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Clinical Neuroscience News, February 2013

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Case Study: Subdural Hematoma with Diffuse Axonal Injury

Rick Madhok, MD

A 60-year-old woman was found unresponsive at home, presumed to have sustained a severe closed TBI due to a fall. Rushed to the ER by ambulance, her GCS was a critically low six. A CT scan showed a large subdural hematoma with resulting cerebral swelling and herniation, though much of the blood collection within appeared to be old, as though the primary injury had occurred several days earlier. The resulting compression had caused the brain to undergo a large midline shift, and an emergency craniotomy was performed. Re-expansion of the brain was nearly complete 24 hours later.

Postoperatively, the patient showed some improvement in pupil reactivity as well as in facial motor responses, but issues of functional connectivity, visible on a series of fMRIs, continued to indicate underlying structural damage to white matter associated with diffuse axonal injury and cognitive impairment.

The patient was eventually moved to a sub-acute facility where she initially showed little improvement beyond withdrawal motor responses. By month five, however, when it was time for her to be readmitted to the hospital for a cranioplasty, she was able to move about in a wheelchair and to walk short distances unsupported. The patient’s skull was closed using a titanium plate.

After the procedure, her condition steadily improved, and she regained the ability to speak and could move about more easily. Her recovery exceeded the expectations of her doctors and family, and she has continued to gain strength and cognitive function since then.

Subdural Hematoma Subdural Hematoma Subdural Hematoma
CT scan without contrast showing large acute chronic subdural hematoma CT scan without contrast showing post operative left decompressive craniotomy Post-operative CT scan without contrast demonstrating crainoplasty and skull reconstruction




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