Case Report and Review of Literature of Delayed Acute Subdural Hematoma

BACKGROUND: The authors present a case of delayed acute subdural hematoma and review all reported cases in the literature. The focus of this paper is to identify the subset of the population who are at risk, and determine whether they should be admitted for observation in the setting of mild traumatic brain injury.

CASE DESCRIPTION: A 75-year-old woman taking daily aspirin (81 mg) had a fall with loss of consciousness. Her Glasgow Coma Scale (GCS) score was 15 at the time of presentation to the emergency department. However, because of her postconcussive symptoms, computed tomography (CT) of the head was obtained, and the results were negative for any intracranial hemorrhage or fractures. She was admitted for workup. The next day, she neurologically deteriorated to a GCS score of 6. CT of the head was reobtained and showed acute, left-sided subdural hematoma with shift and herniation. She was taken to operating room for emergent decompressive craniotomy. Postoperatively, she developed left-sided temporal and occipital intraparenchymal hemorrhage. She died after being placed on comfort care.

CONCLUSION: Delayed acute subdural hematoma occurs mainly in the middle-aged or older population who are taking anticoagulation or antiplatelet therapy. Most patients have a GCS score of 15 with no loss of consciousness. Neurological deterioration occurs within the first 24 hours for 70% of the patients. Therefore, we recommend admission and observation of these selected group of patients. Due to small reported population of patients, we could not determine whether the patients taking anticoagulant, antiplatelet, or both anticoagulant and antiplatelet medication are at higher risk. In addition, the role of delayed CT of the head without change in the examination result needs to be explored further.