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Case 281

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80 years- old female patient complains of asthenia and mental confusion with progressive worsening for 24 hours associated with headache and spatial and temporal disorientation. There is a report of a fall from hers own height two weeks ago, with an injury (a cut) in the frontal region. Previous history of ischemic stroke one year ago, presenting a motor sequel in the left dimidium.

According to the clinical case and the images provided, what is the most likely diagnose and the best approach?

a) Subacute subdural hematoma - refer the patient to emergency surgery for hematoma drainage.

25%

b) Epidural hematoma - refer the patient to emergency surgery for hematoma drainage.

25%

c) Subacute ischemic stroke - initiate thrombolysis with r-tPa and refer the patient to the Intensive Care Unit.

25%

d) Precocious subacute hemorrhagic stroke - refer the patient to emergency surgery for aneurysm clipping.

25%
   

Image analysis

 

Image 1: noncontrast computed tomography (CT) scan of the head, axial section. Left frontoparietal subdural colletion (green), predominantly hypodense in relation to the cerebral parenchyma, conditioning mass effect in the adjacent brain, with contralateral deviation of the midline (yellow arrows).

 

 

Image 2: noncontrast computed tomography (CT) scan of the head, coronal reconstruction. Left parietal subdural collection (green): predominantly hypodense in relation to the cerebral parenchyma, conditioning the mass effect in the adjacent brain. Contralateral deviation of the midline (yellow arrow). Infracentimetric  calcification near to the left lateral brain surface, non-specific.

Highlights

-The appearance of subacute subdural hematoma on noncontrast computed tomography scan of the head is of a half-moon shaped collection ("crescent"), isodense in relation to the cerebral parenchyma;

- It usually manifests in an insidious way: drowsiness, apathy, behavioral changes and, if worse, convulsions and global neurological deficits;

- All subdural hematomas with a thickness greater than 10 mm or that generate a midline deviation greater than 5 mm should be approached surgically;

- The main surgical method used is trepanation craniotomy.

References

- McBride, W; Biller, J; Wilterdink, J.L. Subdural hematoma in adults: Prognosis and managment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. [Access in June of 2017]. Available in: https://www.uptodate.com/contents/subdural-hematoma-in-adults-prognosis-and-management

- McBride, W; Biller, J; Wilterdink, J.L. Subdural hematoma in adults: Etiology, clinical features and diagnosis. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. [Access in June of 2017]. Available in: https://www.uptodate.com/contents/subdural-hematoma-in-adults-etiology-clinical-features-and-diagnosis

- DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. Subdural hematoma. [Updated in 03/16/2017, quoted in 08/06/2017]. Available in: http://web.a.ebscohost.com/dynamed/detail?vid=2&sid=22d9ae67-21eb-4a45-907b-b9ab6c3f2606%40sessionmgr4010&hid=4112&bdata=Jmxhbmc9cHQtYnImc2l0ZT1keW5hbWVkLWxpdmUmc2NvcGU9c2l0ZQ%3d%3d#db=dme&AN=114154&anchor=top

- Rocha, A.J; Vedolin, L; Mendonça, R.A. Traumatismo Cranioencefálico - Hematoma subdural. Colégio Brasileiro de Radiologia – Encéfalo. p. 577-583.

Author

André Dias Nassar Naback, 10th year medical student at Federal University of Minas Gerais.
E-mail: andrenaback[arroba]gmail.com

Supervisors

Júlio Guerra Domingues, Resident Physician in Radiology and Diagnostic Imaging at Madre Teresa’s Hospital, Belo Horizonte, MG.
E-mail: jgdjulio[arroba]gmail.com

Reviewers

Eduardo Paolinelli, Bruno Campos, Laio Paiva, Prof. José Nelson Mendes Vieira; Profa. Viviane Parisotto.

Translated by

Joice Carneiro Dias Prodígios, 10th year medical student at Federal University of Minas Gerais
E-mail: joicecdp[arroba]hotmail.com

Test question

(Santa Casa / RJ - 1994) A 68 year old patient with cerebral atherosclerosis presents with mental confusion, headache and somnolence, 15 days after falling on the stairs of his residence. What is the most likely injury?

a) Brain concussion

25%

b) Brain contusion

25%

c) Epidural Hemorrhage

25%

d) Subdural hemorrhage

25%

e)

25%
   

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