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NewYork-Presbyterian Hospital Psychiatry
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Case of the Month 07/06

55 year old male presented to ED complaining of a headache for 2 days with associated dizziness but no nausea or vomiting. He had fallen down a flight of stairs 4 days previously. At that time, he was seen at an outside hospital and was discharged without any imaging studies being done.

Q: If you were told that the fluid within the crescent-shaped area on the patient’s right side of the head CT was isodense to CSF, what would be your two leading diagnoses?
View answer

The lesion could be either a chronic subdural hematoma or a subdural hygroma. A subdural hygroma is an excessive collection of CSF in the subdural space which is typically caused by a traumatic tear of the arachnoid membrane which allows CSF to leak from the subarachnoid space to the subdural space. Some of the other possible etiologies of subdural hygromas are excessive dehydration and rapid decompression of the ventricular system after shunting. They are typically small and asymptomatic and usually resolve spontaneously without neurosurgical intervention.

Q: What imaging study can differentiate these two diagnoses?
View answer

MRI can differentiate a chronic SDH from a subdural hygroma. In this case the head CT was read as “crescentic hypodensity along the right frontoparietal extraaxial region which measures fluid density suggestive of a cystic hygroma or chronic subdural hematoma.” A repeat head CT was done after 12 hours and when the patient remained stable, he was discharged home with close outpatient follow up.

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