A 79yo stumbled and sustained a minor head injury 2 weeks ago. He has become increasingly
confused, drowsy and unsteady. He has a GCS of 13. He takes warfarin for Afib. What is the most
likely dx?
a. Extradural hemorrhage
b. Cerebellar hemorrhage
c. Epidural hemorrhage
d. Subdural hemorrhage
e. Subarachnoid hemorrhage
answer: D
Consider this very treatable condition in all whose conscious level fluctuates, and
also in those having an ‘evolving stroke’, especially if on anticoagulants. Bleeding
is from bridging veins between cortex and venous sinuses (vulnerable to deceleration
injury), resulting in accumulating haematoma between dura and arachnoid.
This gradually raises ICP, shifting midline structures away from the side of the clot
and, if untreated, eventual tentorial herniation and coning. Most subdurals are from
trauma but the trauma is often forgotten as it was so minor or so long ago (up to
9 months). It can also occur without trauma (eg >ICP; dural metastases). The elderly
are most susceptible, as brain atrophy makes bridging veins vulnerable. Other
risk factors: falls (epileptics, alcoholics); anticoagulation.
Symptoms Fluctuating level of consciousness (seen in 35%) ± insidious physical
or intellectual slowing, sleepiness, headache, personality change, and unsteadiness.
Signs >ICP, seizures. Localizing neurological symptoms (eg unequal pupils,
hemiparesis) occur late and often long after the injury (mean=63 days).
Imaging : CT/MRI shows clot ± midline shift (but beware bilateral isodense
clots). Look for crescent-shaped collection of blood over 1 hemisphere. The sickleshape
differentiates subdural blood from extradural haemorrhage.
Treatment Irrigation/evacuation, eg via burr twist drill and burr hole craniostomy,
can be considered 1st-line; craniotomy is 2nd-line,162 if the clot has organized.163 Address
causes of the trauma (eg falls due cataract or arrhythmia; abuse).
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