Presentation
Vasovagal episode six weeks prior to presentation with occipital headstrike. Gradually worsening morning headache, nausea and vomiting. No regular medications.
Patient Data
Bilateral isodense subdural collections overlying the cerebral convexities bilaterally, larger on the right. Associated mass effect and early right sub-uncal herniation were noted.
The patient was arranged to have emergency craniotomy and decompression of his bilateral subdural hematomas. The post-operative CT is below.
Bi-frontal craniotomies with bilateral subdural drains. The bilateral subdural collections have reduced in size, now measuring 8 mm on the right and 9 mm on the left. Small volume acute blood within both collections. Small volume pneumocephalus. Marginally reduced mass-effect on cerebral sulci and bilateral lateral ventricles and 3rd ventricle. No intra-axial hemorrhage. No CT evidence of established infarct.
Case Discussion
This patient presented with symptoms suggestive of raised intracranial pressure. The bilateral subdural hematomas are somewhat crescent shaped; however, on the axial slices one may appreciate a degree of convexity, which is sometimes seen in chronic subdural hematomas. This, coupled with their isodensity, suggest they are at least some weeks old.
The presence of mass effect with subuncal herniation are consistent with critical mass effect that requires urgent neurosurgical intervention.
This patient made an excellent recovery with no residual neurological deficits.
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