Peer-Review Short Reports Spontaneous Chronic Subdural Hematoma in a 22-Year-Old Healthy Woman Diana De Carvalho1,3, Saleh Almenawer4,5, Marco Lozej1, Heather Noble2, Naresh K. Murty4,5 Key words - BACKGROUND: Chronic subdural hematoma is a common presentation to the - Chronic subdural hematoma neurosurgical practice that tends to occur among the elderly. - Dancer - Female - METHODS: We identify a rare occurrence of a chronic subdural hematoma in - Headache a young and otherwise healthy female patient who denied a traumatic brain injury. - Neck pain - Young Abbreviations and Acronyms CSDH: Chronic subdural hematoma CT: Computed tomography From the 1Health and Performance Centre, and 2 Student Health Services, University of Guelph, Guelph, Ontario; 3Department of Kinesiology, University of Waterloo, Waterloo, Ontario; 4Department of Surgery, McMaster University, Hamilton, Ontario; and 5Division of Neurosurgery, Hamilton General Hospital, Hamilton, Ontario, Canada To whom correspondence should be addressed: Diana De Carvalho, D.C., M.Sc. [E mail: ddecarva@uwaterloo.ca] Citation: World Neurosurg. (2013) 80, 5:654.e9 654.e11. http://dx.doi.org/10.1016/j.wneu.2012.11.065 - RESULTS: Upon reviewing the literature, we found only one reported case of a spontaneous nature in a young patient. The subtle presentation of headaches and absence of neurological deficit could be mistaken as migraine and result in a delay in obtaining imaging and necessary treatment. In this report, we present a 22-year-old patient who complained of persistent headaches and was neurologically intact on examination. Cranial computed tomography revealed the presence of a right-sided chronic subdural hematoma; this was followed by magnetic resonance imaging plus angiogram, which ruled out the presence of a vascular abnormality. A burr-hole craniostomy procedure was used that resulted in resolution of symptoms. - CONCLUSION: Without a heightened clinical suspicion, a similar presenta- tion could be missed, resulting in delayed management. Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878 8750/$ see front matter ª 2013 Elsevier Inc. All rights reserved. INTRODUCTION Chronic subdural hematomas (CSDHs) tend to occur in older individuals, and men are affected more commonly than women (2, 9). Despite the propensity to favor the elderly, there have been cases of CSDHs in young active patients with varying levels of head trauma (7, 8, 21, 24). After reviewing the literature, we found only one reported case of spontaneous nature in a young otherwise healthy 29-year-old woman (1). The identification of this diagnosis in young patients is important, as the subtle presentation could be missed if not considered. In this case report, we discuss the clinical finding of a spontaneous CSDH in a 22-year-old female dancer complaining of chronic headaches in the absence of underlying direct trauma or vascular abnormality as well as reviewing the literature for similar occurrences. Subdural hematomas, a collection of blood typically from the tearing of bridging veins, develop when the arachnoid and 654.E9 www.SCIENCEDIRECT.com dura mater become separated in response to disruptive forces (12). They are classified as acute, subacute, and chronic (18). Chronic lesions rarely develop from acute instances and differ by the presence of a neomembrane in addition to the liquefied hematoma (17). They typically present more than 2 weeks after an insult to the head (3, 6, 7). The fragile vessels in this membrane are prone to breakage and rebleeding over a long period of time (17). In a retrospective study of 1097 cases, the common clinical presentation was found to be headache in patients younger than 70 years of age and behavioral disturbances in those older (11). Fernandes et al. also describe altered levels of consciousness, focal motor deficits, papilledema, and unequal pupils (7). Diagnosis is best supported with a computed tomography (CT) or magnetic resonance imaging of the head (20). Resolution can be spontaneous where absorption of the hematoma is greater than rebleeding or in cases of membrane maturation (17). Craniotomy, twist-drill craniostomy, and burr-hole craniostomy are three surgical options for CSDH management. A recent review by Lega et al. comparing between the three surgical modalities showed that burr-hole craniostomy is the most efficient choice for CSDH surgical management (19). MATERIALS AND METHODS We identify a rare occurrence of a CSDH in a young otherwise healthy female patient who denies a traumatic brain injury. RESULTS A 22-year-old right-handed female patient with an unremarkable medical history presented with severe headaches. The headaches started bilaterally at the temples area, radiating to the forehead and associated with nausea. Aggravating factors