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Duret Hemorrhage Following Subdural Hematoma Evacuation

S. Arthur Moore, MD; Manoj K. Mittal, MD; Alejandro A. Rabinstein, MD
JAMA Neurol. 2013;70(4):518. doi:10.1001/jamaneurol.2013.614.
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A 54-year-old woman with a history of an inferior vena cava occlusion in 1978, membranous nephropathy following renal transplantation in 1979 with secondary chronic renal insufficiency (baseline creatinine level, 2.0 mg/dL; to convert to micromoles per liter, multiply by 88.4) and hyperhomocysteinemia, and factor V Leiden mutation on long-term anticoagulation presented with hypertension and confusion following a brief period of unresponsiveness. On initial presentation, she was slowly responsive to commands but moving all extremities spontaneously. Subsequent examination 1 hour later showed a fixed and dilated left pupil with no withdrawal to pain in all extremities as well as bilateral Babinski signs. Initial computed tomography of the head showed a large left-sided acute-on-chronic subdural hematoma with significant mass effect and early subfalcine and descending transtentorial herniation (Figure, A, herniation not pictured).

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Figure. Axial computed tomographic scans. A, The patient had an acute 1.3-cm-diameter subdural hematoma (arrow) on the left with a 1.9-cm midline shift. B, Following hemicraniectomy and clot evacuation, there was a 1.2 × 1.6-cm hemorrhage (arrow) at the pontomesencephalic junction.

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