| Summary: | Introduction: A subdural haematoma is an accumulation of blood between the brain and its surrounding dural covering which acts as a space-occupying lesion causing increased intracranial pressure and cerebral compression. Chronic subdural haematomas (CSDH) differ from acute subdural haematomas in so far as occurring mainly in the elderly. A history of direct head trauma is absent in upto 50% of cases.
Case report: A 64-year old man, presented to the emergency centre with a sudden onset of right leg weakness. He initially denied any head injury but later recalled a minor head injury some weeks prior. Half an hour after presentation, his weakness progressed to a complete quadriparesis, while his sensory function remained intact and two hours after presentation he developed a complete flaccid quadriplegia. A CT scan was performed and revealed bilateral CSDH. Bilateral posterior and frontal burr holes were made under local anaesthesia, and 100 ml of blood was evacuated. Clinical improvement was almost immediately noted. After two days, his neurologic examination was without any abnormality.
Discussion: CSDH is more common in the elderly. As reported here, clinical features may be delayed after the causal head injury (often weeks), and the trauma may even be forgotten. Cases manifesting bilateral haematomas are quite rare. The mechanism for quadriparesis is not fully understood. Motor deficit in the arms can be explained by direct compression or distortion of the cerebral hemispheres. This would not, however, account for motor weakness in the legs because the cortical areas responsible for the lower limbs would be relatively protected from the direct effect of compression. CSDH can present in many clinical scenarios, and may develop in the absence of a reported head injury. The diagnosis of CSDH should be considered in the differential when investigating cases of quadriplegia of uncertain aetiology, especially in the elderly population.
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