and all seemed to be just fine. But it wasn´t.

Clara´s MRI showed a very clear left side chronic subdural hematoma, due to hitting her head some times she felt while walking. And this repeated trauma caused bleeding. Clara doesn´t show any neurologic sign although the blood accumulation is significant. This is partially explained by the macrocephalus, one of achondroplasia physical characteristics, that provides a much wider subarachnoid space. It this space exists the CSF fluid, and one of it´s function is to absorb forces produced by external movements, protecting the brain.

So, for the brain to get under life threatening pressure in achondroplasia, a larger quantity of blood has to escape from the bridging veins, that extend across the brain to the dura. These veins have the ability to stretch until a certain point. Over this point, they can rupture releasing blood to the subdural space.

Image taken from Neurosurgery PA

This an image from a real craniotomy. The dura has been reflected above to reveal the bridging veins that extend across to the superior aspect of the cerebral hemispheres. These cerebral veins can be torn with trauma, particularly if there is significant cerebral atrophy (as with aging) that exposes these veins even more. Image taken from University of Utah

Image taken from The University of Chicago medicine

Although there is more CSF fluid and space for the brain inside a macrocephalus (is the compensatory external hydrocephaly) these bridging veins are naturally more stretched, being in a more tension mode. For that, when a baby or child with a larger head (as it happens in achondroplasia) hits the head in an object with relative intensity, this might cause slight bleeding of the bridging veins. And this repeated trauma can cause a slow but major bleeding with serious neurologic signs and potential death…

These are some images from Clara´s latest MRI. I outlined (red) the hematoma. It´s obvious the length of it, covering all left side and producing already some frontal brain compression. The wider point of the hematoma has about 11-12 mm (0,43-0,47 in).

A- forehead. P- back of the head

H-top of the head. R- right side. L- left side. F – head base

The hematoma reaches in some part the right side too. One positive point of this complicated situation is that the brain middle line has not suffered any deviation, that could have major issues if it was, like brain herniation.

In this next image, the cut 13/28 is at the eyes level and the following cuts go up, until getting closer to the top of the head at the cut 24/28.

The neurosurgeon said that Clara is absolutely forbidden of hitting her head any more time and his advice was for Clara to stay at home 24/7, with very close vigilance. There is a major chance for the hematoma to be absorbed during the next 3 months IF she doen´t suffer any more trauma. Hitting her head once more could have serious consequences with an emergency trepanotomy / craniotomy.

She loves to walk. She is starting to walk better. And sometimes she try to run. But she falls. 95% of the times she falls, she falls forward and extend her head not dropping it. But sometimes, she falls and hit a wall or furniture and a big bump on her head. And every time this happened it was like small accidents.

Now Clara should use a helmet foam every time she goes outside or she is playing inside the house with her brother. But she is still trying to adapt to the helmet and we are trying to adapt to all this…

On day after another. One day after another. But good days! It has to be good days. Because tomorrow is just somewhere I´m learning that is not here, with us every moment. It´s not real. Real is this. Is writing this in a… strange rational disposition.

But the emotions are overwhelming… too much.

The following link is real and explicit surgery, so please watch it only if you feel capable of that. This is a video of a craniotomy to resolve a chronic subdural hematoma in a 68 year-old man.