Wierd Case

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

roja

Full Member
7+ Year Member
15+ Year Member
Joined
Oct 20, 2003
Messages
6,040
Reaction score
23
34 yo male with pmh of mild htn, mild dm. emt. gradual onset throbbing r sided headache x 3-4 days relieved with motrin. Came in because was transporting a patient and had a little nausea. No h/o trauma, etc.


100% normal exam, eating drinking talking to buds. felt better with motrin reglan.

2 weeks later, continues to have headaches so gets a scan... acute on chronic SDH. (still with 100% normal exam)

WTF????:eek:


ACEP guidlines and new JAMA headache guidlines don't buy this guy a scan initially.

No problem... but why the heck does this guy have a SDH

Members don't see this ad.
 
Members don't see this ad :)
Man, I hate hearing about cases like this.

If he comes to me for his initial visit, I still don't do the scan. I will, however, think of this case now.

Thanks for that.

Take care,
Jeff
 
good case. was a recent hx of head trauma elicited when he first came in.

might he have a an inheritied bleeding disorder?

the fact that his headache improved with meds from what i remember means nothing. i reckon he would've been sent home without a scan in 99.9 out of 100 ERs with his initial presentation.
 
34 yo male with pmh of mild htn, mild dm. emt. gradual onset throbbing r sided headache x 3-4 days relieved with motrin. Came in because was transporting a patient and had a little nausea. No h/o trauma, etc.


100% normal exam, eating drinking talking to buds. felt better with motrin reglan.

2 weeks later, continues to have headaches so gets a scan... acute on chronic SDH. (still with 100% normal exam)

WTF????:eek:


ACEP guidlines and new JAMA headache guidlines don't buy this guy a scan initially.

No problem... but why the heck does this guy have a SDH

Is it that unusual to find a Chronic SDH without trauma hx? I thought it was like 50%. Risk factors supposed to be brain atrophy leading to stretched bridging veins (alcoholism or aging) or coagulopathy. In this guy, I'll go with Painter's idea.
 
Still adamantly denying h/o trauma.


while etoh chronic is possible, but there was no atrophy on the scan that might go along with chronic alcoholism (and he had no other stigmata of chronic etoh abuse)

Possible bleeding d/o? possilby.. still getting a work up.
 
how likely is it that the motrin is contributing here to the bleed? how much was he really taking and when did he start it?
 
Up to 50% of chronic subdurals don't have a history of trauma. Most of these are elderly patients. In younger patients, you worry about coaguloapthies, intracranial aneurysms, and, rarely, tumors. Anabolic steroid abuse has also been implicated in a few cases.

Was the headache worsened by straining? Posture? Any papilledema, reflex asymmetry or neck stiffness?
 
The only thing weird about this case is the age. If he was 70, I wouldn't bat an eye. I don't think anyone would fault you for skipping the scan. I wouldn't have scanned him on the initial presentation either.

Can't scan everyone - cost and radiation exposure. Also consider the treatment -> nothing. Check coags, monitor neuro, watch for shift, but after 2 weeks unlikely to need intervention. Likely if he hadn't been scanned nothing bad would happen. The reason we make up those guidelines is not to catch every pathology but to catch ones that require treatment.

I agree that EtOH/drugs and occult trauma is the mostly likely cause. Probably had a lot of atrophy on his scan -> big spaces, stretched bridging veins -> setup for SDH.

Aneurysms usually cause SAH or ICH, not SDH.
 
. Likely if he hadn't been scanned nothing bad would happen. .

Not sure you're right about that. Classic teaching is that fibrocytes form a membrane around the hematoma, making it a separate compartment. Then as hemoglobin is broken into smaller pieces, osmotic obligation pulls water in. Compartment swells compressing brain, finally causing symptoms up to herniation. Usually weeks out.

I've seen several patients with precisely the "classic course". Thjey often have presented with no focal findings, just a new organic brain syndrome.

For this reason, I scan every classic dementia the first time they show up. Sometimes I'm surprised.
 
See. that's the thing with this guy. He had a completely normal exam. Even after two weeks, he is sitting up in the stretcher, walking around the ed, yapping, eating, joking around etc. He rates the h/a 4/10. no organic brain syndrome, nada. just still having headaches.


There was NO atrophy on the scan which kind of makes alcoholic atrophy an unlikely cause. Eventhe nuerosurgeons are scratching thier heads.
 
Top