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• Thirty-seven patients with severe head injury underwent radionuclide cisternography to detect early and late effects of trauma on cerebrospinal fluid (CSF) circulation. Thirty-one patients had subdural hematomas or hygromas and six had cerebral contusions without extracerebral masses. Cisternographic results were abnormal in 23 patients with subdural masses and normal in five who had only cerebral contusions. Of eight patients undergoing serial studies, one had persistent partial obstruction, five had partial resolution of abnormalities, and the two with progressive obstruction had their conditions improved by shunting. Angiography suggested transtentorial herniation in 11 patients with cisternal block, six of whom had clinical signs of herniation on the same side.

Between 1958 and 1973, one hundred patients with subdural hematoma were successfully treated without surgery. This was achieved either with bed rest, corticosteroids, mannitol, or a combination. The initial diagnosis and subsequent improvement were confirmed by cerebral angiography, but clinical observations were more important in deciding the selection of therapy. Similar medical treatment was initiated in 22 others who later were operated on because of failure to respond. Medical treatment was not attempted in severely ill or comatose patients. Of 185 patients with subdural hematoma in the Mount Sinai Hospital series, 75 recovered without surgery. After the introduction of corticosteroid therapy in 1968, there was a higher incidence of successful treatment by medical means. Follow-up examinations revealed that recovery was excellent and has been maintained.

• Posterior fossa subdural hematomas in the newborn infant are rare but potentially treatable. The infants are normal after birth, but within days, hydrocephalus hypotonia, and irregular respirations develop. Seizures and third nerve pareses are unusual. We report a neonate in whom this process was identified by computerized tomographic brain scan. We also discuss potential misinterpretations of the computerized tomographic brain scan in neonates.

• Blood causes striking changes on computerized tomography. However, chronic subdural hematomas may become isodense with brain and therefore not visible directly. Midline and ventricular displacement, effacement of cortical sulci, narrowing of white matter on one side, and ventricular distortion should suggest a unilateral isodense process. Bilateral isodense subdural hematomas pose a major problem on computerized tomography since there are no indications of a mass lesion. A negative report could lull the clinician into a false sense of security. In these cases, general disappearance of sulci and considerable narrowing of ventricles are helpful findings. A particularly important and overlooked sign is an abnormally decreased bicaudate cerebroventricular index. Above all, a high degree of suspicion is vital.

At the present time, hypoprothrombinemia induced by anticoagulant drugs is the most commonly encountered coagulation defect in medical practice.1The extensive use of anticoagulants in the treatment of thromboembolic and cardiovascular disorders has been accompanied by reports of neurological complications including subarachnoid bleeding, intracerebral hemorrhage, intraspinal hemorrhage, and subdural hematoma.2-9Although subdural hematoma has been reported least frequently, this study suggests that it occurs more often in relation to anticoagulant therapy than has been realized. As early as 1944, Shleven and Lederer10presented a patient with uncontrollable hemorrhage after therapy with bishydroxycoumarin who at autopsy was found to have a subdural hematoma in addition to extensive bleeding in other parts of the body. Nathanson, Cravioto, and Cohen11in 1958 discussed the development of subdural hematomas in 3 patients receiving anticoagulant therapy. Wells and Urrea12found subdural hematomas in 5 patients out of a group of

To the Editor.— Our purpose was to show that medical therapy was an acceptable alternative to surgery in certain cases. We do not believe that all cases as yet should be treated medically. A controlled prospective study of medical vs surgical therapy for subdural hematoma would be of interest but not feasible nor pertinent. Dr. Geissinger is concerned about what is happening to the brain while the hematoma is being absorbed during medical therapy. The same may be asked as to what happens after surgical therapy. This question has been answered in two publications (Cook et al: J Neurosurg 19:419, 1962, and McLaurin: Neurology , 15:866, 1965). Both showed that after surgical treatment there was persistence of fluid collections, midline shifts, and cerebral edema for up to two months. They also noted that these roentgenographic findings did not correlate with the clinical picture. It could be argued that since medical therapy

We are indebted to Drs. Bender and Christoff for their provocative contribution. It does "... seem a radical departure from convention..." to treat some subdural hematomas nonoperatively. Whether or not it "... actually represents progress..." cannot be determined from their study. Given the observation that some subdural hematomas resolve without surgery, it does not necessarily follow that nonoperative intervention is the initial treatment of choice in all minimally symptomatic patients. It must also be shown that delaying surgery in favor of ineffective nonoperative treatment does not increase mortality and morbidity. Failing this, one must be able to identify at the outset those individuals who will not respond to medical management. The paper of Drs. Bender and Christoff does not provide this information. Being advocates of an unorthodox treatment, Drs. Bender and Christoff must bear the burden of proving to us that nonoperative treatment for patients minimally ill with subdural hematoma is at

