78-year-old man with history of multiple prior falls

78-year-old man with history of multiple prior falls

A 78-year-old male with history of multiple prior falls is brought into the local ED from his care facility because his caretaker noticed his altered mental status. A head CT was obtained.

What type of head injury is seen in this image, and what space does this injury involve?

1. Epidural, extra-axial
2. Epidural, intra-axial
3. Subdural, extra-axial
4. Subdural, intra-axial
5. Subarachnoid, extra-axial
6. Subarachnoid, intra-axial

Subdural hematoma

• Non-contrast CT is the best initial study. MR is better able to depict extent and age.
• CT findings: Extra-axial collection of blood located between inner border cell layer of dura and arachnoid with a crescentic shape that spreads diffusely across cranial convexities as it can extend across cranial sutures but not dural attachments.
  • Hyperacute phase (<6 hrs) can be of heterogeneous density or hypodense on CT
  • Acute phase (6h – 3d) hematoma is homogeneously hyperdense ~60% of the time and mixed hyper- and hypodense 40% of the time.

Taken from Neuroradiology: The Requisites 3rd Edition (2010). Rohini Nadgir, David Yousem, Robert Zimmerman, Robert Grossman,

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 36065

• MR findings: Variable in appearance secondary to the different appearance of blood on MR depending on its age.
• Typically, subdural hemorrhage is secondary to traumatic tearing of bridging cerebral veins. The trauma may be very minor, especially in elderly patients as they are predisposed tearing secondary to cerebral atrophy.
• Patient’s with ventricular shunts are at higher risk due to the shunted system not acting as a natural tamponade.
• Can grow slowly with increasing risk for mass effect and herniation if not identified and treated early.
• Recurrent hemorrhage is common.
• SDH is a neurological emergency that often requires surgical treatment, however the decision between operative or non-operative management is based on multiple factors. Typically, If size is < 1cm with no cerebral edema, they can be managed non-operatively.
• High-dose mannitol is often given to decrease risk of brain herniation prior to surgery.