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Key Image

CT Head without contrast through the level of the falx.

Key Findings

Single axial CT image at the level of the falx demonstrates a high density left parafalcine collection (red arrows). This collection does not cross midline on any other image.

12-hour followup CT

An additional CT was obtained 12-hours after presentation to assess the progression of the hemorrhage. The image demonstrates no additional hemorrhage and interval layering of the subdural collection in the more dependent portions of the left parafalcine space.

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Diagnosis

Subdural Hemorrhage from a traumatic head impact injury.

Discussion

The patient was admitted to the ICU and underwent frequent neurological evaluations. The patient had no neurological deficits. He continued to have a headache, but it did not acutely worsen. A followup CT head was performed and demonstrated dependent settling of the blood (available in 'Findings'). The patient remained hospitalized for other injuries, but did not deteriorate neurologically.

Differentiate between subdural and epidural hemorrhage. Subdural hemorrhage presents as a nonspecific headache with no localizing findings. Extra-axial hemorrhage is best viewed in abdomen window settings (i.e. window level 40, width 400) CT findings of acute hematoma include a hyperdense (65-90 HU) extra-axial collection that may efface adjacent cerebral sulci. (If hemorrhage extends into the sulci, think subarachnoid hemorrhage). Subdural hemorrhage will not cross midline, but will cross sutures. (Epidural hematomas may cross midline but do not cross the suture lines).

Prognosis: Varies. Depends on severity of injury and amount of intracranial pressure. The patient can rapidly deteriorate if the accumulation and mass effect / edema is severe. Patients may have to undergo emergent neurological surgery to drain collections that are rapidly expanding.

References / Resources

Additional Information:

1. Dahnert*: pg 330
2. Primer*:
3. Related Article:

   Strub WM. "Overnight Preliminary Head CT Interpretations Provided by Residents: Locations of Misidentified Intracranial Hemorrhage." October 2007 AJNR, 28: 1679-1682.

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