Spinal subdural hematomas are rare; only 15 cases not associated with major trauma have been reported previously. Over the past four years we have encountered eight patients with thrombocytopenia who developed spinal subdural hematomas following lumbar puncture. In three of the patients, the hematoma was associated with weakness and sensory loss in the lower extremities and with bladder dysfunction. One patient recovered spontaneously, but two remained paraplegic until their deaths several months later.

Nonsurgicalgical Treatment of Subdural Hematomas" is of considerable interest. The author is a noted neurologist and has made many important contributions to the field of neurology. Unfortunately, this article is not one of them. The surgical treatment of chronic subdural hematomas by evacuation with burr holes and drains is a well established neurosurgical procedure. The morbidity and mortality is negligible. Even the most ill patient can be operated on under local anesthesia with minimal risk. The operation is technically simple, the evacuation immediate, and the results gratifying. Clips placed on the dura and arachnoid at the time of surgery enable follow-up by routine skull x-ray study. In view of this, which no neurosurgeon or neurologist who has had experience with this disease can dispute, what is the rationale for the medical management of subdural hematomas? The use of steroids, osmotic agents, multiple angiography, and prolonged bed rest for results

To the Editor.— The report entitled "Nonsurgical Treatment of Subdural Hematomas" by Bender and Christoff in the August issue of the ARCHIVES (31:73, 1974) might be challenged as follows. It is sometimes well to question forms of therapy that have been accepted and unchallenged for years. This becomes especially important if the accepted form of treatment is unsatisfactory. The removal of a subdural fluid collection through a burr hole with the patient under local anesthesia has proved both safe and effective and is certainly one of the most rewarding forms of treatment in medicine. Why is it being challenged? Because of their secondary nature, no emphasis has been placed on the economics of weeks of prolonged hospitalization during medical treatment nor on the infrequent case of unrecognized subdural tumor or empyema treated with corticosteroids. There are several other questions that should be directed to the authors. They mention that their

• A 59-year-old woman with a metastatic adenocarcinoma of unknown origin and no metabolic abnormalities developed a diffuse encephalopathy, with generalized triphasic waves seen on the electroencephalogram. Postmortem examination revealed widespread, multifocal perivascular carcinomatosis of the cerebral cortices. Triphasic waves have been described with dementing processes, subdural hematomas, and cerebrovascular disease, but they are more commonly seen with metabolic encephalopathies. This case demonstrates an additional nonmetabolic cause of triphasic waves.

MORE than a century ago, Virchow 1 pointed out the difficult problems often encountered when attempting to diagnose subdural hemorrhage. Unfortunately, not all of the problems have been solved. The electroencephalogram now has become a valuable and practical supplement to the clinical neurologic evaluation for diagnosis of intracranial lesions, and it has been widely used for assessment of cerebral function after head injury. In 1940 Jasper and co-workers 2 found low-amplitude activity in EEGs recorded from scalp areas overlying subdural hematomas; in the same year Walter 3 reported the occurrence of abnormal slow (delta) activity overlying epidural hematomas. Since that time, most investigators have found a high proportion of abnormal EEGs associated with either subdural or epidural hematomas, 4,5 but there has been disagreement regarding the relative importance of the different types of EEG abnormality for diagnosis and localization of these lesions. Some authors 6-12 have emphasized the localizing

This, the eighth edition of A Guide to Neurology , addresses itself to medical students and physicians and, as such, is useful to help the uninitiated in clinical neurological examination. The section dealing with peripheral nerve lesions is exhaustive and replete with useful diagrams and tables, particularly those summarizing syndromes due to lesions of roots or nerves. The rest of the nervous system, however, is treated unevenly, and this presumably reflects the personal interests of the author. The discussion of subdural hematomas, for example, occupies but 11 lines. In the treatment of cerebrovascular disease, arterial blood letting as a therapeutic measure is thought contraindicated, but it is somewhat surprising that such medieval measures are even mentioned in a modern book. The student interested in neurology will not find the key references which he might wish to consult in order to broaden his knowledge, and it is regrettable that textbooks are published