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Images in Neurology |

Suspected Subdural Hematoma

Ozlem Ozkul-Wermester, MD1; Evelyne Guégan-Massardier, MD1; Aude Triquenot-Bagan, MD1; Olivier Langlois, MD2; Romain Lefaucheur, MD1; Bertrand Bourre, MD1
[+] Author Affiliations
1Department of Neurology, Rouen University Hospital, University of Rouen, Rouen, France
2Department of Neurosurgery, Rouen University Hospital, University of Rouen, Rouen, France
JAMA Neurol. 2014;71(7):916-917. doi:10.1001/jamaneurol.2013.6013.
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A 71-year-old woman was admitted for 3 inaugural right-sided focal seizures. Shortly before, she had experienced a minor head trauma. Her neurological examination finding was normal. A brain computed tomographic scan and magnetic resonance imaging (MRI) showed abnormalities supporting the diagnosis of chronic subdural hematoma (SDH), with a subcutaneous collection regarding this subdural hematoma (Figure, A-C). She did not undergo surgery, and monitoring with brain MRI was recommended. Three months later, while partial seizures persisted despite anti-epileptic treatment (levitiracetam, 2000 mg/d), follow-up brain MRI showed increased extra-axial and subcutaneous gadolinium-enhanced masses (Figure, D and E). Given this unusual subdural hematoma evolution and radiological worsening of the suspected hematoma, craniotomy and biopsies were performed. The histopathology findings revealed a low-grade B-cell marginal zone lymphoma involving dura with bone and scalp invasion. The patient underwent radiotherapy after surgery, which reduced the residual mass. Six months later, her neurological condition deteriorated with progressive appearance of a right hemiparesis, aphasia, and drug-resistant epilepsy.

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Figure.
Brain Computed Tomographic (CT) Scan and Magnetic Resonance Imaging (MRI) Follow-up Demonstrating a Presumed Left Frontoparietal Subdural Hematoma

A, Brain CT scan without injection showing discrete left frontoparietal hypodensity compatible with a subdural hematoma and subcutaneous collection (arrowhead). Fluid-attenuated inversion recovery sequence (B) and T2-gradient echo brain MRI (C) showing left frontoparietal isointense lesion. Axial (D) and coronal T1-weighted brain MRI (E) at 3 months showing a homogeneously gadolinium-enhanced hyperintensity (arrowhead).

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