Presentation
Altered concious state following fall. Patient on anticoagulation (warfarin) for atrial fibrillation.
Patient Data
A very large acute subdural hemorrhage is present with marked midline shift and right uncal herniation. The left temporal horn is dilated in keeping with obstruction to the outflow of the left lateral ventricle.
There has been a right craniectomy, and postoperative pneumocephalus is now present. The previously demonstrated dense subdural blood has been evacuated. Extraaxial CSF density fluid is seen adjacent to the right temporal pole.
There is now an established right anterior cerebral artery infarct. A shallow layer of subdural blood persists along the posterior falx and right tentorium cerebelli.
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The huge acute subdural overlying the right cerebral hemisphere as well as filling the floor of the middle cranial fossa and tracking along the posterior aspect of the falx (blue arrow), results in marked mass effect and midline shift (red).
There is marked uncal herniation (yellow) with significant distortion of the midbrain (blue dotted line).
Following the craniectomy (orange arrow) and evacuation of the hematoma, an anterior cerebral artery infarct has developed on the right (green *).
Case Discussion
This case illustrates just how large acute subdural hemorrhages can be, and that with prompt surgery patients can be saved. In this case the degree of midline shift was such that a right sided anterior cerebral artery infarct developed.
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