87-year old gentleman was brought to OPD with complaints of right-sided weakness and inability to speak of 48-hours duration. He was apparently well prior to that. He had earlier been treated for cardiac disease, however, details were not known. There was no history of head trauma. On examination, he was conscious, however, had global aphasia. He had right hemiplegia (grade 0/5 power). Vital signs and cardiac examination were within normal limits.
An urgent CT brain showed left-sided acute/subacute subdural hematoma (SDH). Blood was hypodense anteriorly (yellow arrows), and hyperdense posteriorly (red arrows). There was an evidence of mass effect with mild midline shift and mild effacement of ipsilateral lateral ventricle. This could be suggestive of subacute SDH (arbitrarily defined as SDH of 4-21 days duration). However, duration of symptoms in this case was 48 hours, and therefore, a diagnosis of acute SDH was made (acute SDH is defined as symptoms of 0-4 days duration).
A diagnosis of left fronto-parietal acute SDH causing right hemiplegia and aphasia was made. Patient was referred to Neurosurgeon for evacuation of hematoma.
Conclusion: Acute SDH should always be considered in the differential diagnosis of acute stroke. Emergency surgery can reverse the clinical symptoms. Older people have a higher risk of developing SDH due to rupture of bridging veins in subdural space, as the veins are over-stretched due to cerebral atrophy.