Case Presentation
A 63-year-old North American Caucasian man was admitted to our hospital after falling down four steps and sustaining head trauma. At presentation, he stated he had a headache, but denied visual changes, numbness or weakness. He was neurologically intact; notably, pronator drift was absent. His medical history was significant for NPH for which a programmable Medtronic Strata® ventriculoperitoneal (VP) shunt was placed three years prior to this event.
A computed tomography (CT) examination showed the ventricular catheter and an acute right posterior convexity subdural hematoma (Figure 1). The SDH overlying the right convexity measured 3cm in the greatest transverse diameter, causing mass effect on the ipsilateral brain parenchyma and posterior horn of the lateral ventricle.
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Figure 1.
Pre-valve adjustment computed tomography scan. The pre-valve adjustment computed tomography scan showing a high-density subdural hematoma in the right convexity and a mixed density subdural hematoma in the left convexity.
Our patient was admitted to the intensive care unit for close neurological monitoring. Our patient was neurologically intact, and, thus, conservative management was favored over operative treatment. However, given the propensity for expansion of acute subdural hematomas in the presence of low-pressure ventriculoperitoneal shunts and given the moderate size of our patient's subdural hematoma, simple observation was thought to be high risk. In addition, our patient reported dramatic improvement of his NPH symptoms after shunting, and, thus, simple shunt closure via ligature was not optimal. The authors chose to treat our patient's acute subdural hematoma by utilizing a technique that has been used in the treatment of subdural hygromas and chronic subdural hematomas. This technique, wherein the programmable valve setting is changed to reduce CSF drainage, allowed conservative management and observation of our patient without operative intervention.
The programmable valve was adjusted transcutaneously from 1.0 to the maximum setting of 2.5, thereby reducing CSF drainage. A repeat head CT obtained the following day revealed no significant change in the size of the subdural hematoma. He remained clinically unchanged and neurologically intact. He was then discharged from the hospital with a plan for close follow-up. Six days later, our patient was admitted with worsening symptoms of NPH including gait ataxia and urinary incontinence. CT examination showed complete resolution of the acute SDH and dilated ventricles consistent with our patient's known history of NPH (Figure 2). The valve setting was reduced from 2.5 to 0.5 in order to promote greater CSF drainage. This alleviated the NPH symptoms. Our patient remains well one year after sustaining the traumatic subdural hematoma (Figure 3).
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Figure 2.
Computed tomography scan conducted six days after valve adjustment. The computed tomography scan obtained six days after valve adjustment shows ventricular dilation, residual trace bifrontal extra-axial hypodense collections, and encephalomalacia in the right posterior parietal lobe.
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Figure 3.
Computed tomography scan one year after subdural hematoma. The computed tomography scan performed one year after subdural hematoma shows resolution of the subdural hematoma and dilated ventricles.