Clinical History:

This 58-year-old man had a history of alcohol abuse. He developed increasing weakness on his right side over several days. Upon admission he was mildly agitated and complaining of a headache. His right arm and leg were weak and there was flattening of the nasolabial fold on the right. He denied any recent head trauma. A head CT scan was obtained.

Image 4.1:

This is the CT scan. What does it show? What is the diagnosis?

There is a hematoma in the subdural space on the left. This would make the diagnosis of subdural hemorrhage.

Image 4.2:

This is a gross photograph of a similar lesion in a patient who died. What would have been the treatment for this lesion?

This picture shows a more chronic subdural hematoma which has a capsule around it. The treatment is evacuation of the blood through burr holes in the skull.

Answers:

1. What are the possible causes for his weakness?

A progressive stroke due to vascular occlusion on the left side or an enlarging subdural are possible causes in spite of the negative history of trauma. An intraparenchymal tumor or abscess are other possibilities.

2. Why did the patient deny any history of recent trauma?

With his history of alcoholism, he most likely was intoxicated (drunk) at the time and did not remember striking his head.

3. What age groups commonly present with this type of lesion after head trauma?

Subdural hematomas are most commonly seen in the very young and the very old. Alcoholics commonly present with subdurals because of their propensity to fall.

4. What blood vessels are ruptured to produce this lesion?

The crossing dural veins are ruptured. Because of the slower accumulation of blood, the patient may not present acutely with the symptoms of a space occupying mass. Chronic subdurals are thought to be caused mainly by minor movements of the head, tearing the small vessels taking part in the resorption of the original clot.