AN UNUSUAL CASE OF SUBDURAL HAEMATOMA

Theuns van Jaarsveld

28 January 2009

CASE REPORT

• A 21 yr old male attended the emergency department after “sustaining” a head injury the previous day

• He was playing football and had headed the ball several times in a row

• After this he started to develop a headache but was able to finish the football game

• The following day he still had the headache and went to his local emergency department

• No loss of conciousness was reported after the incident or any other neurological symptoms

ON EXAMINATION

• He was alert and fully orientated

• Pupils equal and reactive to light

• No focal neurology found in limbs

He was given advice on concussion and analgesia and discharged

• He re-attended the emergency department 2 weeks later complaining of persistent headaches

• Again no focal neurology was found and he was given further advice on analgesia and discharged

• 3 weeks after the initial injury he re-attended complaining of headaches

• He had vomited 1 time during the previous day and had transient episodes of blurred vision

• In view of the persistent symptoms, despite the triviality of the original injury, a CT scan of the head was done

CT SCAN

•

CT SCAN

• Bilateral chronic subdural haematomata

• Mild frontal oedema

• Left middle cranial fossa arachnoid cyst

The case was discussed with neurosurgery and a MRI scan was done of the head

MRI SCAN

• He was reviewed at the neurosurgery OPD and it was decided to drain the cyst surgically

• He made an uneventfull recovery

DISCUSSION

• Intracranial arachnoid cysts account for about 1% of IC space occupying lesions

• They are non-tumorous congenital sacs lined with an arachnoid-like membrane and filled with CSF like fluid

• Pathologically they can increase in size, remain the same or completely resolve

SUGGESTED EXPLANATION FOR INCREASE IN SIZE

• Unidirectional flow through a ball-valve opening in the wall with trapping of CSF in the cyst

• Active secretions of fluid by cells lining the cyst wall

• Most common site is the middle cranial fossa

SIGNS AND SYMPTOMS

• Compression on surrounding tissues by the cyst

• Most common Sx and Sx – Increased

ICP

- Craniomegaly

- developmental

delay

• CHILDREN - craniomegaly

- seizures

- psychomotor retardation

• ADULTS - headaches

- seizures

- focal neurological deficits

COMPLICATIONS

• Acute increase in cyst size• Subdural effusion after rupture• Subdural or intra-cyst bleeding• DIAGNOSES - CT or MRI• PROGNOSIS- untreated arachnoid cysts may

cause permanent neurological damage because of progressive expansion or haemorrhage but with trratment most individuals do very well

• Pasients who re-attend after minor head injuries represent a high risk group of pasients in whom a CT scan usually yield a positive scan in 14 % of cases

• CT scans in these pasients may pick up previously asymptomatic neurological conditions such as aneurysms, abcesses or tumours or unexpected pathology such as a chronic subdural