Neuroscience · Year 2 · from Neuroscience
Case 2: Subdural Hematoma
Patient Presentation
Demographics: 78-year-old male
Chief Complaint: Progressive confusion and left-sided weakness over 3 weeks
History of Present Illness: The patient's daughter noticed her father becoming increasingly forgetful and confused over the past 3 weeks. He was previously independent but now requires assistance with activities of daily living. She also noticed he was dragging his left leg when walking. On direct questioning, the patient recalled falling and hitting his head on a coffee table approximately 4 weeks ago. He did not lose consciousness and did not seek medical attention at the time. His medical history includes atrial fibrillation for which he takes warfarin.
Physical Examination:
- Vital signs: BP 158/92, HR 72 irregular, T 36.8C
- General: Elderly male, mildly confused, knows name but not date
- Neurological:
- Mental status: Oriented to person only, follows simple commands inconsistently
- Cranial nerves: Pupils equal and reactive; subtle left facial droop
- Motor: Left upper extremity 4/5 strength, left lower extremity 4/5 strength, right side normal
- Sensory: Intact to light touch bilaterally
- Reflexes: Left-sided hyperreflexia with upgoing Babinski response
Workup:
- CT head without contrast: Large right-sided crescent-shaped extra-axial collection measuring 2 cm in maximum thickness with mixed density (acute and chronic blood), causing 8 mm rightward midline shift with effacement of right lateral ventricle
- INR: 3.8 (supratherapeutic)
- Complete blood count: Normal
- Basic metabolic panel: Normal
Diagnosis: Subacute-on-chronic subdural hematoma, right hemisphere
Treatment:
- Warfarin held; INR reversal with vitamin K 10 mg IV and 4-factor prothrombin complex concentrate (PCC)
- Neurosurgical consultation for urgent evacuation
- Burr hole drainage performed with evacuation of approximately 80 mL of mixed clot and liquefied blood
- Post-operative CT showed resolution of midline shift
- Gradual clinical improvement over 5 days with return to baseline mental status
- Cardiology consultation for alternative anticoagulation strategy (left atrial appendage closure considered)
Clinical Pearl: Subdural hematomas result from rupture of bridging veins in the subdural space. They appear crescent-shaped on CT because blood can spread along the cerebral convexity, unlike epidural hematomas which are limited by dural attachments at suture lines. Risk factors include advanced age (brain atrophy increases tension on bridging veins), anticoagulation, and trauma (often minor in elderly patients).