A Case of Subdural Haemorrhage Following a Trivial Fall - A Case Report
Navin Kumar Devaraj*
Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia
*Corresponding author: Navin Kumar Devaraj, Department of Family Medicine, Faculty of Medicine and Health Sciences, University Putra Malaysia, 43400 Serdang, Selangor, Malaysia
Received: 01 September 2019; Accepted: 20 September 2019; Published: 23 September 2019
Navin Kumar Devaraj. A Case Of Subdural Haemorrhage Following A Trivial Fall- A Case Report. Archives of Internal Medicine Research 2 (2019): 030-033.View / Download Pdf Share at Facebook
Mr. A initially presented with history of right sided headache for 2 weeks. He had a history of hitting his head against the floor after slipping from the last step of home stairs, but was well till this onset of headache. Computed tomography done showed right temporo-parietal subdural haemorrhage measuring 1.3 cm with a midline shift of 0.7 cm. Burr hole evacuation was done and he is currently recovering well.
Subdural Haemorrhage; Chronic; Fall; Headache; Burr Hole
Chronic subdural haemorrhage (SDH) is known to occur spontaneously in older individuals, with or without a history of falls. It typically presents with headache, seizures, syncope, altered mental state and extra pyramidal symptoms for e.g. dystonia and dyskinesia . Risk factors for subdural haemorrhage include older male, presence of medical problem, including diabetes, hypertension and atrial fibrillation, intake of oral anti-platelets or anti-coagulant therapy and history of falls . Diagnosis requires a high index of suspicion based on the clinical presentation, as sometimes the patient may not reveal that they had any trauma unless asked specifically. Computed tomography or magnetic resonance imaging of the brain is needed for diagnosis depending on the size of the bleeding. The former is able to delineate larger bleeds, especially those with middling shift, but the latter will be needed for smaller collection of haematoma .
2. Case Report
Mr A, a 50 year old man, works as a car mechanic. Pre-morbidly, he had hypertension well controlled on perindopril 8 mg daily and amlodipine 10 mg daily. One fine day after waking up from sleep, he suddenly developed a dull aching headache over his right temporal region that had persisted for the past 2 weeks with pain score of 3-7/10. There was no vomiting, dizziness or blurring of vision. He had severe headaches before, but none as long as this current episode or in this specific region. When asked, he recalled falling on the right side of his scalp 3 months ago when he accidentally missed the last step of his home, which just cause him some mild swelling which he treated on his own with ice compression and the swelling then spontaneously resolved.
On physical examination, Mr A repeatedly was holding the right side of his scalp during the consultation. His blood pressure (sitting) was 146/82 and 142/80 mmHg (standing). The pulse rate was 74 beats per minute, regularly regular with a temperature of 36.8°C. Neurological examination, including the cranial nerves and cerebellar signs examination was normal. Gait was normal. The Romberg test was negative. A provisional diagnosis of possible stroke or space occupying lesion was made. Case was referred for urgent non- contrast computed tomography of the brain, which noted showed right temporo-parietal subdural haemorrhage measuring 1.3 cm with a left midline shift of 0.7 cm (Figure A and B). The radiologist proceeded with magnetic resonance imaging of the brain, which confirmed the above findings.Case was referred to the neurosurgery team, which conducted an urgent burr hole surgery Subsequently Mr A was warded in the neurosurgical ward where he made an uneventful recovery. He was discharged after 5 days of undergoing the emergency burr hole surgery. His blood pressure in the ward was normal.
Urgent evacuation is usually done in cases of subdural haemorrhage with either a single or two burr hole craniostomy or craniotomy [1, 3]. There is no difference in term of prognosis following treatment with either first two methods of craniostomy . The craniotomy surgical procedure is usually reserved as a second line procedure for cases of recurrence and for patients that have ‘hard to evacuate’ solid haematoma . The excess mortality risk following chronic subdural haemorrhage persists throughout life. Factors determining this risk of mortality will include the degree of disability or dependence upon discharge and the presence of cerebral atrophy medical risk factors like stroke and hypertension . In those having risk factors like hypertension, diabetes and dyslipidaemia, adherence to medication is important to prevent the complication of subdural haemorrhage [4-6].
In summary, this was a case of chronic subdural haemorrhage that presented in a 50 year old man with only trivial symptoms of right sided headache and a history of fall three months prior to the development of the headache. It needed a high index of suspicion and investigation with a computed tomography of the brain to reach the diagnosis of intracranial haemorrhage before urgent burr hole surgery was done.
The author like to thank Mr A for his permission to publish this case.
Conflict of interest
The author declares no conflict of interest
- Sangondimath G, Chhabra HS, Venkatesh R, et al. A rare case of chronic subdural haematoma presenting with paraparesis: A case report and review of literature. Journal of Clinical Orthopaedics and Trauma 6 (2015): 265-268.
- Manickam A, Marshman LAG, Johnston R. Long-term survival after chronic subdural haematoma. Journal of Clinical Neuroscience 34 (2016): 100-104.
- Smith MD, Kishikova L, Norris JM. Surgical management of chronic subdural haematoma: One hole or two?. International Journal of Surgery 10 (2012): 450-452.
- Chia YC, Ching SM, Chew BN, et al. May Measurement Month 2017 blood pressure screening: findings from Malaysia-South-East Asia and Australasia. European Heart Journal Supplements 21 (2019): D77-D79.
- Rashid AA, Devaraj NK. Oh no! now I have diabetes. Rawal Medical Journal 43 (2018): 776-778.
- Devaraj NK. Prevalence, Factors Influencing, and Knowledge About Adherence to Lipid-Lowering Therapy Among Hyperlipidemia Patients. International Journal of Cardiology 249 (2017): S7-S8.