Case (27)

[Admin]

A 55-year-old salesman exhibiting signs of confusion was brought to the hospital. The history gathered from his landlady disclosed that he had been separated from his family because he drank too much. Although he was apparently in good health, his landlady had entered the apartment on the day of admission because he did not respond to her calls. She found him lying on the floor, incontinent of urine and appearing bewildered; he had also bitten his lip. The landlady remembered that 2 months earlier he had been involved in a fight in a bar; 3 weeks previously he had fractured his wrist falling down stairs.
On examination, the patient was unconcerned, disheveled, and dirty. Bruises on his head and legs were consistent with recent trauma from a fall. The patient appeared to fall asleep when left alone. Neurologic examination showed normal optic fundi, normal extraocular movements, and no abnormalities that would result from dysfunction of other cranial nerves. The reflexes were normal and symmetric, and there was a left sided plantar extensor response.

Vital signs, complete blood count, and urinalysis were within normal limits. A lumbar puncture showed an opening pressure of 180 mm of water, xanthochromia, a protein level of 80 mg/dL, and a glucose level of 70mg/dL. Cell counts in all tubes showed red blood cells, 800/µL; lymphocytes, 20/µL, and polymorphonuclear neutrophils, 4/µL. A CT scan of the head was obtained.

Over the next 36 hours, the patient became deeply obtunded and seemed to develop a left-sided hemiparesis.

Questions:
1- Could the patient's problems be due to recent trauma?
2- What do the findings from the lumbar puncture indicate?
3- What is the most likely diagnosis?
Regards
Dr.Mahdi

[Mustafa]

Assalam aleikum dr. Mahdi,

I will tackle this case step by step to support my arguments why I came up with the answers to your three questions.
- The patient is an ancoholic. He might fell due to excessive drinking and then had a trauma to the head.
- He seems to have had an epileptic insult ( he has bitten his lip and he is  incontinent for urine) and his level of conciousness ( falling asleep) is deteriorated. both signs are suggestive for cerebral involvement.
- Neurologic examination showed a left sided plantar extensor ( Babinski sign); suggestive for a lesion in the right motor cortex or near that area.

All these above -mentioned are more indicative for a hemorrhage than subarachnoidal bleeding. SAB from a rupture of an aneurysma or arteriovenous malformation is less likely since the process has been initiated by head injury. Thus SH exceeded SAB.
Xanthochromia: (pink or yellow tint) represents hemoglobin degradation products and indicates that blood has been in the CSF for at least two hours.
This can be a cause of a tear from the arachnoid and that this phenomenon could have produced the bloody CSF rather than a leakage or rupture from an aneurysma.

The patients  condition is deteriorated ( the deeply obtundation and developing a left-sided hemiparesis ). It can be due to an imminnent herniation of the cerebrum.

1. It is most likely that this patient's clinical findings are caused by the recent head trauma.
2. The lumbar puncture indicate xanthochromia, a normal opening pressure ( 70-180 mm H2O), an increased level of protein, a normal range of glucose level and an increased level of RBC which normally are not present in LP. this is indicative for traumatic hemorrhage. In SAB , the opening pressure usually rise.
3. Given the time and the clinical diagnosis, I would say it is a subacute  right-sided subdural hemorrhagia.

wa salam aleikum

[Admin]

Good answer & well done
This patient is suffering from Right-sided subdural hemorrhage>>
Congratulations, 15 points has been added to your credit!
Dr.Mahdi