Unveiling the Hidden Tumour - Differentiating an Acute Subdural Hematoma from a Brain Tumour

Background

A gentleman in his 60s presented to our Emergency Department with a recent history of word-finding difficulties and right-sided weakness. Over the past 1-2 weeks, his condition had worsened, rendering him bedridden and unable to speak. Initially, a CT scan at a local hospital suggested an acute subdural hematoma, and due to the severity of his condition, he was transferred to our multispecialty hospital in Kolkata for advanced care.

Investigation & Analysis

While the subdural hematoma was initially considered, the CT scan revealed a typical left-sided acute subdural hematoma with significant cerebral edema, a (swelling) in the same hemisphere. This unusual finding raised the suspicion of an underlying tumour as the cause of the hematoma.

To clarify the diagnosis, a CT head with contrast was performed. This imaging revealed the presence of a mass, confirming that the hematoma was secondary to an underlying brain tumour rather than a primary acute subdural hematoma.

Treatment and Management

Given the significant mass effect caused by the acute subdural hematoma and the presence of a brain tumour, a comprehensive surgical approach was planned:

• Preoperative Preparation: This involved administering high-dose steroids to manage brain swelling before the surgery.
• Surgical Procedure:Owing to the delicate nature of this case, a customised surgical plan was devised and executed as follows: 
• Craniotomy: The operation involved removing a section of the skull to access the brain.
• Tumour Resection: Contrary to initial expectations, the procedure revealed a tumour of the brain’s meninges (meningioma) rather than an acute subdural hematoma. Over 98% of the tumour was successfully resected.

Upon removal the tumour was sent for histopathological examination, to rule out signs of malignancy.

Post-Operative Care

Following the surgery, the patient showed notable improvements. He began to speak a few words and his right-sided weakness improved significantly.He continued on high-dose steroids to manage post-surgical brain swelling. This case underscores that atypical features in imaging should prompt further investigation, as early and accurate diagnosis can significantly alter the management approach and improve patient outcomes. Dr Mitra and his Neuro team’s ability to identify the true nature of the patient’s condition allowed for successful tumour resection and a promising recovery trajectory.