CASE 316 Published on 26.11.2000
0

Unilateral isodense subdural hematoma

Section

Neuroradiology

Case Type

Clinical Cases

Authors

Micallef M., Gillespie J.S., Sharkey A.N.

Connected authors
Patient

62 years, male

Categories
No Area of Interest ; Imaging Technique CT, CT, CT, CT
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Clinical History
Recurrent confusion. No history of trauma.
Imaging Findings
One week prior to admission had an episode of confusion that resolved without neurological deficit. On the day of admission he had increasing headache and confusion. No history of trauma. Not taking any medications. On examination, a right sided facial weakness was noted.
Discussion
Subdural hematoma (SH) can be acute (usually hyperdense on CT), subacute (1-2 weeks after injury, isodense) and chronic (3-4 weeks after injury, usually hypodense). Up to 50% of subacute and chronic hematomata do not have a history of trauma. An acute subdural hematoma can appear isodense in anemia and clotting disorders. A chronic SH may appear isodense on CT due to recurrent acute bleeds. True isodensity is rare. High resolution images will usually show slightly abnormal attenuation with the SH. The separation of isodense collections into hypodense serum anteriorly and hyperdense blood posteriorly is enhanced if the patient supine for at least 30 minutes before the study. CT detection of isodense SH relies on effacement of sulci,ipsilateral ventricular compression, displacement of the grey-white matter away from the ipsilateral inner table and, in unilateral SH, midline shift. Intravenous contrast enhances the inner table and the cortical-subdural interface. Magnetic Resonance (MR) is the imaging modality of choice. In subacute SH it shows as a bright lesion on T1 due to the high sensitivity to met hemoglobin. Small subdural hematomata oriented in the CT plane e.g. tentorial subdurals may be missed on CT but are detected on MR.
Differential Diagnosis List
Subacute right subdural hematoma
Final Diagnosis
Subacute right subdural hematoma
Case information
URL: https://eurorad.org/case/316
DOI: 10.1594/EURORAD/CASE.316
ISSN: 1563-4086
Figure 1

CT brain, no contrast, level of the body of the lateral ventricles

CT brain, no contrast, level of the body of the lateral ventricles
There is prominent transfalcine herniation (midline shift)to the left with no apparent cause and moderate peri ventricular oedema or ischemia on the left. Note ring artefact (concentric circles seen throughout the image), a technical problem caused by CT detector miscalibration.
Figure 2

CT brain, no contrast, level just above the lateral ventricles.

CT brain, no contrast, level just above the lateral ventricles.
There are multiple small cerebral contusions and a small extradural hematoma in and around the right parietal lobe. Note again the loss of white matter around the left lateral ventricle, the midline shift and the ring artefact.
Figure 3

CT brain, iv contrast, level of the temporal horns of the lateral ventricles

CT brain, iv contrast, level of the temporal horns of the lateral ventricles
Note midline shift,effacement of sulci and ipsilateral ventricular compression.Intravenous contrast enhances the inner table and the cortical-subdural interface. This is a feature of an isodense subdural hematoma.
Figure 4

CT brain, iv contrast, level of the bodies of the lateral ventricles

CT brain, iv contrast, level of the bodies of the lateral ventricles
Note midline shift,effacement of sulci and ipsilateral ventricular compression, other features of isodense unilateral subdural hematoma.
Figure 5

CT brain,iv contrast, level just above the lateral ventricles.

CT brain,iv contrast, level just above the lateral ventricles.
Note the small hemorrhage on the right and the disproportionate midline shift to the left.