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Snapshot
  • A 76-year-old man presents to the emergency department with increasing somnolence and lethargy. His symptoms developed on the day of admission. His symptoms are associated with a headache with mild nausea but no vomiting. He tripped over a carpet and hit his head on the floor. A head CT without contrast demonstrates a crescent-shaped hyperdensity that crosses the suture lines.
Introduction
  • Definition
    • venous bleeding in the potential space between the brain parenchyma
  • Epidemiology
    • risk factors
      • cerebral atrophy, which can be seen in
        • aging
        • chronic alcohol use
        • previous tramautic brain injury
      • anti-thrombotic medication use
  • Pathogenesis
    • head injury results in tearing of the bridging veins
Presentation
  • Symptoms/physical exam  
    • acute subdural hematoma
      • coma
      • symptoms of increased intracranial pressure if the bleeding occurs in the posterior fossa
        • headache
        • nausea and vomiting
        • cranial nerve palsies
    • chronic subdural hematoma
      • headache
      • cognitive impairment
      • somnolence
Imaging
  • CT head without contrast
    • indication
      • imaging study of choice in the evaluation of a subdural hematoma
    • findings
      • crescent-shaped and concave hyperdensity that can extend across suture line  
Differential
  • Epidural hematoma
    • differentiating factors
      • lens-shaped and biconvex hyperdensity that does not cross the suture lines
  • Subarachnoid hemorrhage
    • differentiating factors
      • thunderclap headache
      • hyperdensity in the subarachnoid space on CT head without contrast
Treatment
  • Operative
    • surgical evacuation 
      • indication
        • treatment of choice in symptomatic (e.g., cranial nerve palsies, midline shift, and symptoms of increased intracranial pressure) subdural hematomas
Complications
  • Brain herniation
  • Seizures
  • Hydrocephalus

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(M2.NE.16.4684) A 69-year-old patient is brought into the emergency department with complaints of a headache. He states that he fell down about one hour prior and hit his head on the floor. He was unconscious for a few minutes, according to his daughter, but still has a severe headache. Of note, he feels extremely nauseous. His daughter states that the patient takes warfarin for a heart problem. On exam, his vitals are normal. He has no focal neurological deficits, but appears confused when responding to your questions. His CT scan is shown in Figure A. What is the most likely the reason for this patient's complaints? Tested Concept

QID: 107339
FIGURES:
1

Subarachnoid hemorrhage

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(0/2)

2

Subdural hematoma

100%

(2/2)

3

Epidural hematoma

0%

(0/2)

4

Subgaleal hematoma

0%

(0/2)

5

Caput succedaneum

0%

(0/2)

M 6 E

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