Hemaoma

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Neurology

Subdural hematoma
Presentation and management in older adults
Bernard Karnath, MD

Subdural hematomas pose diagnostic and therapeutic difficulties in older adults. Presenting signs and symptoms of subdural hematomas—headache, confusion, ataxia, and hemiparesis—can mimic other diseases such as dementia, stroke, transient ischemic attacks, neoplasm, and normal pressurehydrocephalus. Patients with subdural hematomas and focal neurologic signs should be considered for surgical intervention, whereas asymptomatic patients or patients with only complaints of a headache can be managed medically or followed with serial neuroimaging by computed tomography. Patients who have been chronically anticoagulated pose a dilemma when they present with a subdural hematoma.
Karnath B.Subdural hematoma: Presentation and management in older adults. Geriatrics 2004; 58(July):18-23.

Key words: Chronic subdural hematoma • anticoagulation • falls atrial fibrillation

ubdural hematoma in older patients raises diagnostic and therapeutic difficulties. Acute subdural hematomas, which are clinically evident (ie, symptomatic) within 72 hours, usually occur in younger adults. Chronicsubdural hematomas, which usually occur in older individuals with a peak incidence in the sixth and seventh decades of life, are defined as hematomas of more than 20 days of age (typically determined by patient history).1 The incidence of chronic subdural hematoma is approximately 1 in 100,000 population per year; incidence increases to approximately 7

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cases per 100,000 population per year inthe age 70 to 79 group.2 Significantly, subdural hematoma is a reversible cause of dementia.3
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pulse 86 bpm, temperature 36.8oC, and respirations 18/minute. Physical exam is remarkable for a fluctuating mental status, consistent with a delirium. He is somewhat lethargic during examination but cooperative. At other times, he is oriented to place and time. He is normocephalic and withoutevidence of trauma. Pupils and extraocular muscles are intact. Funduscopic exam is difficult secondary to bilateral cataracts. Cranial nerves II through XII are intact. The patient’s gait is unsteady. His motor exam reveals 4/5 strength in the left upper and left lower extremity. Computed tomographic (CT) imaging of the brain is shown in figure 1.
Case #2 A 68-year-old woman with chronic atrialfibrillation (AF),congestive heart failure, and hypertension presents with a oneweek history of worsening headaches. The patient has been on warfarin 5 mg/d for the past 5 years with the international normalized ratio (INR) maintained between 2 and 3.The patient states that she fell on her buttocks two weeks prior to presentation but denies any head trauma. Vital signs on presentation are blood pressure145/90 mmHg,pulse 86 bpm, temperature 37.6oC, and respirations 16/minute.The patient was alert and oriented to time,place,and person.Cranial nerves II through XII are intact. Funduscopic exam is difficult due to bilateral cataracts. The patient’s gait is not impaired. Her strength is 5/5 throughout

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Figure 1 CT scan of subdural hematoma (A) involving right hemisphere. Note the midlineshift (B), blunting of sulci (C), and edema (D). (Visit www.geri.com for a larger image.) Source: Scan supplied by author.

Dr. Karnath is assistant profes-

sor of medicine, University of Texas Medical Branch at Galveston, Tx.

For Client Review Only. All Rights Reserved. Advanstar Communications Inc. 2003

Disclosure: The author has no real or apparent conflicts of interest related tothe content presented here. 18

Case #1 A 64-year-old man presents with a onemonth history of gait ataxia, urinary incontinence, and altered mental status. His past medical history is unremarkable with the exception of chronic alcohol abuse.Vital signs on presentation are blood pressure 110/80mmHg,

Geriatrics

July 2004 Volume 59, Number 7

with equal deep tendon reflexes. Heart exam...
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