Neurogenic Dysphagia in Subdural Hematoma: A case report

Rengaraj. G

Physician Assistant – Neurology, Kauvery Hospital, Cantonment, Trichy

Introduction

Neurologic dysphagia in the context of a subdural hematoma (SDH) refers to difficulty swallowing that arises because of brain injury, typically due to trauma leading to the accumulation of blood between the brain and its protective coverings. SDH can impact the central nervous system, particularly the areas involved in the coordination of swallowing. Dysphagia in this setting is often a result of damage to the brainstem, cranial nerves, or other parts of the brain that are responsible for the complex process of swallowing.

Case Presentation

A 19-year-old male, with a history of RTA. He was initially taken to a local hospital. CT brain scan done at the time of outside admission showed SDH in the right parietal occipital region, bilateral bifrontal contusion with diffuse subarachnoid hemorrhage. He was referred here for further management.

On Examination

On arrival at the Emergency ward, his GCS was E3M6V5 and both pupils were equal and reacting to light. He had evidence of bulbar palsy.

The patient attender gave a history of unconsciousness after the trauma but noticed some improvement in the form of intermittent eye opening and hand movements. The time they reached our hospital, no history of ear/nose bleed, seizure, syncope, or vomiting.

He was shifted to the neuro ICU for close ICP monitoring. An MRI Brain was done here which showed multifocal hemorrhagic contusion in bilateral basifrontal region, ASDH of 2mm thickness in the parietal, temporal and occipital region with diffuse SAH and mass effect.

Management

The patient was managed conservatively with anticonvulsants (Levetiracetam and Phenytoin), anti-edema (Mannitol), appropriate analgesia (Paracetamol), PPI (Pantoprazole), and administered prophylactic antibiotics (Piptaz – Piperacillin/tazobactam), nutritional and other measures.

Speech and swallow assessment were done by a videofluoroscopic test. Swallowing assessment, revealed the cord palsy.

As per swallow pathologist’s order, RT feeds were followed. Aggressive Physiotherapy was given and post-trauma stress disorder was managed by regular monitoring. Then he was shifted to the ward after symptomatically improving. Mobilization was done. Adequate hydration support was given.

Repeat swallow assessment was done after continued RT feeds for 2 weeks. In view of risk of aspiration patient was discharged with RT tube.

Fig (1): Vocal Cord palsy

Fig (2): multifocal hemorrhagic contusion bilateral basifrontal, parietal, temporal and occipital region with thin SDH right parieto- occipital region

Conclusion

Dysphagia is one of the significant and sometimes potentially life-threatening complications of SDH, requiring prompt recognition and management. The impairment in swallowing can lead to malnutrition, dehydration, aspiration pneumonia, and other complications if not addressed adequately. Treatment typically involves a multidisciplinary approach, including neuroimaging for diagnosis, rehabilitation therapy to improve swallowing function, and addressing the underlying SDH, often through surgical intervention in some cases. Early intervention and a tailored care plan are essential for improving the patient’s recovery and quality of life following SDH-related dysphagia.

Rengaraj. G
Physician Assistant

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