BRAIN INJURY , 2001, VOL. 15 NO. 4, 371± 376 Case Study Unilateral spatial neglect associated with chronic subdural haematoma: a case report S H I N I C H I R O M A E S H I M A y, T O M O K O M A T S U M O T O y, A K I T A K A U E Y O S H I y, M A R I K I T A Y A M A z, N A O Y U K I N A K A O z, KUNIO NAKAIz and TORU ITAKURAz y Department of Physical Medicine and Rehabilitation; and z Department of Neurological Surgery, Wakayama Medical University, Wakayama, Japan (Received 26 June 2000; accepted 10 August 2000 ) A 69-year-old right-handed man who exhibited unilateral spatial neglect in association with a chronic subdural haematoma, presented with mild left arm and leg weakness first noted 4 weeks prior to admission. Neurologic examination on admission revealed a mild left hemiparesis, including the face. Neuropsychologic examination revealed left unilateral spatial neglect, but no language disturbance. Minimal support was necessary to maintain activities of daily living. Computed tomography revealed a large right temporoparietal, extraaxial hypodense fluid collection containing scattered hypodense foci. The haematoma was evacuated via a right parietal burr hole. Following surgery, the patient dramatically improved neurologically and neuropsychologically, as well as in independent performance of daily activities. It is suggested that the improvement in ADL provides a behavioural correlate of improvement in the latter, represented a behavioural correlate of improved cerebral function, and that either direct compression by the chronic subdural haematoma or an interhemispheric pressure difference had caused unilateral spatial neglect. Such neglect is an unusual consequence of chronic subdural haematoma. Introduction Patients with chronic subdural haematoma often have headache, disturbance of consciousness, and various neurologic deficits. The latter may include cognitive impairments not sufficiently severe to meet clinical criteria for diagnosis of dementia [1, 2]. Although aphasia can be the presenting symptom of a subdural haematoma, such occurrences are rare. Cognitive impairments such as unilateral spatial neglect have been described as important factors influencing rehabilitation outcome [3, 4]. However, few investigations have examined the relationship between cognitive functions and independent daily activity in patients with chronic subdural haematoma [5]. A patient is described with unilateral spatial neglect caused by a subdural haematoma, considering the relationship of hemineglect to activities of daily living (ADL). Correspondence to: Shinichiro Maeshima, MD, PhD, Department of Physical Medicine and Rehabilitation, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-0012, Japan. email: maeshima@wakayama-med.ac.jp Brain Injury ISSN 0269± 9052 print/ISSN 1362± 301X online # 2001 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/02699050010005878 372 S. Maeshima et al. Case report A 69-year-old, right-handed man presented with a 4-week history of left arm and leg weakness. The patient denied headache, nausea, and vomiting, and had no history of hypertension, stoke, transient ischemic attacks, seizures, or alcoholism. He had 10 years of formal education. Physical examination on admission revealed a blood pressure of 138/88 mm Hg and a pulse of 70/min. Neither carotid bruits nor cardiac murmur were present. On neurologic examination, the patient was alert and co-operative. Visual fields were full to confrontation testing, and normal ocular movements were seen. A mild left hemiparesis was present. Perception of pain, light touch, and vibration, as well as proprioception, graphesthesia, and stereognosis, were intact. Neuroradiologic assessment Computed tomography (CT) of the head demonstrated a large right temporoparietal, extra-axial hypodense fluid collection containing scattered hyperdense foci figure 1. Figure 1. Computed tomography of the head revealed a large right temporoparietal, extra-axial hypodense fluid collection containing scattered hypodense foci. Hemispatial neglect from chronic subdural haematoma Figure 2. 