Hématome sous-dural chronique et décompensation psychotique

Abstract

In Tunisia, with the remarkable progress in health, life expectancy has significantly increased these last decades. Indeed, in 2004, 9.3% of the population was aged over 60, and this rate is predicted to reach 17% in 2029 and about 29% by 2050. In the elderly, chronic subdural hematoma (HSDC) may be caused by even minimal trauma or occur spontaneously. The manifestations of this type of accumulation depend on the degree of cerebral compression and the localisation of the mass. They could be delirium, dementia, convulsions or psychiatric disorders (frontal location). When the psychiatric presentation predominates, the decision to hospitalise an elderly person in a psychiatric unit is difficult and often avoided. We report the case of an 81 year-old man without history of medical condition or personal or family psychiatric history, who, in 2000, began to exhibit behavioural disorders, delusions of persecution and jealousy, visual hallucinations and sexual disinhibition. This clinical picture that set in so insidiously and in moderate intensity was long tolerated by the family circle. The patient was admitted to a psychiatric hospital in January 2008 with the worsening of the symptoms. The clinical examination and investigations confirmed the diagnosis of chronic frontoparietal subdural hematoma without compression. The decision in neurosurgery was to refrain from surgical drainage and administer high doses of steroids under supervision (clinical and biological). The evolution was good with progressive resorption of the hematoma to complete recovery. Currently, the patient is symptom free and the last CT scan on 03/11/2010 confirms the total resorption of the hematoma. It appears from this case and review of the literature that various psychiatric manifestations may reveal an HSDC and that, in the elderly, neuroimaging should be systematic, even for minor symptoms. The total resorption led to the disappearance of psychiatric symptoms in most patients, but this remains a topic of discussion for patients who retain residual symptoms, even after resorption of the mass. Caution is required when faced with an elderly person suffering, and we should strive to explore all possible causes before jumping to the conclusion of the fatality of growing old.