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Subdural Hematoma Presenting as Recurrent Syncope
The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–4, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.01.037
Clinical Communications: Adults SUBDURAL HEMATOMA PRESENTING AS RECURRENT SYNCOPE David I. Bruner, MD, FAAEM, Christine Jamros, MD, and William Cogar, MD Naval Medical Center San Diego, San Diego, California Reprint Address: David I. Bruner, MD, FAAEM, Emergency Department, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
, Abstract—Background: Syncope is a common emergency department (ED) complaint. Recurrent syncope is less common, but may be concerning for serious underlying pathology. It often requires a broad diagnostic evaluation that may include neurologic imaging. Case Presentation: We present the case of a 75-year-old man with non-small-cell carcinoma who presented to the ED for recurrent syncope after coughing spells over the 2 weeks preceding his arrival at the ED. He had a normal cardiac evaluation, however, he had some subacute neurologic changes that prompted obtaining a computed tomography (CT) scan of the head. This led to the diagnosis of atraumatic subdural hematoma that was causing transient transtentorial herniation leading to the recurrent syncope. Why Should an Emergency Physician be Aware of This?: Emergency physicians should be aware that recurrent syncope is a possible presentation of increased intracranial pressure that may be due to a mass lesion, particularly if the patient has any acute or subacute neurologic changes. Although this association with a subdual hematoma is rare, other cases of mass lesions leading to syncope after coughing spells have been reported in the literature. Ó 2015 Elsevier Inc.
INTRODUCTION Syncope is a common Emergency Department (ED) complaint. In the majority of syncope presentations, a computed tomography (CT) scan of the head is not indicated unless there is an acute neurologic deficit. We present a case of a patient with recurrent syncope after coughing who required a CT scan to make the diagnosis for this potentially fatal cause of syncope. CASE REPORT A 75-year-old man presented to the ED after four episodes of syncope occurred at home on the day of presentation. He stated that this had happened several times in the preceding days. His family members saw him lose consciousness for approximately 15 s, twice on the day of presentation. These events occurred after bouts of coughing. He denied any preceding chest pain, palpitations, headache, or dizziness prior to losing consciousness. The patient denied any prior history of fainting, but he did have a medical history notable for a recent diagnosis of advanced non-small-cell lung cancer (NSCLC) with metastatic lesions to the mediastinal lymph nodes, bone, and liver. His symptoms included frequent coughing spells with small-volume hemoptysis. He was undergoing chemotherapy and palliative radiation therapy. His medications included Lantus, gabapentin, furosemide, atenolol, losartan, aspirin, omeprazole, Megace,
, Keywords—syncope; cough; subdural hematoma
The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.
RECEIVED: 2 November 2014; FINAL SUBMISSION RECEIVED: 23 December 2014; ACCEPTED: 5 January 2015 1
2
atorvastatin, cetirizine, and sildenafil. The patient reported an allergy to pioglitazone, causing lower extremity swelling. Family history was noncontributory. He was a former smoker. On physical examination, the patient was found to have normal vital signs and unremarkable pulmonary and cardiac evaluations without any respiratory distress or cardiac murmurs appreciated. The neurologic examination demonstrated normal mental status, normal sensation, and normal cranial nerve evaluation. He did have new subacute decrease in strength to 4 out of 5 that he had noticed on the left upper and lower extremities for the previous 7 days, that had made ambulation more difficult, but he was able to ambulate with a walker. ED evaluation included an electrocardiogram that showed normal sinus rhythm without ectopy, abnormal intervals, or ST-segment changes. Laboratory tests were remarkable only for mild, but stable anemia with a hemoglobin of 9.7 g/dL and slightly decreased calcium of 8.3 mg/dL; sodium, potassium, and renal function were normal. During his stay in the ED, he had another episode of severe coughing, which then led to a syncopal event witnessed by the ED staff. The patient subsequently had a noncontrast head CT scan (Figures 1 and 2) that demonstrated a large right-sided and small left-sided subdural hematoma of mixed density. He had right-to-left subfalcine herniation, and early downward transtentorial herniation was noted as well.
Figure 1. Noncontrast head computed tomography demonstrating a large right-sided (arrow) and small left-sided subdural hematoma (*) of mixed density with right-to-left subfalcine herniation (@).
D. I. Bruner et al.
Figure 2. Coronal view of noncontrast head computed tomography demonstrating a large right-sided (red arrow) and small left-sided subdural hematoma of mixed density (*) with right-to-left subfalcine herniation (@) and early downward transtentorial herniation.
