6.2.3 Acute headache attributed to non-traumatic acute subdural haemorrhage (ASDH)

Identification: Male patient, 72 years old, on chronic oral anticoagulant therapy (warfarin, INR 3.8) for atrial fibrillation, hypertensive, and alcohol user. History of Present Illness: Reports progressive left frontoparietal headache for 48 hours (intensity 8/10). Characteristics: Insidious onset, but with acute worsening in the last 6 hours. Continuous pressure-like pain, without pulsatile characteristics. Worsens with coughing and head movements. Associated Symptoms: Progressive mental confusion. Nausea and vomiting (2 episodes). Weakness in the right hemibody (started 3 hours ago). Denies recent head trauma or falls. Neurological Examination: General state: GCS 12 (E3V4M5), disoriented in time and space. Focal signs: Right hemiparesis (3/5). Anisocoria (left mydriasis). Slow pupillary light reflex on the left. NIHSS: 10. BP: 190/100 mmHg. Complementary Exams: Non-contrast cranial CT: Acute left convexity subdural hematoma (thickness 15mm). Midline shift (8mm). Mass effect on the frontal and parietal cortex. No associated skull fractures. Coagulation profile: INR: 3.8 (therapeutically elevated). PTT: normal. CT Angiography: Excludes vascular malformations. Confirms compression of adjacent parenchyma.