Moving the Blood and Transforming Stasis for Chronic Subdural Hematoma: A Case Report
Liang-In Liu, MD; Helen Chang1, MD; Lung Chan2, MD
Section of Traditional Chinese Medicine, Section of Family Medicine1, Section of Neurology2
Far Eastern Memorial Hospital
Taipei, Taiwan, R.O.C.
A 44 year-old female fainted when she went to the bathroom at midnight. There was a bruise over her right cheek when she regained consciousness. Patient has no headache and no neurological defect on physical examination. The computed tomographic (CT) scan of brain showed a chronic subdural hematoma over right fronto-parietal lobe 12 weeks after the fainting episode. She took modification of xuě fǔ zhú yū tāng (血府逐瘀湯, XZT, House of Blood Stasis-Expelling Decoction) for quickening the blood and transforming stasis. The subdural hematoma disappeared 2 months later.
The mechanisms of XZT to treat chronic subdural hematoma might be (1) regulating the permeability of hematoma capsule to prevent recurrent bleeding, (2) promoting the microcirculations around the hematoma to accelerate resolution of subdural collection.
(Chang Gung Med J 2006;29(4 Suppl):47-53)
Key words: chronic subdural hematoma, xuě fǔ zhú yū tāng (XZT, House of Blood Stasis-Expelling Decoction), moving the blood and transforming stasis
Chronic subdural hematoma is an encapsulated collection of old blood, mostly or totally liquefied and located between the dura mater and arachnoid. It is most common in the older age groups (80% of patients are over the age of 40 years). Generalized cerebral atrophy and increased venous fragility associated with aging are the major predisposing factors. With aging, the mass of the brain decreases leading to an increase in the space between the brain and skull. This causes stretching of the bridging veins and the greater movement of the brain within the cranium makes these veins vulnerable to trauma. Trauma is an important factor in the development of chronic subdural hematoma and symptoms might occur weeks or months after a trivial injury. However, a history of head injury is absent in about 30%-50% of these cases. Other predisposing factors include anticoagulation, alcoholism, epilepsy, bleeding diathesis, low intracranial pressure secondary to dehydration or after the removal of cerebrospinal fluid. (1-2)
Treatment of chronic subdural hematoma is usually by surgical evacuation, although small hematomas may resolve spontaneously. For over 40 years, investigators have attempted to treat patients with chronic subdural hematomas by medical means. Various combinations of bed rest, corticosteroids, mannitol, and other hypertonic solutions were used. Medical management has the highest likelihood of success in small size hematoma, minimal mass effect, and few neurologic symptoms. (1,3,4)
Chronic subdural hematoma is described as the blood away from the channel, which means static blood in traditional Chinese medicine. Some physicians used Chinese herbal formulas to treat the hematoma by quickening the blood and transforming stasis. (5-7)
Mrs. Sun, a 44-year-old housewife, had the medical history of β-thalassemia minor and lead poisoning before. About 10 years ago, she had an episode of abdominal pain and fainted on the way to the bathroom at midnight. She suffered from abdominal pain again at midnight on January 9, 2003. She had blackout and fainted on the way to the bathroom similar to 10 years ago. When she regained consciousness, a bruise over her right cheek was noted. She visited our emergency room. The blood pressure was 120/80 mmHg. Her consciousness was clear. There was no headache or vomiting. The neurological examinations were normal. The electroencephalogram, electrocardiogram, 24-hour Holter electrocardiogram were all normal. The hemoglobin was 12.3 g/dl (reference 12.0-16.0 g/dl), platelet was 177´103/μl (reference 140-400´103/μl), and plasma lead was 1.7 μg/dl (reference 0-30 μg/dl).
Mrs. Sun had her menstrual cycle 21 to 25 days before. Her last menstrual period was February 10, and menstruated again on February 25. The amount of bleeding was moderate. A painful skin colored papule over her left axilla was noted before menstruation. She came to our out patient department of traditional Chinese medicine on March 4 for further evaluation and treatment. According to the four physical examinational categories of Chinese medicine, the inspection showed moderate body form and pinkish tongue with an uneven thin slimy white fur. The listening and smelling examinations were normal. Her oral intake, defecation, urination, and sleep were normal in inquiry. Palpation revealed a skin colored papule over her left axilla and her wrist pulses were stringlike and rough. We prescribed jiā wèi xiāo yáo sǎn (加味逍遙散, JXS, Supplemented Free Wanderer Powder) for coursing liver (treating emotional depression) and nourishing blood, xiān fāng huó mìng yǐn (仙方活命飲, XHY, Immortal Formula Life-Giving Beverage) for dispersing swelling and dissipating bind, and liù wèi dì huáng wán (六味地黃丸, Six-Ingredient Rehmannia Pill) for enriching kidney yin (regulating gonadal function). She menstruated on March 21 and the papule over the left axilla was dispersed slightly. We continued the prescriptions of JXS to regulate menstruation and XHY to disperse the axillary papule. Her menstruations remained normal later.
