Review Question - QID 107339

This elderly patient with confusion after a fall and a non-contrast CT scan of the head demonstrating a crescent-shaped hyperdensity has likely developed a subdural hematoma.

Subdural hematomas are particularly common in the elderly population (whether acute or chronic) due to the decrease in brain parenchymal volume creating a risk of tearing of the bridging veins. Patients with trauma and anticoagulation (especially vitamin K antagonists such as warfarin) are at a much higher risk than their counterparts. Typically, subdural hematomas present with a crescent shaped hyperdensity (blood) on CT scan and present with neurological symptoms such as fatigue, nausea, dizziness, confusion, and seizures.

Iliescu et al. report on the diagnosis and treatment of subdural hematomas. They state the best treatment is therapies such as hyperventilation, diuretics, and fluid restriction. Hyperventilation can be used in acute cases where the decrease in partial pressure of CO2 (PCO2) in the blood can cause vasoconstriction in the cranium. They also report that for large hematomas that may be at risk for causing herniation, surgical options such as decompression (via burr holes or a ventriculoperitoneal shunt) may be the best management.

Connolly et al. report on the incidence of subdural hematomas with anticoagulants. In their meta-analysis, they report that rate of subdural hematoma patients with atrial fibrillation treated with vitamin K antagonists (VKAs) was 2.9 per 1000 patient-years. They also report that VKAs were associated with a significantly higher proportion of subdural hematomas compared to antiplatelet agents (odds ratio=3, P<0.05) and factor Xa inhibitors (odds ratio=2.9, P<0.05).

Figure A shows an axial CT scan with a crescent shaped hyperdenisty, representing blood in the subdural space. These findings are characteristic of subdural hematoma

Incorrect Answers:
Answer 1: Subarachnoid hemorrhage typically occurs due to ruptured berry aneurysms and presents with a "thunderclap" headache that is sudden in onset and associated neck pain. CT imaging would classically reveal blood in the basal cisterns or fissures.

Answer 3: Epidural hematomas may occur due to a laceration of the middle meningeal artery. Patient's characteristically have initial loss of consciousness, followed by a lucid interval before deteriorating. CT imaging classically demonstrates a lens shaped hyperdensity, often with an overlying scalp hematoma.

Answer 4: Subgaleal hematoma typically presents in neonates due to trauma sustained at birth, and present with subaponeurotic bleeding that crosses suture lines.

Answer 5: Caput succedaneum typically present in neonates due to trauma sustained during birth. This causes a subcutaneous hemorrhage that crosses the suture lines. It is not common in elderly patients.

Bullet Summary:
Subdural hematoma classically occurs in the the elderly as a result of trauma, and is characterized by a crescent-shaped hyperdensity on CT imaging.