Critical Care Medicine-Neurologic Disorders>>>>>Neurotrauma
Question 2#

A 73-year-old female with hypertension, hyperlipedemia, and atrial fibrillation on oral anticoagulation with coumadin sustained a mechanical fall backwards and hit the right posterior aspect of her head. Following the fall, there was no loss of consciousness. On initial arrival to the emergency department (ED), she was interactive, but over the course of 30 minutes, she had neurologic deterioration with loss of spontaneous movement on the left side and multiple episodes of emesis and was intubated for airway protection. A head CT was completed at that time and is shown below. Her labs are remarkable for an elevated international normalized ratio (INR) of 2.1, Cr 1.4.

Vitals are remarkable for blood pressure (BP) 126/88 mm Hg, pulse 80 but irregular.

What is the age of the hemorrhage that is present on the noncontrast head CT?

a. There is only acute subdural hemorrhage.
b. There is mixed acute and subacute subdural hemorrhage
c. There is mixed acute and chronic subdural hemorrhage
d. There is only chronic subdural hemorrhage
e. There is only acute epidural hemorrhage

Correct Answer is A

Comment:

Correct Answer: A

The head CT demonstrates a large right-sided subdural hemorrhage. This blood collection accumulates in the space between the dura and arachnoid mater. This hemorrhage is not limited by the cranial sutures as is the case with an epidural hemorrhage. Subdural hemorrhages are seen in all ages, most commonly due to trauma. Subdural hemorrhages are typically formed from stretching and tearing of bridging critical veins as they cross the subdural space. In the hyperacute (first hour) phase, the hemorrhage typically will have a swirled appearance due to a mixture of clot, serum, and unclotted blood. An acute subdural hemorrhage is typically a homogenous hyperdense extra-axial collection and can have areas of unclotted blood causing mixed densities within the hemorrhage. A subacute subdural hemorhage (between day 3 and 21) will become isodense to the adjacent cortex. Lastly, a chronic subdural hemorrhage becomes hypodense and appears similar to cerebrospinal fluid (CSF) and can mimic subdural hygromas.

Although not pictured here, MRI imaging can be used to age hemorrhage.

References:

  1. Jallo J, Loftus CM. Neurotrauma and Critical Care of the Arin. Thieme Medical Publication; 2009.
  2. Brant WE, Helms CA. Fundamentals of Diagnostic Radiology. Lippincott Williams & Wilkins; 2007.
  3. Atlas SW, Thulborn KR. Intracranial Hemorrhage. Magnetic Resonance Imaging of the Brain and Spine. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2002:773-832.