Author Affiliations: Department of Neurology, Mayo Clinic, Rochester, Minnesota.
A 54-year-old woman with a history of an inferior vena cava occlusion in 1978, membranous nephropathy following renal transplantation in 1979 with secondary chronic renal insufficiency (baseline creatinine level, 2.0 mg/dL; to convert to micromoles per liter, multiply by 88.4) and hyperhomocysteinemia, and factor V Leiden mutation on long-term anticoagulation presented with hypertension and confusion following a brief period of unresponsiveness. On initial presentation, she was slowly responsive to commands but moving all extremities spontaneously. Subsequent examination 1 hour later showed a fixed and dilated left pupil with no withdrawal to pain in all extremities as well as bilateral Babinski signs. Initial computed tomography of the head showed a large left-sided acute-on-chronic subdural hematoma with significant mass effect and early subfalcine and descending transtentorial herniation (Figure, A, herniation not pictured).
Moore SA, Mittal MK, Rabinstein AA. Duret Hemorrhage Following Subdural Hematoma Evacuation. JAMA Neurol. 2013;70(4):518. doi:10.1001/jamaneurol.2013.614