Q: My 59 years old father suffered a subdural haematoma. Initially, this was classed as an acute subduarl haematoma. His Glasgow coma scale (GCS) fluctuated between 4 and 14 over a number of weeks and all indications were that the clot was liquefying. His GCS remained at 13 or 14 for 3 days and suddenly plummeted to 3. He was incubated and removed to a specialist hospital where 2 burr holes drained the clots. However, he never regained consciousness and died a day later. He was given anaesthesia for this surgery. Was this normal? It seemed from the postmortem report that he had suffered a stroke too, which was not detected on CT scan. He was sitting up, conversing and eating 30 minutes before his sudden death. Could this explain sudden deterioration and is sudden demise normal?

A:The term acute subdural haematoma is a misnomer. It places emphasis on the clot outside the brain instead of the severe associated injuries within the brain. The latter are associated with life-threatening, extensive swelling of the brain. The clot outside the brain can be easily removed at surgery. The severe brain swelling is extremely difficult to treat and has, in large western neurosurgery centres, even led to heroic surgery on the skull to relieve the pressure on the vital central segment of the brain termed the brainstem. Despite the most heroic surgery, the chances of successfully treating an acute subdural clot remain small and the mortality from it disappointingly high. I do not know the nature of the stroke detected at autopsy in your father. If there was bleeding into the brainstem, it was the consequence of severe increase in intracranial pressure despite all therapy. Yes, such worsening of pressure on the brainstem can be acute. Another kind of acute stroke suffered by such patients is severe rise in intracranial pressure to the extent that it is higher than the pressure at which the heart pumps blood into the brain. Such extremely high resistance disallows the flow of blood to the brain and results in fatal ischaemia.