The patient was taken to the operating room by the neurosurgeon, where he had an open craniotomy to relieve the subdural clot. DISCUSSION To our knowledge, this is the first reported case of syncope as the presenting symptom for a subdural hematoma. Situational syncope due to coughing has been reported. There also have been reports of known brain tumors and cerebral sinus venous thrombosis contributing to syncope when intracranial pressure (ICP) became elevated. Our patient likely had a similar mechanism of action whereby his ICP became transiently increased during coughing spells, causing brief periods of transtentorial herniation, leading to loss of consciousness. Syncope due to coughing is unusual, and the mechanism has not been definitively established. One study suggests that patients with typical cough-induced syncope have a greater likelihood of pronounced hypotension and bradycardia secondary to a cough-triggered neural reflex, when compared to patients without cough-induced syncope (1). Prior reports of increased ICP causing syncope have been noted in cases of brain tumors, Chiari malformation, and cerebral sinus venous thrombosis (CSVT) (2–4). The proposed mechanism for this phenomenon is increased ICP temporarily impeding cerebral blood flow, causing a transient loss of consciousness. Any type of Valsalva maneuver such as coughing or sneezing can increase
Subdural Hematoma Presenting as Recurrent Syncope
intrathoracic pressure and decrease jugular venous return, and this can, in turn, increase the ICP and lead to loss of consciousness (5). Posterior fossa tumors and CSVT have been reported to obstruct flow of cerebral spinal fluid at the foramen magnum or fourth ventricle, contributing to increased ICP and subsequent syncope with Valsalva maneuvers (2,3). Patients with mass lesions in the brain are susceptible to temporary impedance of cerebral perfusion due to elevated ICP in association with normal plateau waves. Plateau waves are pressure waves that can normally occur in the brain when an event transiently raises the ICP. Mass lesions (such as subdural hematoma in our case) can raise baseline ICP. In this setting, even small elevations in intracranial fluid volume from coughing can cause significant elevations in ICP, and thus cut off cerebral blood flow and lead to syncope. The management of mass lesions leading to increased ICP and syncope clearly depends on the type of lesion present and the surgical options to relieve the increased pressure. In most cases, as in our patient, immediate neurosurgical consultation is recommended, as well as efforts to limit elevations in ICP while the patient is in the ED. These maneuvers include elevating the head of the bed 30 degrees, treating the underlying cause of coughing, and attempting to decrease edema with steroids for tumors, and possibly with hypertonic solutions, after discussion with the neurosurgery service (6,7). In routine cases of syncope, neurologic imaging with CT or magnetic resonance imaging is to be avoided according to both the American Academy of Emergency Physicians and American Heart Association clinical policies. These guidelines recommend that neurologic imaging is to be done only when there are new neurologic deficits (8,9). If there is significant trauma from the fall, CT imaging may be needed as well, but for routine syncope, even in the face of possible seizure activity, CT is not considered necessary (10). Although our patient’s deficits were present for the previous week, they could still be considered new and thus warranted imaging. In discussing our patient with the neurosurgical service, it was decided that his syncope was a result of increased ICP during episodes of coughing. We believed that the subdural hematoma increased his ICP such that his coughing spells caused him to transiently herniate and limit cerebral blood perfusion. He had no trauma or bleeding diathesis as a reason to suspect a subdural hematoma initially, and as in most cases of a patient with syncope with a nonfocal neurologic examination, a head CT scan was not initially ordered. Our patient had known metastatic NSCLC, but did not have known brain metastases. However, on the basis of this metastatic NSCLC and several days of mild left-sided weakness, we obtained
3
a CT scan to see if a mass lesion was contributing to his symptoms, and we found the source of this symptom. Our patient went from the ED to the operating room for an open craniotomy and evacuation of a right frontoparietal acute-on-chronic subdural clot. He did well postoperatively with resolution of his left hemiparesis. He was eventually discharged to a skilled nursing facility for rehabilitation. However, at 4 weeks follow-up, although his left hemiparesis resolved, he showed new right hemiparesis concerning for either a worsening left subdural collection, stroke, or metastatic brain disease. Due to his overall poor prognosis and the recent death of his wife, the patient eventually transitioned to hospice. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case report is important for emergency physicians to be aware of because we do often see cancer patients with metastatic disease, and these lesions can cause edema and bleeding in certain settings. Situational syncope is often seen in the ED as well, and we rarely obtain head CT scans on these patients. Whether or not a patient has known brain metastases, one should be aware of the possibility of atraumatic bleeding and increased ICP leading to syncopal events, particularly with coughing or other Valsalva type maneuvers. Recurrent syncope is a possible presentation of increased ICP due to a mass lesion, particularly if any acute or subacute neurologic changes are present. Subdural hematoma as the lesion in this setting, as in our case, is rare, and to our knowledge, unreported thus far. However, other cases of mass lesions leading to syncope after coughing spells have been reported in the literature.
