02 | Chronic subdural hematoma without recent evident trauma: the crucial role of medical history in prompt diagnosis

Background. Chronic subdural hematoma (CSDH) may present with nonspecific symptoms, particularly in older adults, and can be difficult to recognize in the absence of recent trauma or neurological deficits. Persistent, treatment-refractory headache is an important red flag for secondary causes. According to the SNOOP10 criteria, this case exhibited multiple warning features, including older age, progressive worsening despite therapy, and persistent symptoms lasting several days.

Case presentation. A 62-year-old man presented to the emergency department with a week-long refractory fronto-temporal headache. Despite these concerning features, neurological examination was entirely normal, illustrating a typical example of clinically “silent” mass effect that can mislead clinicians without high diagnostic vigilance. Early warning and stroke scales were unremarkable (NEWS2 = 1; NIHSS = 0). A non-contrast head CT scan showed a large left fronto-parieto-temporal chronic subdural hematoma (maximum thickness 20 mm) with a 13 mm midline shift. The patient underwent urgent surgical evacuation with an uneventful postoperative course.

Conclusions. This case highlights the importance of considering secondary intracranial pathology in older patients presenting with persistent, progressive, and treatment-refractory headache, even when the neurological examination is normal. Early recognition of headache red flags, careful medical history taking, and timely neuroimaging are essential to ensure prompt diagnosis and optimal outcomes.

Introduction

Persistent headache unresponsive to home analgesic therapy may represent the initial manifestation of potentially serious intracranial conditions, including Chronic Subdural Hematoma (CSDH). Diagnosis may be particularly challenging in the absence of recent head trauma or focal neurological deficits. In this case, the patient presented with a refractory headache—unresponsive to treatment, persisting for several days, and occurring in a man over 60 years old without an apparent cause. According to the SNOOP10 criteria, which summarize the main red flags for secondary headaches, this presentation fulfilled at least three warning features:

· Older age, due to the increased risk of secondary causes after 50–60 years;

· Progressive headache, as symptoms continued to worsen despite analgesic therapy;

· Persistence, with symptoms lasting for several consecutive days.

Despite these concerning red flags, the neurological examination was completely normal. This represents a typical example of a clinically “silent” mass effect, which can easily mislead clinicians if a high degree of diagnostic vigilance is not maintained. We report this case to highlight the importance of thorough clinical history taking, careful recognition of red flags, and timely neuroimaging — even when no clear traumatic event is initially reported.

Case Presentation

A 62-year-old man with a history of arterial hypertension and type 2 diabetes mellitus presented to the emergency department with a one-week history of persistent fronto-temporal headache, refractory to home analgesic therapy. On arrival, vital signs were stable: heart rate 77 bpm, blood pressure 150/95 mmHg, and oxygen saturation 98% on room air. The patient was alert and fully oriented, with a Glasgow Coma Scale (GCS) score of 15 and no focal neurological deficits. Early warning and stroke assessment scores were unremarkable: the National Early Warning Score 2 (NEWS2) was 1, indicating no signs of imminent deterioration, and the National Institutes of Health Stroke Scale (NIHSS) was 0, confirming the absence of measurable neurological deficits. Electrocardiogram showed sinus rhythm with a single ventricular ectopic beat. SARS-CoV-2 antigen test was negative. Laboratory tests revealed mildly elevated D-dimer levels (454 ng/mL). Given the persistence and severity of symptoms, a non-contrast head CT scan was performed, revealing a left fronto-parieto-temporal chronic subdural hematoma with a maximum thickness of 20 mm, a midline shift of 13 mm, and ipsilateral ventricular compression. Neurosurgical consultation was activated promptly, and the patient was urgently transferred to a neurosurgical referral center for operative management.

Results

During his stay in the emergency department, the patient remained hemodynamically stable, alert, and without new neurological findings. Urgent surgical evacuation of the chronic subdural hematoma was performed the same day. Postoperative recovery was uneventful, with early autonomous mobilization and no neurological complications. The patient was discharged with a tapering corticosteroid regimen, anticoagulant prophylaxis, and instructions for a follow-up CT scan in 20 days.

Discussion

Chronic subdural hematoma is a common neurosurgical condition, particularly in elderly patients, often related to minor or remote head trauma. In many cases, the traumatic event may be forgotten or initially not reported, contributing to diagnostic delay. This case illustrates several important clinical concepts:

1. Refractory headache as a red flag

Persistent headache unresponsive to standard analgesics should immediately raise suspicion of a secondary cause. Headache that is progressive and lasting several days, particularly in patients over 60 years old, should prompt neuroimaging—even in the absence of clear neurological deficits.

2. The value of SNOOP10 criteria

The SNOOP10 framework is a validated tool assisting clinicians in identifying red flags for secondary headaches. The patient fulfilled three criteria:

· Older age (>60 years)

· Progressive headache

· Persistence

These elements alone justified brain imaging.

3. Normal neurological exam does not exclude serious pathology

A striking feature of this case is the presence of normal neurological examination despite a 20 mm hematoma and 13 mm midline shift. This demonstrates a clinically “silent” mass effect, which can occur due to slow expansion and cerebral adaptation in CSDH. Reliance solely on neurological examination may therefore be misleading.

4. Importance of complete medical history

Only after neuroimaging did the patient recall a minor head injury occurring several weeks earlier. Detailed and repeated history-taking plays an essential role, particularly when symptoms evolve slowly or appear nonspecific.

5. Timely neuroimaging prevents complications

Early CT allowed prompt neurosurgical referral and intervention, preventing possible deterioration such as acute decompensation, seizures, or herniation.

Conclusions

This case underscores the importance of maintaining a high index of suspicion in elderly patients with persistent, progressive, and treatment-refractory headache, even in the absence of trauma or neurological deficits. Recognition of SNOOP10 red flags, thorough clinical history taking, and timely neuroimaging are essential for achieving early diagnosis and preventing severe complications.