Presentation
Sustained a fall, hit the left temporal region.
Patient Data
An about 6 cm long hyperdense thin subdural collection is visible in the left fronto-temporal region in line with acute subdural bleeding.
No associated fracture (bone kernel recons not shown in all imaging planes).
Scroll though a representative axial slice displayed with different window settings to see its profound effect on the depiction of the hemorrhage. In order we see a standard brain window, a wider subdural/IC blood window, and a very narrow acute stroke window. Due to the CT blooming artifact the thickness of the collection is better estimated by the broader subdural window, whilst on the very narrow stroke window the hematoma blends in entirely with the inner table of the skull.
Case Discussion
While the diagnosis here is straightforward, particularly thin "smear" subdural bleeds are prone to be missed and are a common source of medicolegal lawsuits. Meticulous search strategy is crucial, always incorporating multiplanar recons (bleeds e.g. near the planum sphenoidale or temporal poles are easily missed in the axial plane). It is also key to not rely exclusively on standard brain windows, where the blooming artifact caused by the inner table of the skull can hide thin subdural collection. What the subdural window lacks in parenchymal contrast is well compensated by its sensitivity to small collections. Stroke window in particular should never be used to assess for the presence of bleeding.
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