Acute Subdural Haemorrhage

Clinical:

  • A 59 years old man
  • Underlying DM, HPT and hyperuricaemia
  • Alleged fall at home, missed steps and landed backward
  • No loss of consciousness, no vomiting, no headache, no blurred vision
  • Complaint of scalp swelling at left temporoparietal region
  • Examination showed GCS 15/15, no neurological deficit
  • Skull radiograph showed no depressed skull fracture
  • Patient was discharged home
  • Presented again after 2 days with severe headache and vomiting

Radiographic finding:

  • Skull radiograph do not demonstrate any fracture line.
  • An incidental finding of calcification, most probably¬† falx calcification
  • No obvious soft tissue haemotoma

CT findings:

  • Urgent non-contrast CT brain done
  • Acute subdural haemorrhage (red arrows) is seen at left cerebral hemisphere causing compression to the underlying brain parenchyma, particularly at the left temporal -parietal lobe.
  • It extends to left interhemispheric fissure and left tentorium
  • It has the maximum thickness of 2.0 cm at left tentorium.
  • It is associated with effacement of the adjacent sulci and right lateral ventricle. Poor grey white matter junction differentiation of the left cerebral hemisphere in keeping with cerebral oedema
  • There is about 1.1 cm midline shift to the left.
  • Prominent temporal horn of the left lateral ventricle noted, in keeping with obstructive hydrocephalus.
  • No skull fracture. Falx calfication (yellow arrows) as noted on skull radiograph
  • Scalp hematoma at left parieto-occipital region.

Diagnosis: Acute left subdural haemorrhage

Discussion:

  • Subdural haemorrhage is accumulation of blood in potential space between pia-arachnoid membrane with dura mater
  • Elderly patient is predisposed to this type of injury due to longer bridging veins in senile brain atrophy
  • No consistent relationship with skull fracture
  • CT scan shows¬† crescent-shaped hyperdensity at cerebral convexity with frequent extension to interhemispheric fissure and along tentorial margins
  • Haematoma freely extending across suture lines, but do not cross midline
  • Can be bilateral in 15-25% (adults) and 80-85% (infants)
  • Mortality rate 35-50% due to various associated injuries

Progress of patient:

  • Patient deteriorated with drop in GCS
  • Left decompressive craniectomy with duroplasty performed
  • Develop new onset AF
  • Septic shock secondary to pneumonia
  • Died 8 days after admission

 

 

Author: radhianahassan