27th National Clinical Education Symposium Presentation Abstracts
28 APRIL 2025, MONDAY
13:00-14:00 POSTER PRESENTATION SESSION-1
Refusal of Surgical Treatment for Subdural Hematoma in a Patient with Schizophrenia: A Case Report and Discussion of Clinical Dilemma
Dilara Nur Yılmaz1, Eren Yıldızhan1, Büşra Güney Taşdemir1, Mustafa Nuray Namlı1
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1. Bakırköy Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, 3rd Psychiatry Department, Istanbul
DOI: 10.5080/kes27.abs118 Page 144
OBJECTIVE:Subacute Subdural Hematoma (SDH) is characterized by detection of hematoma usually 3 days to 3 weeks after head injury. Burr hole surgery is the main treatment intervention for chronic SDH. We present a case of a subacute SDH in a patient with schizophrenia, and the patient refused surgical interventions for SDH. Our aim is providing clinicians insight about this difficult situation managed with ciritical decisions of the patient, family and treating physicians. CASE (The patient consent must be provided and specified with appropriate terms.):The patient was a 32-year-old female with 8-year history of schizophrenia and she was admitted to the inpatient clinic because of treatment refusal. Her psychiatric examination revealed blunted affect, dysphoric mood, grandiose delusions, auditory and visual hallucinations, and disorganized speech with the absence of insight. Positive and Negative Syndrome Scale (PANSS) score was 91 upon admission. In cranial MRI, subacute SDH with a size of 25 mm in left frontoparietal location; leading to mild shift midline structures was detected. There was no neurological symptoms. Despite neurosurgical consultation recommending surgery, the patient refused any surgical intervention, but she complied with non-surgical treatments. Given that the surgery was not urgent, decision was made for close neurological monitoring. The initial psyhciatric treatment was olanzapine 20 mg/day; later, aripiprazol up to 30 mg/day was added because of treatment resistance regarding positive symptoms. During discharge after 55 days of psychiatric hospitalization, the SDH had regressed to 16 mm, and there was minimal improvement in psychotic symptoms (PANSS score: 81). In the outpatient follow-up examination after a month with regular antipsychotic treatment; there was complete regression of the SDH and her control PANSS score was 77. (The patient's legal representative provided written informed consent for publication of this case.) DISCUSSION:Treatment refusal in psychotic patients presents ethical challenges. Clinicians must balance respecting patient and caregiver desicions with ensuring appropriate medical interventions.