The CT scan of brain without contrast enhancement was done on April 3 (Fig. 1). It showed a chronic subdural hematoma over right fronto-parietal lobe with brain swelling and the midline slightly shifting to the left. The neurosurgeon suggested operation. Mrs. Sun hesitated. She continued to do well and do not have a headache and the neurological examinations were normal. Chinese herbal therapy was started after detailed discussion. If the hematoma was not absorbed, then the operation will be performed. Xuě fǔ zhú yū tāng (血府逐瘀湯, XZT, House of Blood Stasis-Expelling Decoction) 2 gm for quickening the blood and transforming stasis, JXS 2 gm for coursing liver and nourishing blood, and XHY 1 gm for dispersing swelling and dissipating bind were prescribed four times per day. The follow-up CT scan of brain without contrast enhancement on June 21 (Fig. 2) showed that the right fronto-parietal chronic subdural hematome disappeared and the brain swelling subsided without midline shift.
Fig. 1. CT scan of brain without contrast enhancement 12 weeks after head injury showed a chronic subdural hematoma over right fronto-parietal lobe, brain swelling, and midline slightly shifting to the left.
Fig. 2. CT scan of brain without contrast enhancement 2 months after Chinese herbal therapy showed the right fronto-parietal chronic subdural hematoma disappeared, and the brain swelling subsided without midline shift.
Trauma is an important factor in the development of chronic subdural hematoma. The initial trauma to the bridging veins results in hemorrhage in the subdural space. A day after hemorrhage, the outer surface of the hematoma is covered by a thin layer of fibrin and fibroblasts. Migration and proliferation of the fibroblasts lead to formation of a membrane over the clot within 1 week. The outer membrane progressively enlarges and the fibroblasts invade the hematoma and form a thinner inner membrane within 3 weeks and liquefaction of the hematoma occurs due to the presence of phagocytes. The hematoma may either resorb spontaneously or slowly increase in size resulting in a chronic subdural hematoma. (1,8)
Two major theories have been proposed to explain the growth of a chronic subdural hematoma. Osmotic theory was based on the hypothesis that the liquefaction of the hematoma increases the protein content and oncotic pressure in the encapsulated fluid, thus attracting fluid from the neighboring vessels into the cavity due to osmotic pressure gradient across the semipermeable membrane. However this theory was disproved by Weir in 1971, who demonstrated no significant difference in the osmolality of the contents of chronic subdural hematoma compared with cerebrospinal fluid and serum. Recurrent bleeding from the hematoma capsule is the proven and more widely accepted theory. The hematoma capsule has abnormal and has dilated blood vessels with incomplete basement membranes causing protein and red blood cells to leak through the defective capillary endothelium into the evolving chronic subdural hematoma. Increased fibrinolytic activity and coagulation abnormalities may also play a part in the expansion of chronic subdural hematoma. (1,8)
The clinical presentations of chronic subdural hematoma include altered mental state (confusion, drowsiness, coma), alternations in personality or intellect, focal neurological deficit (hemiparesis, weakness, difficulty in speaking), headache, falls, seizures, and transient neurological deficits (disturbance in language, hemiplegia, hemisensory deficit). The presentation in the elderly is different from that in younger adults. The normal atrophy of the brain associated with aging results in more intracranial space in which the hematoma can develop. Symptom onset in older patients is typically more insidious, and symptoms are more likely to manifest as changes in cognition or focal findings rather than increased intracranial pressure. Younger patients are more likely to present with signs of increased intracranial pressure such as papilledema, vomiting, and headache. (1,2,9)
Computed tomography is the procedure of choice for the initial evaluation of suspected chronic subdural hematoma. A chronic subdural hematoma is a dynamic lesion and its appearance on computed tomography is dependent on its age. Soon after a hemorrhage (acute phase), the hematoma looks hyperdense when compared with the normal brain, due to the presence of fresh blood. Hematomas between 3 days and 3 weeks old are considered to be subacute and appear isodense. After about 3 weeks (chronic phase) it appears hypodense. However repeated microhemorrhages into a chronic subdural hematoma can increase the density, giving rise to a heterogeneous or a hyperdense picture. The use of intravenous contrast medium during CT scanning may identify the membrane surrounding the hematoma. (1,10)
