Unresponsive man on the street

[hydatidcyst]

This does not seem to be a contre-coup injury, you can see soft tissue damage overlying the hematoma and there is also soft tissue edema over the left occipital region, so less likely that the direct injury was to the right side.

[de.malady]

ok the scenario here is taking an interesting turn, thank you friends for sharing but i'm pulling myself away & waiting for the answer from 'jnus'..

[Walrus]

Before the answer, JNUS seems to be waiting to be enjoying the discussion and may be we still need some more discussion before hearing the answer.

Looking at it all over again and just giving one more thought - why can't it be Acute Subdural Hemorrhage instead?

The cause could be acceleration-deceleration force causing tear of the vessles. CT shows the mass to be somewhat crescentic shape if you notice the ends.

[JNUS]

[Walrus]

[JNUS]

What do u think about Acute SDH over Chronic SDH, with midline shift, Uncal herniation, left parietal soft tissue swelling...?? Is it part of chronic SDH in left occipital region ??

H/o is clear -->> Alcoholic

[JNUS]

Why Burr hole ??
Why not Craniotomy ??

[Walrus]

I would say this is Acute SDH and go for Craniotomy.

[JNUS]

Originally Posted by Walrus

I would say this is Acute SDH and go for Craniotomy.

How would u explain the density behind the acute SDH in left occipital region, do u think that its the senile cortical degeneration or its a chronic SDH.

[JNUS]

ANSWER

Acute Subdural hematoma over Chronic SDH

a brief negotiated intervention: Substance use is the leading risk factor for traumatic injury and is a serious problem among patients with trauma. In some clinical studies, as many as 50% of patients admitted to a trauma service have positive results on screening tests for drugs or alcohol. Up to 36% of patients have a blood alcohol concentration greater than 100 mg/dL, and up to 23% test positive for cocaine or methamphetamine. As this case illustrates, patients with trauma who screen positive for drugs or alcohol can be at chronic risk for traumatic injury.

The patient had previously traumatic injury leading to Chronic SDH, and now re-injured developing Acute on Chronic. This is usual presentation in chronic alcoholic Patient.. and Most of the times it remain as Chroic SDH,.... presenting on OPD's as long standing Headache on chronic alcoholic patient with no clear h/o trauma.

The patient in our case underwent an emergency craniotomy and evacuation of the subdural hematoma. After surgery, a CT scan of the head showed resolution of the hematoma (Picture not available). In general, his postoperative course was uncomplicated. After the patient's neurologic status improved, he was extubated and underwent treatment for alcohol withdrawal. Further consultation with the patient revealed a long history of alcohol abuse with resulting homelessness, an arrest for assault and battery, strained family relationships, and other trauma while intoxicated. Three months ago, the patient was admitted for a separate alcohol-related injury. Although he was referred for medical follow-up after discharge at that time, he did not request, and was not given, any counseling or referrals for alcohol-abuse treatment. The patient had been drinking about a liter of liquor per day since he was 15 years old without any sustained periods of sobriety. He ultimately recognized that drinking alcohol put him at risk for future injury and made it difficult for him to find housing and to financially support himself. After a few weeks of sobriety in the hospital, he contemplated maintaining abstinence. He was presented with a range of sober-living options, and he agreed to go to a halfway house and to follow up with mental health providers. Six months later, he had substantially decreased his alcohol intake, had no further injuries, and was in treatment with a primary care physician and a psychiatrist.

Substance-use disorders are often chronic illnesses, and change can be difficult; however, standardized and proven techniques (such as motivational interviewing) can change behaviors, especially when an injury occurs. Such interventions may raise the doubts and questions necessary to promote a turnaround, or they may present new options that eventually help even initially reluctant patients to change.
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Please come forward for further discussion, if it creates some arguments or questions.