Jomli R, Zgueb Y, Nacef F, Douki S
Service de psychiatrie A, hôpital Razi-Manouba, Tunis, Tunisie.
Encephale. 2012 Sep;38(4):356-9. doi: 10.1016/j.encep.2011.11.008. Epub 2012 Jan 5.
In Tunisia, with the remarkable progress in health, life expectancy has significantly increased these last decades. Indeed, in 2004, 9.3% of the population was aged over 60, and this rate is predicted to reach 17% in 2029 and about 29% by 2050. In the elderly, chronic subdural hematoma (HSDC) may be caused by even minimal trauma or occur spontaneously. The manifestations of this type of accumulation depend on the degree of cerebral compression and the localisation of the mass. They could be delirium, dementia, convulsions or psychiatric disorders (frontal location).
When the psychiatric presentation predominates, the decision to hospitalise an elderly person in a psychiatric unit is difficult and often avoided. We report the case of an 81 year-old man without history of medical condition or personal or family psychiatric history, who, in 2000, began to exhibit behavioural disorders, delusions of persecution and jealousy, visual hallucinations and sexual disinhibition. This clinical picture that set in so insidiously and in moderate intensity was long tolerated by the family circle. The patient was admitted to a psychiatric hospital in January 2008 with the worsening of the symptoms. The clinical examination and investigations confirmed the diagnosis of chronic frontoparietal subdural hematoma without compression. The decision in neurosurgery was to refrain from surgical drainage and administer high doses of steroids under supervision (clinical and biological). The evolution was good with progressive resorption of the hematoma to complete recovery. Currently, the patient is symptom free and the last CT scan on 03/11/2010 confirms the total resorption of the hematoma.
It appears from this case and review of the literature that various psychiatric manifestations may reveal an HSDC and that, in the elderly, neuroimaging should be systematic, even for minor symptoms. The total resorption led to the disappearance of psychiatric symptoms in most patients, but this remains a topic of discussion for patients who retain residual symptoms, even after resorption of the mass. Caution is required when faced with an elderly person suffering, and we should strive to explore all possible causes before jumping to the conclusion of the fatality of growing old.
在突尼斯，随着健康领域取得显著进展，过去几十年里预期寿命大幅提高。事实上，2004年，60岁以上人口占比9.3%，预计到2029年这一比例将达到17%，到2050年约为29%。在老年人中，慢性硬膜下血肿（HSDC）可能由哪怕极轻微的创伤引起，也可能自发出现。这类血肿的表现取决于脑受压程度和肿块位置。可能表现为谵妄、痴呆、惊厥或精神障碍（额叶部位）。
当以精神症状为主时，很难决定将老年人收治到精神科病房，且这种情况往往会被避免。我们报告一例81岁男性病例，他无病史，也无个人或家族精神病史，2000年开始出现行为障碍、被害妄想和嫉妒妄想、视幻觉以及性抑制。这种隐匿出现且程度较轻的临床表现长期被其家人所容忍。2008年1月，随着症状加重，患者被收治到一家精神病院。临床检查和各项检查确诊为慢性额顶叶硬膜下血肿且无压迫。神经外科的决定是暂不进行手术引流，在监测下（临床和生物学监测）给予大剂量类固醇。病情进展良好，血肿逐渐吸收直至完全康复。目前，患者无症状，2010年11月3日的最后一次CT扫描证实血肿已完全吸收。
从该病例及文献回顾来看，各种精神症状可能提示存在慢性硬膜下血肿，在老年人中，即使症状轻微，也应进行系统的神经影像学检查。大多数患者血肿完全吸收后精神症状消失，但对于即使肿块吸收后仍有残留症状的患者，这仍是一个讨论话题。面对患病老人时需谨慎，在匆忙得出衰老导致病情严重的结论之前，应努力探寻所有可能的病因。
