AN UNUSUAL CASE OF SUBDURAL HAEMATOMA Theuns van Jaarsveld 28 January 2009

CASE REPORT A 21 yr old male attended the emergency department after “sustaining” a head injury the previous day He was playing football and had headed the ball several times in a row After this he started to develop a headache but was able to finish the football game

The following day he still had the headache and went to his local emergency department No loss of conciousness was reported after the incident or any other neurological symptoms

ON EXAMINATION He was alert and fully orientated Pupils equal and reactive to light No focal neurology found in limbs He was given advice on concussion and analgesia and discharged

He re-attended the emergency department 2 weeks later complaining of persistent headaches Again no focal neurology was found and he was given further advice on analgesia and discharged

3 weeks after the initial injury he re- attended complaining of headaches He had vomited 1 time during the previous day and had transient episodes of blurred vision In view of the persistent symptoms, despite the triviality of the original injury, a CT scan of the head was done

CT SCAN

CT SCAN Bilateral chronic subdural haematomata Mild frontal oedema Left middle cranial fossa arachnoid cyst The case was discussed with neurosurgery and a MRI scan was done of the head

MRI SCAN

He was reviewed at the neurosurgery OPD and it was decided to drain the cyst surgically He made an uneventfull recovery

DISCUSSION Intracranial arachnoid cysts account for about 1% of IC space occupying lesions They are non-tumorous congenital sacs lined with an arachnoid-like membrane and filled with CSF like fluid Pathologically they can increase in size, remain the same or completely resolve

SUGGESTED EXPLANATION FOR INCREASE IN SIZE Unidirectional flow through a ball-valve opening in the wall with trapping of CSF in the cyst Active secretions of fluid by cells lining the cyst wall Most common site is the middle cranial fossa

SIGNS AND SYMPTOMS Compression on surrounding tissues by the cyst Most common Sx and Sx – Increased ICP - Craniomegaly - developmental delay

CHILDREN - craniomegaly - seizures - psychomotor retardation ADULTS - headaches - seizures - focal neurological deficits

COMPLICATIONS Acute increase in cyst size Subdural effusion after rupture Subdural or intra-cyst bleeding DIAGNOSES - CT or MRI PROGNOSIS- untreated arachnoid cysts may cause permanent neurological damage because of progressive expansion or haemorrhage but with trratment most individuals do very well

Pasients who re-attend after minor head injuries represent a high risk group of pasients in whom a CT scan usually yield a positive scan in 14 % of cases CT scans in these pasients may pick up previously asymptomatic neurological conditions such as aneurysms, abcesses or tumours or unexpected pathology such as a chronic subdural