Images in Clinical Medicine

Subdural Hematoma

Jeffrey Hurwitz, M.D.

N Engl J Med 1997; 337:1732December 11, 1997

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Figure 1 A 76-year-old man with hypertension and a history of stroke reported headache, difficulty walking, and loss of appetite. He denied using alcohol, having a recent fall, or being assaulted. The initial neurologic examination demonstrated slowed speech, disorientation, somnolence with right homonymous hemianopia, right-sided facial droop, right-sided paresis with marked spasticity, and a flexion contracture of his right arm. Within hours, he became obtunded and his blood pressure rose. Unenhanced computed tomography showed a subdural hematoma with a blood–fluid level (A). The right lateral ventricle was markedly compressed and shifted across the midline (B). There was diffuse edema throughout both hemispheres, but the differentiation between gray matter and white matter was preserved. A small extracerebral space containing cerebrospinal fluid was present (C), along with the calcified choroid plexus (D). The patient underwent emergency craniotomy to evacuate the hematoma, with a remarkable recovery in ability. Nearly two months after the procedure, he was alert and oriented, with intact cognitive function. His speech was nonfluent, with paraphasic stuttering. The right-sided paresis remained, but he had regained full use of his left side and could walk 3 m (10 ft) with a rolling platform walker.

Jeffrey Hurwitz, M.D.
Hospital of the University of Pennsylvania, Philadelphia, PA 19104

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