A 24 yo man, cannabis smoker, had head trauma 2 months ago. Cranial CT showed an acute subdural hematoma 0.5 cm thick over the left hemisphere, with midline shift. In spite of that, in the following days he was asymptomatic. Neurosurgeons decided not to evacuate the blood collection. One month later the patient was still doing well except for a light headache and the image hadn't changed. After that he began with increasing head pain and a third CT performed 10 days ago showed the left subdural collection, now hypodense, persistence of 0.5 cm left to right midline shift, and postcontrast marked enhacement of tentorium with a suggestion of an empty delta sign. MRI has confirmed superior sagital and left transverse sinuses thrombosis.
Neurosurgeons have asked for a neurologist's opinion because they believe that the subdural hematoma has not enough volume to produce intracranial hypertension by itself (patient has bilateral papilledema without other findings on PE), and they are still reluctant to operate.
The neurologist who has seen the patient presented the case in our clinical round seeking a consensus in management, but he couldn't get it. Some think that the hematoma should be evacuated immediately. While others believe that the priority is to treat the intracranial hypertension leaving the hematoma alone. Someone even proposed anticoagulation in order to prevent further progression of the dural thrombosis.
We agreed that both, hematoma and dural sinuses thrombosis are helping to raise intracranial pressure, but there wasn't further agreement on what to do.
I would like to hear your comments on the management of these two well known complications of head trauma, not so frequently associated though. The following are the CT-scans and MRIs on this patient.
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