Literature ReviewCase Report and Review of Literature of Delayed Acute Subdural Hematoma
Introduction
Traumatic acute subdural hematoma is one of the most lethal causes of head injuries. A critical factor in survival has been the timing of intervention for evacuation of hematoma. The mortality rate can be as high as 14% for adult patients with acute subdural hematoma.1 However, delayed acute subdural hematoma (DASH) is an entity that is rarely reported in the literature. We are reporting a case of DASH and reviewing the literature.
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Case Report
A 75-year-old woman with a medical history of hypertension, hypothyroidism, hyperlipidemia, osteopenia, and daily use of aspirin (81 mg) for good health presented to the emergency department (ED) at approximately 1:00 AM after she was found by her family in the kitchen on the floor and minimally responsive. At the ED, her Glasgow Coma Scale (GCS) score was 15 but amnestic to the events. Computed tomography (CT) of the head (Figure 1) was obtained and was negative for any intracranial
Results
In United States and Canada, approximately 1 million patients experience blunt traumatic brain injury (TBI); 66%–75% of these injuries are considered minor.2 Prospective studies have found that 3%–13% of patients with mild TBI and a GCS score of 15 had intracranial findings on CT of the head.2 In the literature, there has been great discussion regarding delayed intracerebral hemorrhage, delayed epidural hematoma, and delayed chronic SDH; however, there are limited data regarding DASH.3 In our
Discussion
Mild TBI (mTBI) is defined as a head injury for which the GCS score is 13–15. The majority of patients with mTBI have uneventful recovery; however, misdiagnosis can result in death, prolonged vegetative states, or significant disability.4 The acute phase of mTBI is characterized by approximately 10% risk for intracranial abnormalities such as contusion, subdural or epidural hematoma, brain swelling, subarachnoid hemorrhage, or pneumocephalus.5 There is an approximately 1% risk of
Conclusion
According to our review of the literature, DASH mainly occurs in middle-aged to older patients who are taking anticoagulation or antiplatelet therapy. It has been postulated that the rupture of bridging veins or small perisylvian arteries,7, 8, 9 in the presence of hypotension followed by fluid resuscitation, might be the mechanism for the delayed development of acute SDH. However, the exact mechanism has not been determined. In about 70% of patients, neurological deterioration due to DASH
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Cited by (0)
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Funding: Department of Neurological Surgery at Medical College of Wisconsin.