An 80-year-old woman is brought to the emergency department due to progressive confusion, generalized weakness, and unsteadiness for the past several days. The patient had a right femoral fracture 4 months ago and underwent hip surgery. She has been using a walker to ambulate since coming home from a physical rehabilitation facility 3 weeks ago. She has had no fever, chest pain, vomiting, diarrhea, or dysuria. The patient's medical problems include hypertension, hyperlipidemia, coronary artery disease, transient ischemic attack, and persistent atrial fibrillation. Her medications include aspirin, warfarin, metoprolol, and a statin. Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 72/min and irregular, and respirations are 14/min. CT scan of the head without contrast is shown below. Which of the following is the most likely cause of this patient's condition?

Question

An 80-year-old woman is brought to the emergency department due to progressive confusion, generalized weakness, and unsteadiness for the past several days.  The patient had a right femoral fracture 4 months ago and underwent hip surgery.  She has been using a walker to ambulate since coming home from a physical rehabilitation facility 3 weeks ago.  She has had no fever, chest pain, vomiting, diarrhea, or dysuria.  The patient's medical problems include hypertension, hyperlipidemia, coronary artery disease, transient ischemic attack, and persistent atrial fibrillation.  Her medications include aspirin, warfarin, metoprolol, and a statin.  Temperature is 37.2 C (99 F), blood pressure is 140/90 mm Hg, pulse is 72/min and irregular, and respirations are 14/min.  CT scan of the head without contrast is shown below.  Which of the following is the most likely cause of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d5cf_43f8_bc81_3bc4c4d2c57c_MD0003_00 This patient has an acute subdural hematoma (SDH), which occurs when traumatic shearing forces cause tearing of the bridging veins, leading to slow bleeding into the subdural space. Patients with cerebral atrophy (eg, advanced age, alcohol use disorder) are at a higher risk of developing SDH as the bridging veins must traverse a longer distance, thereby becoming more susceptible to tears. The use of anticoagulants (eg, warfarin) can also increase bleeding risk. This elderly patient's gait instability and recent hip fracture raise suspicion for falls and traumatic head injury. acute subdural hematoma (SDH) Symptoms of acute SDH usually develop gradually 1-2 days after the initial injury and often include impaired consciousness, confusion, or symptoms of intracranial hypertension (eg, headache, nausea/vomiting). Noncontrast head CT scan typically shows a crescent-shaped hyperdensity that crosses suture lines. Small hematomas are managed conservatively whereas larger ones causing neurologic deficits require urgent surgical evacuation. (Choice A) Cardioembolic stroke can occur in the setting of atrial fibrillation when a left atrial thrombus dislodges and occludes a cerebral artery. Patients typically have sudden-onset neurologic deficits that may follow a stuttering course. Neuroimaging classically shows multiple lesions at the grey-white matter junction. Cardioembolic stroke (Choice B) Chronic hypertension causes hyalinosis of small penetrating branches of the major cerebral arteries, leading to lacunar stroke. This typically affects deep brain structures (eg, basal ganglia, thalamus, internal capsule). Due to their small size, lacunes are often not appreciated on noncontrast CT scans obtained shortly after the event. (Choice C) Normal-pressure hydrocephalus is the result of decreased cerebrospinal fluid resorption by the arachnoid granulations. Symptoms include progressive gait difficulties, cognitive disturbances, and urinary incontinence. Neuroimaging reveals ventricular enlargement that is out of proportion to sulci enlargement. Normal-pressure hydrocephalus (Choice D) Middle meningeal artery injury usually results from trauma to the sphenoid bone and causes an epidural hematoma, which appears as a biconvex hematoma on CT scan. epidural hematoma (Choice E) Subarachnoid hemorrhage typically occurs due to a ruptured saccular aneurysm and presents with thunderclap headache associated with brief loss of consciousness and meningismus. Head CT scan shows acute hemorrhage between the arachnoid and pia mater. Subarachnoid hemorrhage (Choice F) Diffuse axonal injury is the result of traumatic acceleration/deceleration shearing forces that diffusely damage axons in the brain. Patients typically have coma, and head CT scan may show diffuse small bleeds at the grey-white matter junction. Diffuse axonal injury (Choice H) Posterior cerebral artery thrombosis results in an occipital ischemic stroke, which typically presents with contralateral homonomous hemianopia with macular sparing. occipital ischemic stroke (Choice I) A tumor originating from the arachnoid cap cells is called a meningioma. These extra-axial, well-circumscribed, dural-based masses can be partially calcified on neuroimaging. Patients may present with headache, seizure, and focal neurologic deficits due to mass effect. meningioma Educational objective: Subdural hematoma results from the rupture of bridging veins, most commonly from head trauma. Risk factors include advanced age and chronic alcoholism (due to brain atrophy), as well as anticoagulant use. On non-contrast head CT scan, acute subdural hematoma appears as a crescent-shaped hyperdensity that crosses suture lines. References: Acute subdural hematoma from bridging vein rupture: a potential mechanism for growth. (http://www.ncbi.nlm.nih.gov/pubmed/24313607)

An 80-Year-Old Woman Is Brought to the Emergency Department Due