373 Unilateral spatial neglect of left hemispace was demonstrated by line and star cancellation tests on the Behavioural Inattention Test. Neuropsychological examination The patient was disoriented with respect to time and place. His total score on the Mini-Mental State Examination was 22/30, and word fluency (animal naming) was 6/min. On the Osaka Memory Scale (the Japanese version of the Wechsler Memory Scale) was 39; his score for Raven’s coloured progressive matrices was 4/36. Digit retention span was five forward recall and two for reverse recall. Scores on the Revised Wechsler Adult Intelligence Scale (WAIS-R) were verbal intelligence quotient (IQ), 92; performance IQ, 51; and full-scale IQ, 71. These results indicated obvious and extensive cognitive deficits. Unilateral spatial neglect of left hemispace was demonstrated by line bisection, a cancellation test figure 2, and a figure-copying test. On the Behavioural Inattention Test (BIT)[6] the conventional score was 35/146. Aphasia, ideomotor apraxia, ideational apraxia, and anosognosia were not demonstrated table 1. 374 S. Maeshima et al. Table 1. Mini-mental state (/30) Osaka Memory Scale (/100) Word fluency (/min) Raven’s CPM (/36) WAIS-R Verbal IQ Performance IQ Full scale BIT (/146) Results of neuropsychologic examinations 28 October 1 November 30 November 22 39 6 4 25 39 12 18 28 66 14 21 92 51 71 35 94 68 80 123 100 87 94 142 CPM: Coloured Progressive Matrices; WAIS-R, Revised Wechsler Adult Intelligence scale; IQ, Intelligence quotient; BIT, Behavioural Inattention Test. Assessment of ADL The patient’ s ability to perform ADL as measured by the Functional Independence Measure (FIM) was 74 on admission. Minimal support was required for maintenance of self-care functions such as eating, grooming, and dressing. The patient also had difficulty with transferring and showed little independent movement figure 3. Clinical course The patient underwent right parietal burr hole placement for evacuation of the haematoma on 30 October 1999. The volume evacuated was 130 ml. Follow-up CT on the second post-operative day demonstrated only a small amount of residual fluid with little mass effect. Clinical improvement followed surgery. Hemiparesis resolved, activity level increased, and self-care improved. The FIM score had increased to 118 at 3 days after surgery. The results of neuropsychologic examination repeated 3 days following surgery were also markedly improved table 1. Reevaluation 1 month following surgery demonstrated continued progress. While neuropsychologic examination showed some further improvement at this time, the FIM score had risen notably to 126. The patient was able to perform nearly all self-care activities and walked without a cane. Discussion The patient had mild dementia, left-sided spatial neglect, and relatively preserved language function. The BIT confirmed the presence of left-sided unilateral spatial neglect. A patient with chronic subdural haematoma causing disproportionate right hemispheric dysfunction may exhibit such spatial neglect if tested adequately, provided that dementia is not more than moderately severe. Unilateral spatial neglect, which causes the patient to disregard objects encountered in the involved spatial field, generally is known to be an impediment to ADL. However, unilateral spatial neglect has not been reported to affect ADL in the specific context of chronic subdural haematoma. On admission, ADL performance in this patient was hampered by both mild hemiparesis and unilateral spatial neglect. Although the patient Hemispatial neglect from chronic subdural haematoma 375 November 30 Figure 3. Course of recovery as assessed by the Functional Independence Measure-activities of daily living (FIMADL) scale: pre-operative (28 October), 3 days post-operatively (1 November), and 1 month after evaluation (30 November). FIM score on admission was 74, and minimal support was required for maintenance of self-care functions such as eating, grooming, and dressing. The patient also had difficulty with transferring and showed little independent movement. Hemiparesis resolved, activity level increased, and self-care improved after surgery. The FIM score had increased to 118. Reevaluation 1 month following surgery demonstrated continued progress, the FIM score had risen notably to 126. The patient was able to perform nearly all selfcare activities and walked without a cane. recovered from hemiparesis after surgery, it was found that unilateral spatial neglect itself affected ADL. It is assumed that subsequent improvement of ADL in this and other patients with