A 90 year old female presented to her local hospital after her family found her to be having difficulty speaking. She was a pretty healthy and active 90 year old. She did have a history of atrial fibrillation and pulmonary emboli and therefore she was on Warfarin.

Upon presentation to her local ER, the physician did find her to have expressive and probably receptive aphasia. Her INR was therapeutic at 2.0. She underwent a noncontrast CT scan of the brain (image above) showing the left subdural hematoma with subfalcine herniation. A Neurosurgical consultation was obtained and the patient was transferred to my NeuroIntensive Care Unit.

The consulting Neurosurgeon was not impressed by the presentation of aphasia and elected to observe her in the ICU. Overnight her aphasia started to improve and then worsen again. A repeat CT showed the same subdural. The patient went to the OR later that day for evacuation.

I was always taught that a subdural hematoma with neurological findings was a surgical emergency. I was confused as to why the Neurosurgeon did not think so. I think I know the answer. Aphasia is not a usual presentation of a subdural hematoma (SDH).

To briefly review, head trauma is the leading cause of SDH usually related to car accidents, falls and assaults. Diffuse cerebral atrophy and the use of anticoagulation round out the list. A seemingly spontaneous unprovoked SDH occurs only 2.6% of the time.

The clinical finding associated with acute SDH is coma in 50% of cases. Posterior fossa SDH presents with symptoms of increased intracranial pressure like headache, vomiting. ataxia. Chronic SDH hematoma usually presents with headache, lightheadedness, apathy and somnolence.

Interestingly in my review, I did not find an aphasia as presenting symptom for SDH. I did find 2 studies- one from the Annals of Neurology which had 4 patients with aphasia and SDH and one form the Journal of American Medical Directors Assocation which had 1 patient with aphasia as a presenting symptom. Having seen this literature I understood a little bit more why the Neurosurgeon was not initially impressed with the case. Next time I will be an even more educated advocate for my patient in terms of needing to go to the OR with SDH presents with aphasia.