She had hit her head.
When?
No one in the family ever saw that, and she never said anything. She was sleeping last night safe and sound in her bed. How could she have hit her head while she was asleep?
It didn't happen last night. It probably happened weeks ago. In fact, she probably didn't think much of it then. It may even have been a minor bump perhaps bumping her head on the car roof as she tried to get into the car during that rainstorm a few weeks ago.
Could that have caused all of this trouble?
This is the world of the subdural hematoma.
The brain does not reproduce itself. And, as we age,that brain we were born with gradually shrinks.
On the other hand, the skull, once fully grown, never gets smaller. The result is that our heads become very much like walnuts: seeds dehydrate and shrink within the firm shell. You can hear the kernel shake as you try to open the shell.
As the brain shrinks, it too pulls away from its covering shell of bone(our skull); the intervening space is replaced by brain fluid (CSF. Sorry, no rattle).
At the same time the blood vessels which come from the brain and extend up into the skull become stretched, like rubber bands. When they reach a certain limit, even a minor bump to the skull can cause them to snap and bleed into the subdural space between the inner skull surface and the brain.
With the body's excellent blood-controlling mechanisms at work, the first few "episodes" may go unnoticed, since there is plenty of room for the blood. However, with repeated episodes, a critical volume is reached, and the brain suffers with a compression.
This is the time that the lady awakens with a noticeably malfunctioning brain--slurred speech and wobbly gait.
More often than not, these chronic Subdural Hematomas are not fresh clots, but rather liquefied, old blood mixed with some fresh blood. Thus, they can be easily drained by a very small hole in the skull. In fact (see History) , the earliest operations known to man were done for this reason. More than 3,000 years ago, many peoples including the Incas of South America and the Sumerians of the Middle East performed these operations called trephination, in the hopes of expelling evil spirits from the brains of men they felt were possessed. Many such skulls have been found at archeological digs the world over. These operations often were successful even then.
By far the most common cause of a subdural hematoma is severe brain
injury after a car accident or a fall from a great height. These traumatic
subdural hematomas are always associated with considerable brain damage,
and occur immediately after the injury. These injuries will be further
addressed under the heading of Brain Injury(under construction).
Occasionally an artery on or near the surface of the brain will
burst, causing a very large and emergent subdural hematoma to develop.
These are due to vascular malformations of the brain (e.g. aneurysm, AVM,
dural AVM), containing a threat for future bleeding. Because of the high
pressure (and therefore volume) and rapid expansion of these SDH's, the
patient is most often in serious trouble, requiring emergency surgey be
performed.