included turning the head suddenly. She was denying any history of traumatic brain injury. Socially she does not smoke nor consume alcohol. There was no history of diplopia, weakness, numbness, or seizures. The patient was an active member of a university dance team and participated in tumbling and acrobatics; she reported an increase in “head whipping” maneuvers WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2012.11.065 PEER-REVIEW SHORT REPORTS DIANA DE CARVALHO ET AL. within the last 4 years because of changes in the style of popular dance. Hemodynamically she was stable with no fevers. She had normal tone, power, reflexes, and sensation of the four limbs. No dysmetria was seen on examination. Neuropsychiatric evaluation revealed intact memory, language, and attention. Funduscopic assessment showed no papilledema. Both pupils were reactive to light, with full range of eye movement. No facial weakness or cranial nerve palsies were detected on examination. Musculoskeletal findings included tight and tender suboccipital and trapezius muscles and tender facet joints of the upper cervical and thoracic spine. The rest of the neurologic examination was within normal. Cranial CT revealed a right-sided CSDH with mass effect on the frontal lobe. Subsequently, a magnetic resonance imaging (Figure 1) was arranged plus angiogram, which ruled out an underlying vascular abnormality. Two-burr-hole craniostomy was performed over the CSDH that resulted in resolution of symptoms. CT scan showed good evacuation of the hematoma at a follow-up exam 1 month later (Figure 2). On physical examination, no neurologic deficits were found and the scalp incision was noted to have healed well. The patient was discharged with instructions to avoid all aggravating activities for the next 3 months and to Figure 1. Magnetic resonance imaging/ angiography taken prior to surgery confirming the diagnosis of chronic subdural hematoma and ruled out the presence of vascular abnormality. CSDH IN A 22 YEAR OLD HEALTHY WOMAN Figure 2. Computed tomography imaging 1 month after surgery shows full resolution of condition. gradually return to normal physical activity thereafter. DISCUSSION A number of case reports have detailed the occurrence of CSDH in young, otherwise healthy individuals. Of these reports, the most obvious causes include mild to moderate head trauma during various activities: basketball (16), soccer (5), and snowboarding (24). The more subtle cases, however, are those attributed to an activity involving rotational head and neck accelerations such as those experienced by the patient in this case. In the literature, similar occurrences have been reported in young individuals riding a rollercoaster (7, 10, 15, 23, 25), head-shaking at rock concerts (4, 14, 22), breakdancing (21), or bungee cord jumping (8). These are situations of indirect head trauma and might not be determined from history questions, especially if the patient is only asked whether or not they have hit their head recently. Although not a factor in this case, but worthy of mentioning when discussing young adult patients, is the effect dehydration (caused by exercise or alcohol) could also have in the generation of this injury. In their case of CSDH in a bungee cord jumper, Fitzgerald et al. discusses the potential that slight brain shrinkage secondary to dehydration (in this situation caused by the lingering effect of alcohol intoxication) could increase the space between the brain and calvarium and thus WORLD NEUROSURGERY 80 [5]: 654.e9 654.e11, NOVEMBER 2013 the sheer force experienced by the subdural vessels (8). In the literature, one spontaneous case of CSDH has been identified in a 29-year-old woman with no history of direct or indirect trauma (1). The subtle signs that lead to the initial referral for special imaging in this case include the following: a novel headache type, a reproduction of symptoms with specific head accelerations (specifically quick head rotation side to side), and a sense on the patients’ part that something was wrong. Indeed, numerous reports in the literature recommend that the diagnosis of CSDH should be ruled out with an evaluation including CT and/or magnetic resonance imaging in active individuals presenting with headache and a history of head injury (even mild) or exposure to acceleration forces (7, 16, 24). In this case, special imaging was scheduled within a week of the patient presenting; unfortunately, the wait-time for this test was lengthy. Informing the patient to access emergency care, in retrospect, was appropriate and in this circumstance resulted in earlier identification of the condition. CONCLUSION In this case the physical examination findings of myofascial pain and joint irritations could have been the result of typical