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Acute subdural hematomas are usually related to the rupture of a bridging vein with or without tearing of brain matter. In some instances the origin of the hemorrhage is due to the shearing of a cortical arteriole bleeding directly into the subdural space, generally after a minor head trauma. Ten cases were reviewed at Geneva's Neurosurgical clinic over a period of thirteen years (1973-1986). They represent less than 5% of all acute and subacute subdural hematomas treated during that period. Subdural hematomas of venous origin are usually encountered on previously normal brain whereas those of arteriolar origin are thought to result from the disruption of a small arteriolar knuckle adhering to the arachnoid and dura. While the majority of arteriolar hematomas reported here and in the literature are of traumatic origin, some are undoubtedly spontaneous. The clinical features of these hematomas are characterized by a high incidence of falsely localising motor signs, presumably due to the so called Kernohan's phenomenon. Their treatment requires a wide exposure, allowing identification and coagulation of the bleeding source located in most instances around the Sylvian fissure. Although a rare entity, the existence of arteriolar subdural hematomas must be emphasized, since any delay in their treatment may result in a dramatic outcome.

Between 1978 and 1984, the University Hospital of Geneva (Hôpital Cantonal Universitaire) received 46 head injured patients who "talked and died" after their brain insult. Only 14 of them had associated systemic lesions whilst two thirds of the series had an isolated head injury. Detailed review of the case records shows that death was preventable in a quarter of the cases. For 28 patients (60%), the factors contributing to death are avoidable or, at least, their management should be greatly improved. The diagnosis was confirmed by autopsy in 31 patients (67%).