Expert Opinion: Subdural Hematoma Presenting as Expressive Aphasia: A Case Report and Review

Patients with intracranial bleeds present with a myriad of possible symptoms, including headache, altered mental status, seizures and focal motor and sensory deficits. Subdural hematomas (SDH) account for nearly half of all intracranial hemorrhages.1 There is a paucity of case reports citing aphasia as an isolated symptom. The goal of this paper is to add to the literature a report of expressive aphasia as the primary complaint in a patient found to have an acute or chronic SDH. A literature search was performed using the keywords “aphasia” and “SDH.”

Case Presentation

A 59-year-old Caucasian man with metastatic lung cancer presented to the emergency department with expressive aphasia. He is a classical musician who lives alone in an apartment and hadn't spoken to anyone. He didn't realize he couldn't speak. A friend called and when the patient was unable to communicate, the friend called 911.

The night prior to his presentation the patient suffered a minor head trauma when he stood up from bending over and hit his head on a marble table. He went to bed and was woken with a severe headache. No history of level of consciousness change or frank seizure was noted.

Additional past medical history includes chronic deep vein thromboses (not on coumadin), and hypertension controlled by benazepril and atenolol. One year prior to this admission the patient developed a spontaneous subdural hematoma while on anticoagulation for treatment of deep vein thromboses. His anticoagulant was stopped after the initial bleed. He had no clinical sequelae from the bleed, and had a chronic area of hypodensity in the left frontoparietal region from the event.  

For lung cancer, his treatment regimen consisted of carboplatin; his last chemotherapy session was three months prior to visit.

Patient has no prior neurosurgical history. Social history includes moderate alcohol use, no drug use, no smoking history.

On physical exam, his vitals were stable, he was afebrile and normotensive. He was awake and alert with severe expressive aphasia, and mild right facial droop and right pronator drift were present.  

Basic laboratory evaluation was within normal limits. (Should mention specifics of his platelet count, INR and PT/PTT.)

CT revealed an interval acute on chronic subdural hematoma spanning the left frontoparietal region.

He was admitted to neurosurgical service for planned craniotomy with evacuation of SDH. A small left frontal craniotomy was performed without complications. A subdural drain was left in place for 24 hours postoperatively. His aphasia and reported weakness resolved completely, and he was without residual deficit.  

Discussion

Our literature search revealed 34 cases of SDH associated with expressive aphasia, as summarized in Table 1. There is a recurring incidence of subtle right sided motor and sensory symptoms. In the majority of cases, function was regained after evacuation of the hemorrhage. In our case despite minimal mass effect, the patient manifested a frank expressive aphasia, necessitating early surgical evacuation. Had this patient presented with only trace pronator drift alone, conservative treatment would have been considered, given the lack of significant mass effect. In this case the speech disturbance clearly resulted in early consideration of craniotomy with the resulting resolution of symptoms postoperatively confirming the SDH as the etiology of the aphasia.

Conclusion

Aphasia, or other focal neurologic deficits, can be the primary presenting symptom of a subdural hematoma. CT scan of the head without contrast remains the mainstay in identifying occult brain bleeds upon initial presentation. Further neuroimaging work up including CTA of the head and neck, MRI/A of the brain, and/or femoral cerebral angiogram is recommended in select cases of unknown etiology of the source of hemorrhage. Early neurosurgical evaluation and consideration of evacuation of the hematoma is recommended. Complete resolution of aphasia was noted following craniotomy and clot evacuation in the case presented here. Restoration of language function should result in early and emergent consideration of surgical treatment of subdural hematoma in medically and hematologically stable patients with focal speech deficits. n

Claire Reynolds Carrazco, DO, Internal Medicine PGY-1, Lenox Hill Hospital, New York City.

David J. Langer, MD is Chief of Neurosurgery, Lenox Hill Hospital, New York City.

Rafael A. Ortiz, MD is Director of Neuro-Endovascular Surgery, Lenox Hill Hospital, New York City.

Steven Mandel, MD, Electrodiagnostic Medicine, Neurology, New York City.

1. Hart et al. Intracranial Hemorrhage in Atrial Fibrillation Patients During Anticoagulation With Warfarin or Dabigatran The RE-LY Trial. Stroke, June 2012, pp1511-1517

2. Aoki N, Oikawa A, Sakai T. Symptomatic subacute subdural hematoma associated with cerebral hemispheric swelling and ischemia. Neurol Res. 1996 Apr;18(2):145-9. PubMed PMID: 9162869.

3. BOSSI L, CAFFARATTI E. [Some considerations on 2 cases of motor aphasia caused by subdural hematoma following cranial injury. Etiopathogenetic, clinical and radiological aspects]. Minerva Med. 1962 Mar 31;53:970-4. Italian. PubMed PMID: 13871621.

4. Dell SO, Batson R, Kasdon DL, Peterson T. Aphasia in subdural hematoma. Arch Neurol. 1983 Mar;40(3):177-9. PubMed PMID: 6830461.

