CASE

A 72-year-old man was missing for 2 days before being found unconscious on the ground and admitted to our hospital. He showed impaired consciousness with a score of 11 on the Glasgow coma scale (E3-V3-M5), subtle left hemiparesis, and a contused wound on the left side of his head. Computed tomography (CT) of the head showed right acute subdural haematoma (ASDH) and a small infarction in the striatocapsular area (Figure 1), which was confirmed to be in the acute phase by diffusion-weighted magnetic resonance (MR) imaging (Figure 2a). MR angiography revealed an occlusion of the right middle cerebral artery (MCA) (Figure 2b). We considered that his symptoms could be accounted for by a widespread haemodynamic ischaemic penumbra of the right cerebral hemisphere rather than the ASDH, and therefore attempted fluid resuscitation. His consciousness showed remarkable improvement, to an almost alert state, and the hemiparesis disappeared. He was monitored closely in hospital. After 7 days, the volume of the ASHD increased and it was surgically evacuated. The patient was discharged from hospital with no sequelae.

According to the recommendation [1], the patient’s ASDH on admission was a candidate for surgical evacuation. However, about 30% of striatocapsular infarction cases are caused by atherosclerotic MCA occlusion [2], which often accompanies a wide ischaemic penumbra and leads to progressive infarction.

Therefore, the haemodynamic state of the brain should be assessed in traumatic injury cases with signs of brain ischaemia, especially in the striatocapsular area.

LEARNING POINTS

l  Traumatic head injury can be accompanied by an acute ischaemic brain lesion.

l  Infarction in the striatocapsular area often suggests underlying major artery occlusion accompanied by a widespread ischaemic penumbra.

The haemodynamic state of the brain should be assessed in traumatic injury cases with signs of brain ischaemia, especially in the striatocapsular area, to avoid progressive infarction.

1. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute subdural hematomas. Neurosurgery 2006; 58:S16–24; discussion Si–iv. doi:10.1227/01.NEU.0000210364.29290.C9

2. Lee KB, Roh H, Park HK, et al. Analysis of the lesion distributions and mechanism of acute middle cerebral artery infarctions involving the striatocapsular region. J Clin Neurol 2006; 2:171–8. doi:10.3988/jcn.2006.2.3.171