MunteanuV_Differential


 

 

 

 

 
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Differential diagnostic problems in elderly chronic 

subdural hematoma patients 

Valentin Munteanu1, Ionut Luca-Husti2, Teodora Camelia Coman1, 

Alexandru Vlad Ciurea2,3 

1“Bagdasar Arseni” Emergency Hospital, Bucharest 
2Sanador Clinical Hospital, Bucharest 
3“Carol Davila” University of Medicine and Pharmacy, Bucharest 

 
Abstract: Chronic subdural hematomas (CSDH) are recognized as common in older 

people (over 70 years). They are produced in minor injuries (falls on the same level). 

These CSDH have minor symptoms (headache, memory disorders, balance disorders, 

cognitive disorders, etc. and are classified as signs for the onset of dementia, circulatory 

failure - basilar vertebra, Alzheimer, etc. A simple brain CT scan can highlight these 

hematomas and a neurosurgical intervention will achieve extremely favorable prognosis. 

There are many pitfalls in the differential diagnosis of CSH especially with strokes being 

so common at this age. 

Key words: chronic subdural hematoma, older patients, CT scan, GCS, GOS, and 

neurosurgery 

 
Introduction 

Diseases with surgical recommendation in 

elderly patients, especially for those over 70 

years old, involve significant risks both 

surgically and anesthetically, given the 

associated  rich pathological context, as well as 

a very likely reduction in the body`s available 

capability to recover after as a resource-

consuming event, as surgery. 

The most common diseases of the elderly 

are obvious and indisputable, cardiovascular 

diseases accompanied by disorders of lipid 

metabolism with formation of atheroma 

plaques, leading most often to ictal 

neurological pathology like the hemorrhagic 

or ischemic strokes. In neurovascular 

pathology, the transitory ischemic stroke is an 

event that foresees severe lesions with 

permanent effects that can present itself later 

on. 

These considerations determine a more 

aggressive therapeutic approach from the 

neurological medical community in order to 

prevent events with significant consequences. 

In the case of neurosurgical pathology of 

these patients an important place is occupied 

by the chronic subdural hematoma. The main 



 

 

 

 

 
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etiological factor in the occurrence of subdural 

hematic collections is obviously the traumatic 

brain injury, but in the case of chronic 

subdural hematoma the traumatic factor is 

often unrecognized by patients or persons 

around them. The reason is that the traumatic 

event has taken place usually far away from the 

moment of the deceleration of the collection 

(usually at least 3 weeks) and the trauma is 

usually minor and overlooked immediately 

after production. 

The reasons favoring this particular type of 

intracranial fluid accumulation are related on 

one hand to the age-related involution of the 

brain parenchyma with subsequent atrophy 

and increased peri-cerebral spaces and on the 

other hand the long-term use of 

antithrombotic medication such as aspirin or 

other anticoagulants in the context of very 

likely associated  cardiovascular diseases, 

which implies a more difficult hemostasis in 

case of any lesion in the “bridging” dural veins 

tensed the by reduction of the volume of the 

cerebral parenchyma. 

The most commonly used diagnostic 

method is computed tomography imaging 

which brings enough information to establish 

a diagnosis and a suitable treatment plan. 

Chronic subdural hematomas occur classically 

under the form of a crescent hypo-dense 

collections located extra axially with mass 

effect on the adjacent brain parenchyma. 

Depending on the time elapsed from the initial 

bleeding until the diagnosis the images can be 

different in relation to the adjacent 

parenchyma. This describes three phases of 

evolution: the first 7 days of collection has a 

hyper-dense appearance corresponding to the 

acute phase of bleeding, then for approx. 2 

weeks iso-dense collection compared to the 

brain parenchyma, followed only after the 

third week of evolution to be described as 

having the classical hypo-dense fluid 

accumulation. Thus between the first and 

third week of chronic subdural hematoma 

bilateral evolution can be very difficult to see 

on the native CT imaging, especially because 

the midline structures might not be deflected 

in this case. 

Clinical symptoms that determines the 

patient to go to the doctor is nonspecific and 

often installs in an insidious way, some 

patients have minor symptoms. Patients may 

complain of impaired consciousness with 

sleepiness, which is associated in varying 

proportions with headache, walk and balance 

disorders, cognitive disorders, personality 

changes or motor deficit or aphasia. Often the 

onset symptoms are super-imposable on a 

clinical picture of transient ischemic stroke. 

The most common symptoms are headache, 

confusion syndrome and various degrees of 

neurological motor deficit. 

Accordingly, when the CT imaging reveals 

iso-dense subdural collection hardly 

distinguishable from the brain parenchyma 

and it will not cause a significant mass effect, 

the differential diagnosis of minor 

neurological disorders and transient becomes 

difficult. Within the neurological therapeutics 

the administration of anticoagulant and anti-

platelet medication is very important in the 

prevention of acute ischemic events. A major 

disadvantage of taking this type of medication 

is that it predisposes to bleeding complications 

if the patients must undergo major surgery. 



 

 

 

 

 
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The latter must be timed according to the 

medication administered, for varying time 

intervals that can reach up to several days. 

These delays in adopting surgical treatment 

solutions may have important consequences 

for the affected patients. On the other hand the 

administration of anticoagulant and anti-

platelet therapy may increase the volume of 

intracranial hematic collections with the 

worsening of the accompanying neurological 

phenomena. 