5. German WJ, Flanigan S, Davey LM. Remarks on subdural hematoma and aphasia. Clin Neurosurg. 1964;12:344-50. PubMed PMID: 5865051.

6. Hernette D, Bregigeon M, Brosset C, Dano P. [Chronic subdural hematoma and transient neurologic deficiency]. Ann Med Interne (Paris). 1995;146(5):370-3. French. PubMed PMID: 8526329.

7. Hosaka S, Higuchi H, Kagawa T. Restoration of brain function in an elderly man. BMJ Case Rep. 2014 Jan 6;2014. pii: bcr2013202118. doi: 10.1136/bcr-2013-202118. PubMed PMID: 24395878.

8. Kaminski HJ, Hlavin ML, Likavec MJ, Schmidley JW. Transient neurologic deficit caused by chronic subdural hematoma. Am J Med. 1992 Jun;92(6):698-700. Review. PubMed PMID: 1605153.

9. Kuwahara S, Miyake H, Koan Y, Fukuoka M, Ono Y, Moriki A, Mori K, Mokudai T, Uchida Y. [A case of organized chronic subdural hematoma presented with transient neurologic deficits]. No To Shinkei. 2004 Apr;56(4):355-9. Japanese. PubMed PMID: 15237729.

10. Lazzarino LG, Nicolai A, Valassi F. Subacute subdural hematoma presenting as reversible ischemic attacks. Ital J Neurol Sci. 1989 Feb;10(1):101-3. PubMed PMID: 2925341.

11. Liu GT, Moore MR, Goldman H. Transcortical motor aphasia due to a subdural hematoma. Am J Emerg Med. 1991 Nov;9(6):620-2. PubMed PMID: 1930409.

12. Melamed E, Lavy S, Reches A, Sahar A. Chronic subdural hematoma simulating transient cerebral ischemic attacks. Case report. J Neurosurg. 1975 Jan;42(1):101-3. PubMed PMID: 1110379.

13. Mishriki YY. Subdural hematoma mimicking a transient ischemic attack due to antihypertensive medication. South Med J. 1999 Sep;92(9):905-6. PubMed PMID: 10498167.

14. Moster ML, Johnston DE, Reinmuth OM. Chronic subdural hematoma with transient neurological deficits: a review of 15 cases.Ann Neurol. 1983 Nov;14(5):539-42. PubMed PMID: 6651241.

15. Nagaratnam K. Subdural haematoma presenting as an isolated speech disorder. Med J Aust. 1992 Sep 7;157(5):352. PubMed PMID: 1435483.

16. Nicoli F, Milandre L, Lemarquis P, Bazan M, Jau P. [Chronic subdural hematoma and transient neurologic deficits]. Rev Neurol (Paris). 1990;146(4):256-63. Review. French. PubMed PMID: 2193336.

17. Rahimi AR, Poorkay M. Subdural hematomas and isolated transient aphasia. J Am Med Dir Assoc. 2000 May-Jun;1(3):129-31. PubMed PMID: 12818026.

18. Schebesch KM, Woertgen C, Rothoerl RD, Ullrich OW, Brawanski AT. Cognitive decline as an important sign for an operable cause of dementia: chronic subdural haematoma. Zentralbl Neurochir. 2008 May;69(2):61-4. doi: 10.1055/s-2007-1004582. Epub 2008 Apr 29. PubMed PMID: 18444216.

19. SIGWALD J, GUILLAUME J, ROGE H, MAZARS Y. [Unusual neurological manifestations of chronic subdural hematoma: aphasia and hemianopsia; with reference to two cases of subdural hematoma with these symptoms and their complete postoperative disappearance]. Sem Hop. 1954 Nov 14;30(72):4003-5. French. PubMed PMID: 13225795.

20. Sterna W, Jarmuzek P. [Chronic subdural hematoma with psychopathological manifestations]. Psychiatr Pol. 1999 Nov-Dec;33(6):933-8. Polish. PubMed PMID: 10776029.

21. Vajramani GV, Akrawi H, McCarthy RA, Gray WP. Bilingual aphasia due to spontaneous acute subdural haematoma from a ruptured intracranial infectious aneurysm. Clin Neurol Neurosurg. 2008 Sep;110(8):823-7. doi: 10.1016/j.clineuro.2008.05.008. Epub 2008 Jul 2. PubMed PMID: 18599195.

22. Welsh JE, Tyson GW, Winn HR, Jane JA. Chronic subdural hematoma presenting as transient neurologic deficits. Stroke. 1979 Sep-Oct;10(5):564-7. PubMed PMID: 505498.

23. Wilkinson CC, Multani J, Bailes JE. Chronic subdural hematoma presenting with symptoms of transient ischemic attack (TIA): a case report. W V Med J. 2001 Jul-Aug;97(4):194-6. PubMed PMID: 11558288.