Practice Easily Missed?

Subdural haematoma in the elderly

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1682 (Published 11 March 2014) Cite this as: BMJ 2014;348:g1682
  1. Elizabeth A Teale, clinical senior lecturer1,
  2. Steve Iliffe, professor of primary care for older people2,
  3. John B Young, professor of elderly care medicine1
  1. 1Academic Unit for Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, Bradford BD9 6RJ, UK
  2. 2Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
  1. Correspondence to: E A Teale Elizabeth.Teale{at}bthft.nhs.uk
  • Accepted 20 December 2013

An 84 year old woman with a history of postural hypotension and frequent falls presented with a two week history of confusion and wandering. Her general practitioner diagnosed delirium secondary to a urinary tract infection on the basis of a positive urinary dipstick test for white blood cells and nitrites. She failed to improve with oral antibiotics and was admitted to hospital for further assessment. Clinical examination showed a lack of focal neurological signs but cranial computed tomography revealed a left sided chronic subdural haematoma.

What is a subdural haematoma?

A subdural haematoma results from tearing of the veins linking the cerebral cortex and the dural sinuses, causing blood to accumulate between the dura and arachnoid maters. Brain atrophy associated with ageing or dementia stretches these fragile veins such that they are more prone to tearing after relatively trivial (and often forgotten) head injury1; in up to half of cases there is a history of fall without head trauma.1 2 3 Over time, there is fibrin deposition and organisation of the haematoma, resulting in a chronic subdural haematoma. Neovascularisation processes within the subdural haematoma increase the propensity for acute or chronic bleeding.4 Anticoagulation increases the risk of subdural haematoma and the likelihood of fresh bleeding into an established haematoma.4

How common is subdural haematoma?

  • The incidence of chronic subdural haematoma increases with age1

  • Case series data from 1996 to 1999 estimate the incidence of chronic subdural haematoma in over 65 year olds at 8.2/100 000/year.5 A recent retrospective case series study from Japan reports the incidence of chronic subdural haematoma in older people to be 76.5/100 000/year in 70-79 year olds and 127/100 000/year in those aged ≥80.6 These higher estimates may reflect better access to diagnostic imaging

  • Two high quality randomised controlled trials estimate absolute rates of chronic subdural haematoma for …

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