REFERENCES 1. Benditt DG, Samniah N, Pham S, et al. Effect of cough on heart rate and blood pressure in patients with ‘‘cough syncope’’ Heart Rhythm 2005;2:807–13. 2. Maznyczka A, Squire AB. Cough syncope—a diagnosis under pressure. Lancet 2010;376:486. 3. Larimer P, McDermott MW, Scott BJ, Shih TT, Poisson SN. Recurrent syncope due to cerebral sinus venous thrombosis and transient elevations in intracranial pressure. Neurohospitalist 2014;4:18–21. 4. Chen-Scarabelli C, Kaxa AR, Scarabelli T. Syncope due to nasopharyngeal carcinoma. Lancet Oncol 2005;6:347–9. 5. Mattle HP, Nirkko AC, Baumgartner RW, Sturzeneggar M. Transient cerebral circulatory arrest coincides with fainting in cough syncope. Neurology 1995;45:489–501. 6. Hayashi M, Handa Y, Kobayashi H, Kawano H, Ishii H, Hirose S. Plateau-wave phenomenon (I). Correlation between the appearance of plateau waves and CSF circulation in patients with intracranial hypertension. Brain 1991;114(Pt 6):2681–91.
4 7. Hayashi M, Kobayashi H, Handa Y, Kawano H, Kabuto M. Brain blood volume and blood flow in patients with plateau waves. J Neurosurg 1985;63:556–61. 8. Strickberger SA, Benson W, Biagionni I, et al. AHA/ACCF scientific statement on the evaluation of syncope. Circulation 2006;113: 316–27.
D. I. Bruner et al. 9. Huff JS, Decker WW, Quinn JV. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med 2007;49:431–44. 10. Moya A, Sutton R, Ammiatti F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30: 2631–71.
http://dx.doi.org/10.1016/j.jemermed.2015.01.037
Clinical Communications: Adults SUBDURAL HEMATOMA PRESENTING AS RECURRENT SYNCOPE David I. Bruner, MD, FAAEM, Christine Jamros, MD, and William Cogar, MD Naval Medical Center San Diego, San Diego, California Reprint Address: David I. Bruner, MD, FAAEM, Emergency Department, Naval Medical Center San Diego, 34800 Bob Wilson Drive, San Diego, CA 92134
, Abstract—Background: Syncope is a common emergency department (ED) complaint. Recurrent syncope is less common, but may be concerning for serious underlying pathology. It often requires a broad diagnostic evaluation that may include neurologic imaging. Case Presentation: We present the case of a 75-year-old man with non-small-cell carcinoma who presented to the ED for recurrent syncope after coughing spells over the 2 weeks preceding his arrival at the ED. He had a normal cardiac evaluation, however, he had some subacute neurologic changes that prompted obtaining a computed tomography (CT) scan of the head. This led to the diagnosis of atraumatic subdural hematoma that was causing transient transtentorial herniation leading to the recurrent syncope. Why Should an Emergency Physician be Aware of This?: Emergency physicians should be aware that recurrent syncope is a possible presentation of increased intracranial pressure that may be due to a mass lesion, particularly if the patient has any acute or subacute neurologic changes. Although this association with a subdual hematoma is rare, other cases of mass lesions leading to syncope after coughing spells have been reported in the literature. Ó 2015 Elsevier Inc.
INTRODUCTION Syncope is a common Emergency Department (ED) complaint. In the majority of syncope presentations, a computed tomography (CT) scan of the head is not indicated unless there is an acute neurologic deficit. We present a case of a patient with recurrent syncope after coughing who required a CT scan to make the diagnosis for this potentially fatal cause of syncope. CASE REPORT A 75-year-old man presented to the ED after four episodes of syncope occurred at home on the day of presentation. He stated that this had happened several times in the preceding days. His family members saw him lose consciousness for approximately 15 s, twice on the day of presentation. These events occurred after bouts of coughing. He denied any preceding chest pain, palpitations, headache, or dizziness prior to losing consciousness. The patient denied any prior history of fainting, but he did have a medical history notable for a recent diagnosis of advanced non-small-cell lung cancer (NSCLC) with metastatic lesions to the mediastinal lymph nodes, bone, and liver. His symptoms included frequent coughing spells with small-volume hemoptysis. He was undergoing chemotherapy and palliative radiation therapy. His medications included Lantus, gabapentin, furosemide, atenolol, losartan, aspirin, omeprazole, Megace,
, Keywords—syncope; cough; subdural hematoma
The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense or the United States Government.