mechanical stressors of prolonged posture and physical activity present in the life of any dancer or university student. The fluctuation in headache symptoms likely followed the chronic healing/re-injury pattern of the lesion but it could have easily been mistakenly attributed to increased stress and activity at school. Indeed, without heightened clinical suspicion, this presentation could be taken as an uncomplicated case of musculoskeletal pain and appropriate imaging and treatment would be delayed. Most clinicians recall the potential of CSDH in “an elderly patient complaining of progressive headache especially with the presence of cognitive impairments” (13); however, we should also be aware of its potential to present in young, active patients complaining of headaches. REFERENCES 1. Arpino L, Gravina M, Basile D, Franco A: Spontaneous chronic subdural hematoma in a young adult. J Neurosurg Sci 53:55-57, 2009. www.WORLDNEUROSURGERY.org 654.E10 PEER-REVIEW SHORT REPORTS DIANA DE CARVALHO ET AL. 2. Cameron MM: Chronic subdural hematoma: a review of 114 cases. J Neurol Neurosurg Psychiatry 32:247-250, 1978. 3. Croce MA, Dent DL, Menke PG, Robertson JT, Hinson MS, Young BH, Donovan TB, Pritchard FE, Minard G, Kudsk KA, Fabian TC: Acute subdural hematoma: nonsurgical management of selected patients. J Truama 36:820-827, 1994. 4. De Cauwer H, Van Giel R, Mortelmans L, van den Hauwe L: An uncommon cause of headache after headbanging at a party. Emerg Med 16:212-213, 2009. 5. Demetriades AK, McEvoy AW, Kitchen ND: Subdural haematoma associated with an arachnoid cyst after repetitive minor heading injury in ball games. Br J Sports Med 38:28-29, 2004. 6. Dolinskas CS, Zimmerman RA, Bilaniuk LT, Gennarelli TA: Computed tomography of post traumatic extracerebral hematomas. J Trauma 19: 163-169, 1979. 7. Fernandes CMB, Daya MR: A roller coaster headache: case report. J Truama 37:1007-1010, 1994. 8. Fitzgerald JJ, Bassi S, White BD: A subdural haematoma following “reverse” bungee jumping. Br J Neurosurg 16:307-308, 2002. 9. Fogelholm R, Waltimo O: Epidemiology of chronic subdural hematoma. Acta Neurochir 32: 247-250, 1975. 10. Fukutake T, Mine S, Yamakami I, Yamaura A, Hattori T: Roller coaster headache and subdural hematoma. Neurology 54:264-268, 2000. 654.E11 www.SCIENCEDIRECT.com CSDH IN A 22 YEAR OLD HEALTHY WOMAN 11. Gelabert-Gonzalez M, Iglesias-Pais M, GarciaAllut A, Martinez-Rumbo R: Chronic subdural haematoma: surgical treatment and outcome in 1000 cases. Clin Neurol Neurosurg 107:223-229, 2005. 12. Haines DE: On the question of a subdural space. Anat Rec 203:3, 1991. 13. Headache Classification Subcommittee of the International Headache Society: The International Classification of Headache Disorders. 2nd ed. Cephalalgia 24 Suppl 1:9-160, 2004. 14. Hopkin J, Mamourian S, Lollis S, Duhaime T: The next extreme sport? Subdural haematoma in a patient with arachnoid cyst after head shaking competition. Br J Neurosurg 20:111-113, 2006. 15. Huang PP: Roller coaster headaches revisited. Surg Neurol 60:398-401, 2003. 16. Keller TM, Holland MC: Chronic subdural haematoma, an unusual injury from playing basketball. Br J Sports Med 32:338-345, 1998. 17. Lee KS: Natural history of chronic subdural haematoma. Brain Inj 18:351-358, 2004. 18. Lee KS, Bae WK, Doh JW, Bae HG, Yun IG: Origin of chronic subdural haematoma and relation to traumatic subdural lesions. Brain Inj 12:901-910, 1998. 19. Lega BC, Danish SF, Malhotra NR, Sonnad SS, Stein SS: Choosing the best operation for chronic subdural hematoma: a decision analysis. J Neurosurg 113:615-621, 2010. 20. Markwalder TM: Chronic subdural hematomas: a review. J Neurosurg 54:637, 1981. 21. McNeil S, Spruill WA, Langley RL, Shuping JR, Leonard JR: Multiple subdural hematomas associated with breakdancing. Ann Emerg Med 16: 114-116, 1987. 22. Neyaz Z, Kandpal H, Sharma R, Kale S: “Head banging” during rock show causing subdural hematoma. Neurol India 54:3, 2006. 23. Roldan-Valadez E, Facha MT, Martinez-Lopez M, Herrera-Mora P: Subdural hematoma in a teenager related to roller-coaster ride. Eur J Paediatr Neurol 10:194-196, 2006. 24. Uzura M, Taguchi Y, Matsuzawa M, Watanabe H, Chiba S: Chronic subdural hematoma after a snowboarding head injury. Br J Sports Med 37: 82-83, 2003. 25. Yamakami I, Mine S, Yamaura A, Fukutake T: Chronic subdural hematoma after riding a roller coaster. J Clin Neurosci 12:81-83, 2005. Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Received 8 March 2012; accepted 20 November 2012 Citation: World Neurosurg. (2013) 80, 5:654.e9 654.e11. http://dx.doi.org/10.1016/j.wneu.2012.11.065 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878 8750/$ see front matter ª 2013 Elsevier Inc. All rights reserved. WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2012.11.065