Endgames Spot Diagnosis

Headache and papilloedema in a 10 year old

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3807 (Published 14 September 2017) Cite this as: BMJ 2017;358:j3807
  1. Anan Shtaya, clinical lecturer in neurosurgery,
  2. Bassam Dabbous, consultant neurosurgeon
  1. St George’s University Hospital NHS Trust and St George’s University of London, London, UK
  1. Correspondence to Anan Shtaya ashtaya{at}sgul.ac.uk

A 10 year old girl described intense headaches at the front of her head, which had been coming and going since she banged her head two months earlier. She also described feeling sick with the headaches, and had vomited on several occasions. On examination, she had papilloedema, otherwise neurological examination was normal. She had a computed tomography (CT) scan of the head (fig 1A) followed by magnetic resonance imaging (MRI) of the brain (fig 1B). What is the relevant finding?

Figure1

Fig 1 Axial computed tomography (CT) image of the head (A), and axial T2 weighted magnetic resonance image of the brain (B)

Answer

Left subacute subdural haematoma with mass effect.

Discussion

Minor head trauma is common in children and often benign.1 The need to perform CT on patients with normal neurological examination is not usually required.2 The number of CT scans performed remains high in community emergency departments3; however, clinical decision rules include strict criteria to assess the need for imaging, aiming to reduce exposure to radiation in evaluating minor head injuries in children.23

The CT scan showed a left crescent shape isodense collection overlying the convexity of the left hemisphere, which represents a subacute subdural haematoma with midline shift and mass effect (fig 2A, arrow). The isodense collection, representing the subacute haematoma, is of similar density to brain tissue, which can make it more difficult to identify than acute (hyperdense) or chronic (hypodense) haematomas.

Figure2

Fig 2 CT (A) and MRI (B) scan images of the head, with arrows identifying subacute subdural haematoma

Patient outcome

The patient was transferred urgently to a neurosurgery unit where she had an MRI scan (fig 2B) to rule out any underlying vascular causes of the haematoma, since the injury was of low impact. The MRI confirmed the left subacute subdural haematoma (fig 2B, arrow) and ruled out any other causes.-Her blood clotting tests were normal. The patient then proceeded to have emergency drainage of the subdural haematoma with a single burr hole. She made a complete recovery. Traditionally a substantial impact is required to cause an acute subdural haematoma. However, minor head injuries have been reported to cause acute subdural haematoma in children, especially those with coagulopathies.45

Learning points

  • Clinicians should be aware of the development of subacute and chronic subdural haematoma, even following minor head injury

  • Perform suitable brain imaging if there are clinical signs of raised intracranial pressure.

Footnotes

  • We have read and understood BMJ policy on declaration of interests and declare there are no competing interests.

  • Patient/next of kin consent obtained.

  • Provenance and peer review: not commissioned; externally peer reviewed.

References

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