• Twitter
  • Facebook
  • Vimeo
  • FCUS Courses
  • Register for FCUS Course
  • Login
Intensive Care Network
  • About Us
    • What is the ICN?
    • The ICN Story
  • Events
  • Podcast Series
    • ICN Activities
      • ICN Hot cases
      • Semantic sMatter
      • ECG Proving Ground
      • Echo Cases
      • SMACC 2013
      • ICU Radiology Cases
      • Game Changing Evidence
  • Regional Networks
    • SIN
    • BIN
  • Exams
    • Primary ANZCA
      • Pharmacology
      • Physiology
    • Primary ACEM
      • Pharmacology
      • Physiology
      • Pathology
      • Anatomy
    • Fellowship CICM
      • Notes
      • Past Papers
    • Fellowship Paeds
      • Approaches to Questions
      • Clinical Exam
      • Core ICU
      • Clinical Governance
      • Medicine
      • Surgery
    • Fellowship ANZCA
      • Notes
      • Past Papers with Answers
  • Resources
    • Links
    • The ICN meta feed
    • Reviews
      • Courses
      • Conferences
      • Websites & Blogs
      • Books & Journals
    • Clinical Resources
      • Clinical Calculators
    • Non-clinical resources
      • Research
  • Discussion Forum
    • Main Page

Radiology Case Test

Home Radiology Case Test
ICU Radiology logo

Case

History

79yo woman brought sent in by her GP for imaging. She has new onset L sided weakness. The GP is concerned about a possible stroke.

She has a history of mild cognitive impairment, mastectomy for breast cancer 3yrs earlier, ischaemic heart disease, diabetes and obesity.

She denies any trauma. Her family state she has been more confused in the last 2 weeks, but attributed this to a recent urinary tract infection.

She has a CT scan. What are the findings? What is the next course of action?

Imaging

CT Brain Results

There is a large R sided extra axial haematoma with associated midline shift. The increased density in the middle of the haematoma indicates new haemorrhage. This indicates it is in fact an acute-on-chronic bleed. Despite the biconvex shape, this is a <strong>subdural haemorrhage</strong>, since the haematoma crosses the suture lines of the skull.

Pre-existing cerebral atrophy has allowed the patient to tolerate this degree of midline shift. Her new L sided weakness likely reflects the newer onset bleed, which has exhausted her cerebral tolerance &amp; resulted in climbing intracranial pressures.

Skeptics will think this is more likely to be an extra-dural haematoma, due to the biconvex shape. However, EDHs do not cross suture lines, while subdural haematomas can cross them. SDHs most commonly form concave layer over the brain, but can be almost any shape. An EDH would be extremely rare for this patient: she is over 60yrs old (the dura becomes more adherent to the skull with age); atraumatic EDH is a very rare occurance.

What now?
  • This diagnosis needs to be discussed with the patient & her family
  • Stop +/- reverse her anti-platelet agents (for her ischaemic heart disease)
  • Avoid further anti-coagulation
  • Discuss with neurosurgical team
Resources

Radiopaedia has a wealth of resources about SDHs:

  • intracranial haemorrhage
  • what does extra-axial mean anyway?
  • subdural haematoma
  • extradural haematoma 

Life in the Fast Lane has a great basic summary of traumatic brain injury.

Monro-Kellie Hypothesis

  • Monro-Kellie 2.0 is Mark Wilson’s podcast from SMACC Gold (2014) on Intensive Care Network. He is a neurosurgeon who discusses the Monro-Kellie hypothesis & ICP monitoring.
  • Radiopaedia’s explanation of the Monro-Kellie hypothesis, with great diagrams showing what happens with various pathologies.

Share this
101. Rose on AnaphylaxisSeptic Shock: NEJM Critical Care Challenge Case 1 ANSWER
IPSN – Intensivist Parent Support Network WIN – Women in Intensive Care Network ICN UK ICN NZ ICN WA ICN VIC ICN NSW ICN QLD The ICN Story The Team Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video ECG Simulator by aclsmedicaltraining BASIC SCIENCE CLINIC Simulation Game Changing Evidence ICU Radiology Echo Guide ECHO Cases Clinical Cases EXAMHELP Jellybean Podcasts ICN Blog SMACC Video SMACC Audio Video CICM Fellowship ANZCA FELLOWSHIP PAEDS FELLOWSHIP EMERGENCY PRIMARY ANAESTHETICS PRIMARY End-o-bed-o-gram

  • About
    •  What is ICN
    •  The Team
    •  ICN NSW
    •  ICN QLD
    •  ICN VIC
    •  ICN WA
    •  ICN NZ
    •  ICN UK
  • Resources
    •  Lung US
    •  Exam Help
    •  Clinical Cases
    •  Echo Cases
    •  Echo Guide
    •  ICU Radiology
    •  Game Changing Evidence
    •  ICN Metafeed
    •  Simulation Resouces
  • Media
    •  SMACC Posters
    •  Audio
    •  Video
    •  Pecha Kuchas
  • Upskill
    •  Clinical Cases
    •  Echo Cases
    •  ICU Radiology
  • Exam Help
    •  End-o-Bed-o-Gram
    •  ICU Primary Exam
    •  CICM Fellowship
    •  ANZCA Fellowship
    •  Paeds Fellowship
    •  Emergency Primary
    •  Anaesthetics Primary

® 2023 The Intensive Care Network || All rights reserved || Disclaimer || Site Map || Contact ICN Support

Log in with your credentials

or     Create an account

Lost your password?

Forgot your details?

I remember my details

Create Account