Archives of Academic Emergency Medicine. 2023; 11(1): e37

PH OTO QU I Z

An 85-Year-Old Man with Gradual Decrease in the Level of
Consciousness and Vomiting; a Photo Quiz
Talayeh Mirkarimi1∗, Mohammad Salek1

1. Emergency Department, Alborz University of Medical Science, Karaj, Iran.

2. Haematology, Oncology and Stem cell Transplantation research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran,
Iran.

Received: March 2023; Accepted: April 2023; Published online: 7 May 2023

Cite this article as: Mirkarimi T, Salek M. An 85-Year-Old Man with Gradual Decrease in the Level of Consciousness and Vomiting; a Photo

Quiz. Arch Acad Emerg Med. 2023; 11(1): e37. https://doi.org/10.22037/aaem.v11i1.2030.

Figure 1: Brain computed tomography (CT) scan of the patient

without contrast materials.

1. Case presentation

An 85-year-old male was brought to emergency department

(ED) from a nursing facility with gradual onset of lethargy

and vomiting from a week ago. No clear history of head

trauma and coagulopathy or using of anticoagulant agents.

His past medical history included mild cognitive impairment

(MCI) and diabetes mellitus, which were treated using

∗Corresponding Author: Talayeh Mirkarimi; Alborz University of Med-
ical Sciences, Taleghani Blvd, Taleghani square, Karaj, Iran. Email:
t_mirkarimi@yahoo.com, ORCID: https://orcid.org/0000-0002-3644-3925.

oral agents. On general examination, the patient looked

underweight with body mass index (BMI) about 17. Neither

specific stationary position of the limbs nor any spontaneous

motor behavior were detected. The patient’s vital signs on

admission to ED were: Blood pressure: 140/60 mmHg, pulse

rate: 82 beats/minute, oxygen saturation: 95%, Respiratory

Rate: 16/minute, and bedside blood-glucose measurement:

268 mg/dl. The patient was afebrile. On neurologic exam-

ination in ED, Glasgow coma scale (GCS) was 10/15 (eye:

3, motor: 5, verbal: 2). Mucosal membranes were dry and

patient seemed to be dehydrated. Pupils were equal but

had poor reaction to light. Oculocephalic maneuver, corneal

reflex, and gag reflex were intact. There was slight decrease

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T. Mirkarimi & M. Salek 2

in muscle tones in lower limbs. Plantar reflex on both sides

seemed upright. Arm and Leg dropping test showed equal

motor response and deep tendon reflexes (DTR) seemed

diminished on both sides. Laboratory tests included: leuko-

cyte count: 12800/mm3 with 85% segmented neutrophils,

hemoglobin: 14.1 g/dl, platelet: 268000/microliter, glucose:

234 mg/dl, sodium: 141 mEq/L, potassium: 5.1 mEq/L,

Blood Urea Nitrogen (BUN): 36 mg/dl, serum creatinine: 1.3

mg/dl, and international normalized ratio (INR) was 1.24.

The patient underwent brain computed tomography (CT)

scan without contrast materials, which is shown in Figure 1.

What is your diagnosis?

1.1. Diagnosis

Bilateral subdural hematoma with bilateral hematocrit effect

(figure1) without any midline shift or patency in basal cis-

terns.

1.2. Case fate

The patient underwent bilateral burr-hole insertion, which is

shown in Figure 2. Clinical and neurological conditions did

not improve after surgery. Unfortunately, the patient died 10

days after surgery due to intubation complications.

2. Discussion

Chronic subdural hematoma (CSDH) is common in older

adults, particularly after mild head trauma. This condition is

caused by the accumulation of blood or blood derivatives in

the subdural space and is usually known as a benign disease

(1). The prevalence of CSDH is increasing throughout the

world due to the ageing population. The peak age of CSDHs

onset has also increased and is regarded as a serious pub-

lic health problem (2). CSDH symptoms vary from asymp-

tomatic to a clear loss of consciousness and usually become

symptomatic more than two weeks after the initial trauma.

CSDH symptoms include cognitive deficits, impaired mem-

ory, personality changes, and focal neurological signs. Since

CSDH can imitate many neurological conditions, it is re-

ferred to as the Great Neurologic Imitator (3). Many fac-

tors are currently considered effective in CSDH in elderly pa-

tients, including, older age, alcohol usage, diabetes mellitus

(DM), coagulopathy, antiplatelet and anticoagulant agents,

and arachnoid cyst also rarely reported after epidural anes-

thesia (4). Dehydration and diuretic usage is another risk fac-

tor that implicates the occurrence and recurrence of CSDH

(5). Obesity, which is a risk factor of CSDH, is also associ-

ated with decreased mortality rate after surgical evacuation

of the hematoma (6). Bilateral CSDH is far less common than

unilateral CSDH, and its clinical and radiological characteris-

tics are scarcely known. Bilateral CSDH progresses faster and

has a higher risk of cerebral herniation, resulting in worse

outcomes than unilateral CSDH. Patients with bilateral SDH

are less likely to suffer hemiparesis than patients with uni-

lateral SDH. Moreover, the recurrence of SDH is more likely

in bilateral cases. Patients with bilateral SDH are older than

those with unilateral type, and the prevalence of alcohol use

is lower in these patients. The bilateral type is commonly

manifested with nausea and vomiting, and midline shift is

less likely in these patients. It is most frequently seen in the

setting of anticoagulation therapy or coagulopathy (7).

Hematocrit effect also called blood-fluid level and hemor-

rhagic sedimentation is a rare condition and is caused by re-

bleeding in CSDH. It is the result of the separation of heavier

cellular elements of blood located lower to a lighter liquid su-

pernatant which could be seen on CT or magnetic resonance

imaging (MRI) (8). The treatments of SDH include burr hole

craniotomy (BHC) (9), the use of corticosteroids as mono-

therapy or combined with surgery, which decreases the risk

of recurrence of CSDH and watchful waiting (10). Surgery

is carried out in symptomatic cases, size more than 10 mm,

or midline shifts more than 5 mm. Watchful waiting is ex-

ercised in patients with small, asymptomatic SDH, with no

symptoms indicating increasing intracranial pressure (2).

The prognosis is significantly worse in patients over 75 years

old compared to those younger than 75 years (7).

3. Conclusion

We should consider the CSDH as an important and probably

treatable cause of decrease in the level of consciousness in

old age, especially in patients with known risk factors.

4. Declarations

4.1. Acknowledgments

We thank Dr. Mehran Moradi, neurosurgeon who partici-

pated in case management.

4.2. Conflict of interest

TM and MS declare that they have no conflict of interest.

4.3. Fundings and supports

TM and MS received no financial support for authorship or

publication of this article.

4.4. Authors’ contribution

TM and MS both contributed to writing of this manuscript

and meet the criteria of authorship.

4.5. Ethical consideration and patient consent

Written informed consent was obtained from patient’s son

for publication of this case report and accompanying im-

age. The proposal has been approved by the Research Ethics

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3 Archives of Academic Emergency Medicine. 2023; 11(1): e37

Figure 2: Post-surgery spiral brain computed tomography scan without contrast after burr hole insertion; revealing appropriate evacuation

of subdural hematoma in both sides.

Committees of Alborz University of Medical Sciences.

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	Case presentation
	Discussion
	Conclusion
	Declarations
	References