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Case of the Month 08/09

Q1: This 91 year old male presented to the ED after a fall at home. Below are images from the head CT done in the ED.

What’s wrong with these pictures?

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A1:

The patient has a subdural hematoma that is visible in the posterior interhemispheric fissure. While this finding is somewhat subtle, it was made because the falx in that part of the brain should be pencil-thin whereas in this patient is is widened and somewhat triangular shaped (circle on first image). It can also be seen in the second image further up where the falx is continuous that the line is denser and brighter posteriorly (circle on second image). At the level that the falx is a continuous line, a normal falx would be of comparable width and density both anteriorly and posteriorly.

Q2: If the diagnosis were not clear, what would be some possible options to help clarify the etiology of the findings above?

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A2:

There are several options to decide if these finding represent a bleed or calcification of the falx. In this case, comparison with CT images (about 5 months before) reveal a much more normal appearing falx (see below.) Other possibilities would be to use houndsfield units, (in this case the area in question is about 46 hounsfield units which is the normal range for blood) or MRI. This patient had serial head CTs done over a 3 day admission period and was discharged in stable condition with unchanged images.