Treatment of chronic subdural hematoma is usually by surgical evacuation, although small hematomas may resolve spontaneously. The common surgical procedures include twist-drill craniostomy, burr-hole drainage, or craniotomy. The complications of surgery are infection, inappropriate secretion of antidiuretic hormone, hematoma reaccumulation, seizures, tension pneumocephalus, intracerebral hemorrhage, and subdural empyema. For over 40 years, investigators have attempted to treat patients with chronic subdural hematomas by medical means. Various combinations of bed rest, corticosteroids, mannitol, and other hypertonic solutions were used. Medical management has the highest likelihood of success in those who have small size hematoma, minimal mass effect, and few neurological symptoms. Patients receiving medical treatment may have more extended periods of bed rest, with the attendant risks of deep venous thrombosis and pulmonary embolism. Prolonged corticosteroid therapy is associated with glucose intolerance, increased infection risk, and gastrointestinal hemorrhage. Mannitol use may result in electrolyte imbalance, dehydration, and renal failure. (1,3,4)
Chronic subdural hematoma is described as the blood away from the channel, which means static blood in traditional Chinese medicine. Some physicians used tōng qiào huó xuě tāng (通竅活血湯, Orifice-Freeing Blood-Quickening Decoction), XZT, or bǔ yáng huán wǔ tāng (補陽還五湯, Yang-Supplementing Troop-Marching Decoction) to treat the hematoma by quickening the blood and transforming stasis. (5-7)
XZT is from Yī Lín Gǎi Cuò (醫林改錯, Correction of Medical Errors) by Wáng Qīng-Rèn (王清任,1768-1831) in the Qing dynasty. The formula is composed of peach kernel (桃仁, táo rén, Persicae Semen), carthamus (紅花, hóng huā, Carthami Flos), Chinese angelica (當歸, dāng guī, Angelicae Sinensis Radix), dried/fresh rehmannia (生地黃, shēng dì huáng, Rehmanniae Radix Exsiccata seu Recens), ligusticum (川芎, chuān xiōng, Ligustici Rhizoma), red peony (赤芍藥, chì sháo yào, Paeoniae Radix Rubra), bupleurum (柴胡, chái hú, Bupleuri Radix), bitter orange (枳殼, zhǐ ké, Aurantii Fructus), achyranthes (牛膝, niú xī, Achyranthis Bidentatae Radix), platycodon (桔梗, jié gěng, Platycodonis Radix), and licorice (甘草, gān cǎo, Glycyrrhizae Radix). It was designed for blood stasis in the chest and expanded to treat all qi stagnation and blood stasis. The clinical applications include cardiovascular (coronary artery disease, myocardial infarction, myocarditis, arrhythmia, cor pulmonale, hypertension, vasculitis), respiratory (asthma, pneumoconiosis), digestive (liver cirrhosis, chronic hepatitis, chronic gastritis), nervous system (migraine, trigeminal neuralgia, facial palsy), gynecology (dysmenorrhea, menstrual irregularity, infertility, climacteric syndrome, fibroadenoma of breast), and surgery (subdural hematoma, epidural hematoma, intracerebral hemorrhage, chest contusion). (11-14)
The pharmacologic effects of XZT are (1) improving microcirculation, vasodilatation and reducing vascular resistance, (2) regulating coagulation and anticoagulation to prevent thrombosis, (3) enhancing the reticuloendothelial function, (4) regulating the permeability of capillaries to decrease exudation and accelerate absorption of exudate, (5) improving neural metabolism and promoting repair of damaged tissue, (6) inhibiting proliferation of connective tissue and decreasing scar formation and adhesion, (7) analgesia, (8) inhibiting growth of tumor cells, (9) activating clearance ability of the liver, (10) lowering blood lipids. (11-13)
The mechanisms of XZT to treat chronic subdural hematoma might be (1) regulating the permeability of hematoma capsule to prevent recurrent bleeding, (2) promoting the microcirculations around the hematoma to accelerate resolution of subdural collection. (5,6,12)
Our case is a middle-aged female who had head injury history without neurological symptoms. Her only symptom was menstrual irregularity. We were not certain whether the menstrual irregularity was associated with the head injury. CT scan of the brain 12 weeks after injury showed a chronic subdural hematoma over right fronto-parietal lobe. The hematoma was heterogeneous due to repeated microhemorrhage. The right brain was swollen and the midline slightly shifted to the left. Chinese herbs were given because of the small size of the hematoma, minimal mass effect, and no neurologic symptoms. The major prescription was XZT for quickening the blood and transforming stasis. The frankincense (乳香, rǔ xiāng , Olibanum) and myrrh (沒藥, mò yào, Myrrha) in XHY also have the effect of quickening the blood and transforming stasis. The chronic subdural hematoma resolved 2 months after Chinese herbal therapy.
Was the hematoma resolved spontaneously or by the effect of herbs? The CT scan of the brain indicated continuous repeated bleeding and provided the evidence that the hematoma has the potential to increase in size. Thus, herbal therapy should be helpful in resolution of the chronic subdural hematoma. However, patient selection (small size hematoma, minimal mass effect, and few neurological symptoms) is the key of nonoperative therapy. The patient should be observed carefully during the course of herbal therapy. Surgical treatment is recommended if the neurological symptoms deteriorated.
I am grateful to Mr. Nigel Wiseman for his inspiration and encouragement in my pursuit of knowledge and the English language.
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劉亮吟 張之申1 陳龍2
亞東紀念醫院 傳統醫學科 家庭醫學科1 神經內科2