Cannot Miss Diagnosis

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Elderly Person with Headache and Unsteadiness
Cannot Miss Diagnosis No.6

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Section Editor: Prof. T.K. Partha Sarathy

A 68 year old retired executive who consumes a fair amount of alcohol everyday came to his family practitioner with the chief complaints of spells of dizziness, headache and brief periods of unsteadiness. He fainted 3 times, for a few seconds and was able to get up and look after his work. He appeared somewhat unhygienic. He denied any history of major medical illness, surgery, trauma, anesthesia, hypertension or diabetes in the past. His BP was 128/84 mmHg. Pulse was regular with a rate of 78/mt. Cardio respiratory status was normal. Abdominal examination was normal. Peripheral pulsations were normal.


A 74 year old woman who was fairly active recently noticed that she was unable to take care of herself properly. She was not able to button up her dress dropped things from hands and felt very unsteady. Suffered from headaches more towards right side of a dull aching type and always felt tired. Her past history revealed that a few months ago, she tripped and fell down and sustained injury to her left ankle and pains in the extremities, back and head which lasted for 2 to 3 days. Her x-rays were normal and after a few days she returned back to normal activities. Her BP on arrival was 140/92 mmHg. Her blood sugar and Hb were normal. Carotid doppler studies were done which did not reveal any significant obstruction. A 58 year old chief educational officer was involved in an automobile accident and was admitted to a medical centre where several x-rays were done. Although he had some concussion of the brain in the beginning the admission and discharge CT scans of the brain failed to reveal any abnormality. 4 days after admission patient was discharged home in good general condition and with no specific complaints. After a fortnight he returned back to full normal activity. 5 months later he started to feel that he was feeling uneasy with his work and had frequent headaches. He was missing words and became emotionally disturbed often. When he came for a follow up visit a complete physical examination was performed and the patient appeared to be in good condition. His BP, pulse rate, cardio respiratory status were all within normal limits. Except for positive extensor plantar response on the right side, a complete neurological examination otherwise was negative.

In all the 3 cases stated above, the symptoms are vague. Headache, dizziness, at times brief spells of unconsciousness and unsteadiness are the symptoms. A history of trauma was not present in the first case and in the second case there was a minor trauma and in the third case even though patient had a major trauma, the 2 CT scans of the head that were done during the admission were normal. Under these circumstances it is very difficult to come to a diagnosis unless one is aware of a particular disease entity. Most physicians would think in terms of a transient ischemic attack and perhaps order carotid doppler study and even start on anticoagulant therapy. The diagnosis we are considering is “chronic subdural hematoma”. If this diagnosis is not thought about and actively investigated any treatment effort could compound the problem. Patients go from doctor to doctor and hospital to hospital with these vague symptoms and no investigation is done till patient develops a more significant symptom like epileptic fits, stupor, coma etc. Chronic subdural hematoma almost always follows a head injury which may be a trivial one and go unrecognized or unnoticed when it first happened. Even minimal trauma like hitting the head on a car door or falling down with minimal contact to the head can cause linear fractures to the skull and there may not be any acute epidural or subdural hemorrhage. Because of the normal condition when this happens this trivial injury may go unrecognized. Most patients may not even remember the injury when it had taken place. Similarly people who are on anticoagulant therapy can develop a chronic subdural hematoma. This can also happen in children at times. Usually the hemorrhage in the subdural space is due to a tear of the bridging veins of the cortex to the sagittal sinus and the leak may be a low pressure venous ooze. The bleeding may be very small and slow and gradually there may be accumulation of blood. By some process, the blood clot gets absorbed leaving behind a collection of fluid, which may at times look like crank-oil. At times the fluid is clear. Slowly this accumulation of fluid will enlarge and cause problems similar to any space occupying lesion. As the enlargement is slow the symptom development also may be insidious in onset. The scenario that one has to keep in mind falls into the following categories:0

1. Elderly person with demineralized bones
2. Alcoholic who may get injured and not aware of it
3. People on anticoagulation therapy
4. Some one who has had head injury before and was admitted and CT scans done were negative, but symptoms started after a few weeks to months.
5. Occasionally infants and children due to fall injuries and child abuse.

Diagnosis
Awareness of the condition based on a careful history and good neurological examination including plantar response and pupils usually will give some indications. A CT scan of the brain under these circumstances will clinch the diagnosis.

Treatment

Treatment of this condition is essentially surgical. Once the problem is identified a neurosurgeon has to be consulted. Drainage of fluid is effected by the neuro surgeon in one of different ways. In children using a needle through frontonnelle he may be able to decompress the collection. In an adult a formal craniotomy or making burrholes for adequate evacuation can be done.
Once successfully treated patient returns back to normal. Chronic subdural hematoma is a condition which every family practitioner should be aware of and should actively pursue the diagnosis when in doubt. Prompt treatment is indeed a rewarding experience.

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Monte 

probably i m also facing the same problem since yesterday, so can you tell me about the duration until which such torsions in testes are reversible. please reply me quickly. here also the swelling is observed first time in my 19 years & is a bit painful too.

soroush 

it was better if you mentioned that his pain was acute onset or not

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