RECEIVED: 2 November 2014; FINAL SUBMISSION RECEIVED: 23 December 2014; ACCEPTED: 5 January 2015 1
2
atorvastatin, cetirizine, and sildenafil. The patient reported an allergy to pioglitazone, causing lower extremity swelling. Family history was noncontributory. He was a former smoker. On physical examination, the patient was found to have normal vital signs and unremarkable pulmonary and cardiac evaluations without any respiratory distress or cardiac murmurs appreciated. The neurologic examination demonstrated normal mental status, normal sensation, and normal cranial nerve evaluation. He did have new subacute decrease in strength to 4 out of 5 that he had noticed on the left upper and lower extremities for the previous 7 days, that had made ambulation more difficult, but he was able to ambulate with a walker. ED evaluation included an electrocardiogram that showed normal sinus rhythm without ectopy, abnormal intervals, or ST-segment changes. Laboratory tests were remarkable only for mild, but stable anemia with a hemoglobin of 9.7 g/dL and slightly decreased calcium of 8.3 mg/dL; sodium, potassium, and renal function were normal. During his stay in the ED, he had another episode of severe coughing, which then led to a syncopal event witnessed by the ED staff. The patient subsequently had a noncontrast head CT scan (Figures 1 and 2) that demonstrated a large right-sided and small left-sided subdural hematoma of mixed density. He had right-to-left subfalcine herniation, and early downward transtentorial herniation was noted as well.
Figure 1. Noncontrast head computed tomography demonstrating a large right-sided (arrow) and small left-sided subdural hematoma (*) of mixed density with right-to-left subfalcine herniation (@).
D. I. Bruner et al.
Figure 2. Coronal view of noncontrast head computed tomography demonstrating a large right-sided (red arrow) and small left-sided subdural hematoma of mixed density (*) with right-to-left subfalcine herniation (@) and early downward transtentorial herniation.
The patient was taken to the operating room by the neurosurgeon, where he had an open craniotomy to relieve the subdural clot. DISCUSSION To our knowledge, this is the first reported case of syncope as the presenting symptom for a subdural hematoma. Situational syncope due to coughing has been reported. There also have been reports of known brain tumors and cerebral sinus venous thrombosis contributing to syncope when intracranial pressure (ICP) became elevated. Our patient likely had a similar mechanism of action whereby his ICP became transiently increased during coughing spells, causing brief periods of transtentorial herniation, leading to loss of consciousness. Syncope due to coughing is unusual, and the mechanism has not been definitively established. One study suggests that patients with typical cough-induced syncope have a greater likelihood of pronounced hypotension and bradycardia secondary to a cough-triggered neural reflex, when compared to patients without cough-induced syncope (1). Prior reports of increased ICP causing syncope have been noted in cases of brain tumors, Chiari malformation, and cerebral sinus venous thrombosis (CSVT) (2–4). The proposed mechanism for this phenomenon is increased ICP temporarily impeding cerebral blood flow, causing a transient loss of consciousness. Any type of Valsalva maneuver such as coughing or sneezing can increase
Subdural Hematoma Presenting as Recurrent Syncope
intrathoracic pressure and decrease jugular venous return, and this can, in turn, increase the ICP and lead to loss of consciousness (5). Posterior fossa tumors and CSVT have been reported to obstruct flow of cerebral spinal fluid at the foramen magnum or fourth ventricle, contributing to increased ICP and subsequent syncope with Valsalva maneuvers (2,3). Patients with mass lesions in the brain are susceptible to temporary impedance of cerebral perfusion due to elevated ICP in association with normal plateau waves. Plateau waves are pressure waves that can normally occur in the brain when an event transiently raises the ICP. Mass lesions (such as subdural hematoma in our case) can raise baseline ICP. In this setting, even small elevations in intracranial fluid volume from coughing can cause significant elevations in ICP, and thus cut off cerebral blood flow and lead to syncope. The management of mass lesions leading to increased ICP and syncope clearly depends on the type of lesion present and the surgical options to relieve the increased pressure. In most cases, as in our patient, immediate neurosurgical consultation is recommended, as well as efforts to limit elevations in ICP while the patient is in the ED. These maneuvers include elevating the head of the bed 30 degrees, treating