chronic subdural haematoma represented a behavioural correlate of improved cerebral function. Subdural haematomas, caused by haemorrhage from bridging veins between the durra and arachnoid matter, usually result from head trauma. The blood typically lies along the frontal and parietal convexities, sometimes bilaterally. Patients usually complain of headache and may show cognitive impairment, aphasia (with dominant hemisphere involvement), and hemiparesis contralateral to the haematoma. Patients with unilateral spatial neglect typically have a lesion involving the right temporoparietooccipital junction. Resolution of the patient’ s unilateral spatial neglect following haematoma evacuation suggests a causal relationship, and post-operative CT showed no cerebral infarction or mass lesions that might account for this deficit. Daly et al. [7] have suggested that mass lesions can cause neurologic symptoms by mechanical stimulation of the cortex followed by spreading depression of cerebral electrical activity [8]. However, this premonitory rapidly becomes too diffuse to account for focal symptoms. Direct compression or an interhemispheric pressure difference resulting from the haematoma [9] would seen more likely but might also be too widespread. One cannot exclude the possibility that these relatively diffuse 376 Hemispatial neglect from chronic subdural haematoma processes may have induced expression of an otherwise sub-clinical focal lesion. Otherwise, the patient would have shown only a mild cognitive impairment due to a diffuse brain insult. McLaurin [10] has recognized that subdural haematomas may indirectly compromise regional cerebral blood flow by dural compartmental shifts affecting the anterior or posterior cerebral arteries. The size of the haematoma, however, does not necessarily determine symptoms, nor have most reported patients shown significant midline shift or syndromes suggesting anterior or posterior cerebral artery ischemia. The haematoma in this patient would not be expected to cause any shift of intracranial structures sufficient to cause localized compression of the right temporoparietal lobe. Since patients can respond dramatically to surgical evacuation of a subdural haematoma, the possibility must be kept in mind that, alternatively to stroke or tumour, chronic subdural haematoma can be the cause of unilateral spatial neglect. This can be an early manifestation prior to haematoma enlargement, with progression to frank dementia. References 1. McKissock, W., Richardson, A. and Bloom, W. H.: Subdural hematoma: a review of 389 cases. Lancet, 1: 1365± 1369, 1960. 2. Dell, S. O., Batson, R., Kasdon, D. L. et al.: Aphasia in subdural hematoma. Archives of Neurology, 40: 177± 179, 1983. 3. Drummond, A. E. R., Miller, N., Colquohoun, M. et al.: The effects of a stroke unit on activites of daily living. Clinical Rehabilitation, 10: 12± 22, 1996. 4. Olson, T. S.: Arm and leg paresis as outcome predictors in stroke rehabilitation. Stroke, 21: 247± 251, 1990. 5. Maeshima, S., Yamaga, H., Masuo, O. et al.: Cognitive impairment using event-related potentials and neuropsychological tests in chronic subdural hemaotoma. In S. Ueda, R. Nakamura and S. Ishigami (editors) The 8th World Congress of the International Rehabilitation Medicine Association (Bologna: Monduzzi Editore) pp. 301± 304, 1997. 6. Wilson, B., Cockburn, J. and Halligan, P.: Behavioural inattention test (England: Thames Valley Test Company), 1987 (translated into Japanese by S. Ishiai Tokyo, Japan, Shinkoh Igaku Shuppan Co., Ltd). 7. Daly, D. D., Svien, H. J. and Yoss, R. E.: Intermittent cerebral symptoms with meningiomas. Archives of Neurology, 5: 287± 293, 1961. 8. Leao, A. A. P.: Spreading depression of activity in the cerebral cortex. Journal of Neuropshysiology, 7: 359± 390, 1944. 9. Symon, L., Pasztor, E., Dorsch, N. W. C. et al.: Differential pressures recorded in acute epidural expanding lesions. Correlation with local cerebral blood flow by hydrogen clearence in baboons. In T. W. Langfitt, L. C. McHenry M. Reivich et al. (editors) Cerebral Circulation and Metabolism (New York: Springer-Verlag) pp. 235± 237, 1975. 10. McLaurin, R. L.: Contributions of angiography to pathophysiology of subdural hematomas. Neurology, 15: 866± 873, 1965. Copyright of Brain Injury is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.