Material: case presentation 

In the following we want to present the case 

of a 72 years old patient with known 

hypertension in treatment, accusing short 

speech disorder episodes of “verbal barrage”, 

which were resolved at a minimum diuretic 

therapy, the allegations were recorded for 

approx. 2 weeks. 

The medical history revealed the existence 

of a head injury secondary to an accident, 

approx. 1.5 months prior to the installation of 

the symptoms. The injury was considered 

minor, followed by easy and fast reversible 

alteration of consciousness immediately 

posttraumatic with no obvious cranial trauma 

signs. The patient initially addressed the service 

of Neurology, where the patient`s complaints 

were interpreted as the manifestation of 

transient ischemic strokes and was prescribed 

anti-platelet treatment with Plavix. It is worth 

noting that the neurological consult ran a 

cerebral CT scan showing a subdural collection 

in the left cerebral hemisphere, without an 

obvious compressive character and was not 

considered to be an important factor of the 

symptom (Figure 1). 

 
Figure 1 – A.M. – CT aspect at admission 

 

Given the absence of a favorable response 

to therapy by repeating the symptoms present 

at admission, the neurologist guided the 

patient to get a neurosurgical consult. After 

analyzing the CT imaging presented by the 

patient it is decided to adoption of a surgical 

therapeutic solution to evacuate the visualized 

collection. Considering the introduction of 

treatment with Plavix earlier, the surgical 

therapeutic solution, even if it involves a 

minimally invasive approach has high risks in 

terms of bleeding. For this reason it was 

decided to stop the Plavix treatment for at least 

7 days before surgery and replaced with low 

molecular weight heparin with clinical 

supervision to highlight any worsening of 

neurological status of the patient. 

Surgery was performed safely, 7 days after 

discontinuation of anti-platelet medication, 

evacuating the collection through two drill 

holes and abundantly irrigating the subdural 

space (Figure 2). 



 

 

 

 

 
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Figure 2 – A.M. – CT native aspect 24 hours post 

operatory 

 

Post operatory, given the associated 

pathology of the patient, she was monitored 

within the first 24 hours in the intensive care 

unit. The evolution was favorable with the 

relief of the neurological symptoms without 

repeating the episodes of verbal barrage. 

We can say that surgery was postponed 

with more than two weeks from the moment 

of the first consultation with the intention to 

minimize the potential irrigative effect of the 

CT visualizations – even though a little 

compressive - corroborated with a possible 

„illusion” of the symptomatologycal 

interpretation seen through “the lens” of the 

known pathology treated as it currently is.  

This case had, fortunately, a very favorable 

evolution, with restoration of the optimal 

neurological functionality. However, by 

adopting – for a longer time period – of the 

wrong therapeutic attitude, it could have 

evolved towards severe neurological deficits. 

(Figure 3). 
 

 
Figure 3 – 3 days after surgery, patient discharged 

Discussion 

Chronic subdural hematoma (CSDH) is 

one of the major co-morbidities in elderly 

resulting in disability and death. Early 

recognition of CSDH is important for early 

management. However, manifestations of 

CSDH are nonspecific and subtle (8, 9).  

Mixed density of CSDH on radiological 

investigations results from multiple episodes 

of trauma, usually in the aged. Although there 

were membranes within the mixed density 

hematomas, burr-holes were usually enough 

to drain the hematomas (6).  

Surgical evacuation is the basis of 

management for symptomatic patients or 

hematomas exerting significant mass effect. 

Although burr whole craniotomy is the most 

widely practiced technique worldwide, 

approximately 10-20% of surgically treated 

patients experience postoperative recurrence 

necessitating reoperation (2). Recurrence rates 



 

 

 

 

 
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in single and double-burr-hole groups were 

6.15% and 4.83% respectively, which was not 

statistically significant. Most of the subdural 

hematomas can be dealt by single burr-hole 

drainage (4). Trepanation may be superior to 

craniotomy as primary surgery for sub-acute 

and chronic hematomas (1).   

A study on 45 patients 70 years of age or 

older relives that there was a significant 

improvement in the neurological status of 

patients from admission to follow up as 

assessed using the Markwalder grading scale, 

yet no improvement in functional outcome 

was observed as assessed by Glasgow Outcome 

Score (3). Surgery for CSDH is safe and 

positively recommended even in super-aged 

patients over 90 years old if the patient's 

physical status is fair. Pre-illness status is the 

most important factor for considering 

operative indications and represents a limiting 

factor for postoperative outcomes in this age 

population (7).  

Results of a new study on patients with 

anti-platelet therapy (recurrence occurred 

8.9%, one of the lowest rates in the literature) 

relives the safety of early surgery for patients 

on the preoperative anti-platelet therapy 

without drug cessation or platelet infusion. 

Patients with a previous history of infarction 

may need to be closely followed regardless of 

anti-platelet or anticoagulant therapy (5).  

Conclusions 

We believe that the presence of peri-

cerebral fluid collections which indicate the 

presence of a chronic subdural hematoma in 

the cranial-cerebral imaging investigations, 

should lead to the advice and guidance of the 

patients to a neurosurgical therapeutic 

attitude, prior to the initiation of therapy with 

anticoagulant or anti-platelet visa which may 

worsen the neurological status of the patients 

through the potential effect of augmentation 

of the collection by recurrent bleeding and 

difficult self-limiting of the bleeding. 
 

Correspondence 

Prof. Dr. A.V. Ciurea 

E-mail: prof.avciurea@gmail.com 

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