the underlying cause of coughing, and attempting to decrease edema with steroids for tumors, and possibly with hypertonic solutions, after discussion with the neurosurgery service (6,7). In routine cases of syncope, neurologic imaging with CT or magnetic resonance imaging is to be avoided according to both the American Academy of Emergency Physicians and American Heart Association clinical policies. These guidelines recommend that neurologic imaging is to be done only when there are new neurologic deficits (8,9). If there is significant trauma from the fall, CT imaging may be needed as well, but for routine syncope, even in the face of possible seizure activity, CT is not considered necessary (10). Although our patient’s deficits were present for the previous week, they could still be considered new and thus warranted imaging. In discussing our patient with the neurosurgical service, it was decided that his syncope was a result of increased ICP during episodes of coughing. We believed that the subdural hematoma increased his ICP such that his coughing spells caused him to transiently herniate and limit cerebral blood perfusion. He had no trauma or bleeding diathesis as a reason to suspect a subdural hematoma initially, and as in most cases of a patient with syncope with a nonfocal neurologic examination, a head CT scan was not initially ordered. Our patient had known metastatic NSCLC, but did not have known brain metastases. However, on the basis of this metastatic NSCLC and several days of mild left-sided weakness, we obtained
3
a CT scan to see if a mass lesion was contributing to his symptoms, and we found the source of this symptom. Our patient went from the ED to the operating room for an open craniotomy and evacuation of a right frontoparietal acute-on-chronic subdural clot. He did well postoperatively with resolution of his left hemiparesis. He was eventually discharged to a skilled nursing facility for rehabilitation. However, at 4 weeks follow-up, although his left hemiparesis resolved, he showed new right hemiparesis concerning for either a worsening left subdural collection, stroke, or metastatic brain disease. Due to his overall poor prognosis and the recent death of his wife, the patient eventually transitioned to hospice. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS? This case report is important for emergency physicians to be aware of because we do often see cancer patients with metastatic disease, and these lesions can cause edema and bleeding in certain settings. Situational syncope is often seen in the ED as well, and we rarely obtain head CT scans on these patients. Whether or not a patient has known brain metastases, one should be aware of the possibility of atraumatic bleeding and increased ICP leading to syncopal events, particularly with coughing or other Valsalva type maneuvers. Recurrent syncope is a possible presentation of increased ICP due to a mass lesion, particularly if any acute or subacute neurologic changes are present. Subdural hematoma as the lesion in this setting, as in our case, is rare, and to our knowledge, unreported thus far. However, other cases of mass lesions leading to syncope after coughing spells have been reported in the literature.
REFERENCES 1. Benditt DG, Samniah N, Pham S, et al. Effect of cough on heart rate and blood pressure in patients with ‘‘cough syncope’’ Heart Rhythm 2005;2:807–13. 2. Maznyczka A, Squire AB. Cough syncope—a diagnosis under pressure. Lancet 2010;376:486. 3. Larimer P, McDermott MW, Scott BJ, Shih TT, Poisson SN. Recurrent syncope due to cerebral sinus venous thrombosis and transient elevations in intracranial pressure. Neurohospitalist 2014;4:18–21. 4. Chen-Scarabelli C, Kaxa AR, Scarabelli T. Syncope due to nasopharyngeal carcinoma. Lancet Oncol 2005;6:347–9. 5. Mattle HP, Nirkko AC, Baumgartner RW, Sturzeneggar M. Transient cerebral circulatory arrest coincides with fainting in cough syncope. Neurology 1995;45:489–501. 6. Hayashi M, Handa Y, Kobayashi H, Kawano H, Ishii H, Hirose S. Plateau-wave phenomenon (I). Correlation between the appearance of plateau waves and CSF circulation in patients with intracranial hypertension. Brain 1991;114(Pt 6):2681–91.
4 7. Hayashi M, Kobayashi H, Handa Y, Kawano H, Kabuto M. Brain blood volume and blood flow in patients with plateau waves. J Neurosurg 1985;63:556–61. 8. Strickberger SA, Benson W, Biagionni I, et al. AHA/ACCF scientific statement on the evaluation of syncope. Circulation 2006;113: 316–27.
D. I. Bruner et al. 9. Huff JS, Decker WW, Quinn JV. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med 2007;49:431–44. 10. Moya A, Sutton R, Ammiatti F, et al. Guidelines for the diagnosis and management of syncope (version 2009). Eur Heart J 2009;30: 2631–71.