Development of a delayed chronic subdural hematoma 2 months after mild traumatic brain injury with a normal initial...

This is a case involving the development of a delayed chronic subdural hematoma 2 months after a minor head injury with normal clinical neurological findings and brain computed tomography at initial presentation. An 84-year-old man visited the emergency department (ED) after a minor head trauma. The patient complained of dizziness and vomiting 8 hours after an injury. He was not on an antiplatelet or anticoagulant. He did not have any abnormal findings during neurological examination, and brain computed tomography did not show any intracranial pathology or skull fractures. He was admitted to the ED short-stay ward for observation and was discharged asymptomatic and stable 12 hours later. However, he presented 2 months later with dizziness and unsteady gait. He was asymptomatic within those 2 months. At the ED, his brain computed tomography showed a large right chronic subdural hematoma, compressing the right lateral and third ventricles, with a 1.2 cm midline shift, subfalcine and uncal herniations, and early hydrocephalus. An emergency burr-hole evacuation was performed. He was discharged without neurological deficit 3 days later. Emergency physicians attending to patients with normal neurologic examination and initial brain computed tomography after suffering a mild traumatic brain injury should be vigilant for a chronic subdural hematoma should the patient re-present for evaluation subsequently. The attending physician may be biased as patients could have symptoms attributed to postconcussion syndrome that may overlap with symptoms of chronic subdural hematoma. Unsteady gait and ataxia are uncommon clinical signs of postconcussion syndrome and should prompt the physician to consider a repeat brain computed tomography.