The New England Journal of Medicine

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D
C

Subdural Hematoma
A 76-year-old man with hypertension and a history of stroke reported headache, difficulty walking, and loss of appetite.
He denied using alcohol, having a recent fall, or being assaulted. The initial neurologic examination demonstrated slowed
speech, disorientation, somnolence with right homonymous hemianopia, right-sided facial droop, right-sided paresis with
marked spasticity, and a flexion contracture of his right arm. Within hours, he became obtunded and his blood pressure
rose. Unenhanced computed tomography showed a subdural hematoma with a blood–fluid level (A). The right lateral ven-
tricle was markedly compressed and shifted across the midline (B). There was diffuse edema throughout both hemispheres,
but the differentiation between gray matter and white matter was preserved. A small extracerebral space containing cere-
brospinal fluid was present (C), along with the calcified choroid plexus (D). The patient underwent emergency craniotomy
to evacuate the hematoma, with a remarkable recovery in ability. Nearly two months after the procedure, he was alert and
oriented, with intact cognitive function. His speech was nonfluent, with paraphasic stuttering. The right-sided paresis re-
mained, but he had regained full use of his left side and could walk 3 m (10 ft) with a rolling platform walker.

JEFFREY HURWITZ, M.D.

Hospital of the University of Pennsylvania
©1997, Massachusetts Medical Society. Philadelphia, PA 19104

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