Case 12: subdural hematoma (unusual etiology)

posted: December 3, 1996

Resident: Bryan Payne, MD
Attending: Deepak Awasthi, MD

CLINICAL PRESENTATION: This 51 year old balck man was brought to the ER after being found unresponsive at his home by his family. The night before, the patient was complaining of severe headaches. No history of trauma was given. There was no history of hypertension or other medical illnesses. There was no history of illicit drug abuse.

On arrival to ER, the patient was withdrawing to pain- left side much more than the right. His pupils were equal and reactive. The patient was not following commands. He was opening his eyes to painful stimulus. Blood pressure on arrival to ER was 170/100; pulse was in the 60's (sinus). Regular respiration at 16. The patient was afebrile. No external signs of trauma. No other pertinent physical findings. His initial labwork (including hemoglobin, electrolytes, glucose and tox screen were normal).

He was sent for an emergent cranial CT scan without contrast(after initial stabilization). Two select images are shown below:

Note the right frontotemporal acute subdural hematoma (red marker) with mass effect and the subarachnoid hemorrhage (on the left image). Also note the intraventricular (IIIrd vent) blood on the right image.

How would you proceed at this time? Evacuation of hematoma, or angiogram and then evacuation, ventriculostomy-angiogram-then evacuation. What do you think is the etiology of the subdural hematoma?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: A ventriculostomy was placed in the ER. The opening pressure was high (30mm Hg). He continued to be stable with the exam as described above. Subsequently, the patient was taken to the angiography suite for a four vessel angiogram. Select lateral right carotid injection is shown below:

Note the posterior communicating artery (PCoA) aneurysm. No other abnormalities were found.

At this point, the patient was taken to the operating room. A right frontotemporal craniotomy was performed (larger than the standard pterional craniotomy). A moderate size right subdural hematoma was evacuated and then the right PCoA aneurysm was clipped without complications. Intraoperative photograph of aneurysm:

POSTOPERATIVE COURSE: The patient has progressively become more alert- now following commands and moving both sides equally well- drift on the right side. He is being treated for a respiratory infection and abdominal abscess (complication of PEG tube placement). Otherwise, he is doing well.

Subdural hematoma is an unsual presentation for aneurysms.

References

1. Weir B, Myles T, Kahn M, et al: Management of acute subdural hematomas from aneurysmal rupture. Can J Neurol Sci 11:371-376, 1984.
2. Rusyniak WG, Peterson PC, Okawara S-H, et al: Acute subdural hematoma after aneurysmal rupture; evacuation with aneurysmal clipping after emergent infusion computed tomography: Case report. Neurosurgery 31:129-132, 1992.

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