Radiology · Year 4 · from Radiology

Case 1: Acute Subdural Hematoma

Patient Demographics

  • Age: 78 years
  • Sex: Male

Chief Complaint

Found on floor, confused, after witnessed fall

Presenting Symptoms

The patient was found on the floor by his wife after she heard him fall in the bathroom. She estimates he was down for approximately 15 minutes. He is now confused and unable to recall the event. He takes warfarin for atrial fibrillation. His wife reports he has seemed "more unsteady" over the past month with several near-falls.

Physical Exam Findings

  • Vital Signs: BP 168/94 mmHg, HR 82 bpm (irregular), RR 16/min, Temp 36.8C
  • GCS: 13 (E3V4M6)
  • Neurological: Confused, oriented to person only, left-sided facial droop, left arm drift with decreased strength (4/5), left leg 4+/5, plantar response extensor on left
  • Head: 4 cm hematoma over right temporal region
  • Pupils: Equal and reactive, 3mm bilaterally

Imaging Findings and Interpretation

Non-Contrast Head CT: Window Settings Used:

  • Brain windows (W:80, L:40): For parenchymal detail
  • Subdural windows (W:150, L:50): For extra-axial collections
  • Bone windows (W:2000, L:400): For skull fracture evaluation

Findings:

  • Acute Subdural Hematoma: Large crescent-shaped hyperdense (55-60 HU) collection over the right cerebral convexity
  • Thickness: Maximum thickness 18 mm
  • Extent: Extends from the frontal to the occipital region, crossing suture lines
  • Mass Effect:
  • 12 mm leftward midline shift at the level of the septum pellucidum
  • Effacement of the right lateral ventricle
  • Compression of the right cerebral hemisphere with sulcal effacement
  • Herniation: Early subfalcine herniation with the right cingulate gyrus displaced under the falx
  • No Skull Fracture: Bone windows demonstrate no acute fracture
  • Brain Parenchyma: No underlying intraparenchymal hemorrhage

Density Analysis: The hyperdense appearance (55-60 HU) indicates acute hemorrhage. Subdural hematomas become isodense at 1-3 weeks and hypodense when chronic. The homogeneous density suggests single acute hemorrhage event rather than acute-on-chronic bleeding.

Diagnosis

Acute subdural hematoma with significant mass effect and early subfalcine herniation in anticoagulated patient

Management

  1. Immediate Actions:
  • Emergent neurosurgery consultation
  • Reversal of anticoagulation: 4-factor PCC + Vitamin K IV
  • Check INR (resulted at 3.2)
  • Elevate head of bed to 30 degrees
  • Seizure prophylaxis with levetiracetam
  1. Surgical Intervention:
  • Emergency craniotomy for hematoma evacuation given:
  • Thickness >10 mm
  • Midline shift >5 mm
  • GCS decrease from baseline
  • Focal neurological deficits
  • Surgery performed within 4 hours of presentation
  1. Post-operative Course:
  • Post-operative CT showed successful evacuation with improved midline shift
  • Gradual neurological improvement over 1 week
  • Discussion regarding anticoagulation resumption (delayed 2 weeks, then transitioned to DOAC with lower bleeding risk)

Radiological Image

Image Description: Non-contrast head CT demonstrating a large acute subdural hematoma. The hyperdense (white) crescent-shaped collection overlies the right cerebral convexity, causing significant mass effect with midline shift and compression of the right lateral ventricle.

Source: Wikimedia Commons - "CT scan of subdural hematoma" URL: https://commons.wikimedia.org/wiki/File:Subdural_hematoma.jpg License: Creative Commons Attribution-Share Alike 3.0 Unported

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