|Ahead of print
Spontaneous and rapid resolution of acute subdural hematoma in a 5-year-old child: A case report
Prashant Punia, Ashish Chugh, Sarang Gotecha, Shobhit Chhabra
Department of Neurosurgery, Dr. D. Y. Patil Medical College & Hospital, Pimpri, Pune, Maharashtra, India
|Date of Submission||03-Mar-2021|
|Date of Decision||18-Jun-2021|
|Date of Acceptance||19-Sep-2021|
|Date of Web Publication||13-Jun-2023|
Department of Neurosurgery, Dr. D. Y. Patil Medical College & Hospital, Pimpri, Pune 411018, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Subdural hematoma (SDH) following trauma is a common neurosurgical emergency but rapid and spontaneous resolution of the same is a rare phenomenon. Authors report a case of 5-year-old female child in whom spontaneous and rapid resolution of acute SDH was observed. The hematoma spontaneously resolved over a period of only 5 h. Only a handful of case reports exist on this phenomenon and various causes for rapid resolution have been reported to be dilution by cerebrospinal fluid and redistribution of hematoma. A hypodensity inside the hematoma along with improvement in neurological condition of the patient can point to the correct diagnosis. This case report is useful in making the neurosurgeon cognizant of this entity and make timely informed decisions based on radiology and clinical examination. Being forewarned is being forearmed.
Keywords: Rapid resolution of SDH, resolving SDH in children, spontaneous resolution of SDH
| Introduction|| |
Subdural hematoma (SDH) following trauma is a fairly common neurosurgical emergency associated with a high mortality rate of up to 60%. Most commonly these hematomas are promptly subjected to surgical evacuation and spontaneous resolution of SDH is a rare phenomenon. Authors report a case of spontaneous resolution of acute traumatic SDH in a 5-year-old child in a short duration of 5 h. Probable underlying mechanisms for the same have been discussed.
| Case Report|| |
A 5-year-old female child was brought to our hospital at 1930 h by her relatives with a history of road traffic accident 1 h back, that is, at 1830 h. The patient had a severe headache and two episodes of projectile vomiting since then. The patient’s pupils were symmetrical and reacting to light and her Glasgow Coma Scoring (GCS) was 12 at the time of presentation. After initial resuscitation, she was rushed for a plain computed tomography (CT) scan of the head at 2000 h. CT revealed a right frontoparietal SDH with a midline shift of 3 mm [Figure 1]. Considering the preserved level of consciousness and papillary symmetry, a decision was taken to conservatively manage the patient and repeat a scan after 6 h while monitoring her neurological status carefully. At the time of repeat CT scan, at 0100 h, the patient’s GCS had improved to 14 and her scan revealed near-total resolution of the previously seen hematoma along with a resolution of mass effect and compressive symptoms [Figure 2]. Conservative management was continued and the patient was discharged on the third day after a repeat CT scan showed no progression of hematoma.
|Figure 1: Showing CT scan plain brain, axial view, showing hyperdense collection along the right frontoparietal region with mass effect on the ipsilateral ventricle. Time of CT, that is, 2021 h are shown (underlined)|
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|Figure 2: Showing CT brain plain, axial view, showing near-total resolution of SDH with a resolution of mass effect. Time of CT, that is, 0141 h are shown (underlined)|
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| Discussion|| |
A rapid collection of blood below the dura but above the brain itself is labeled as SDH. Unless the patient has irreversible brainstem signs or extremely poor general condition, it is a neurosurgical emergency and treatment consists mostly of the evacuation of hematoma and is derived from standard treatment protocols. Generally, conservatively managed hematomas resolve gradually over a period of 2–3 weeks. Rarely, in a patient with SDH managed conservatively, a rapid resolution is seen. It is defined as a decrease in 50% of the volume of hematoma in 72 h. The current case is exceptional and interesting by virtue of the extremely quick resolution of hematoma in 5 h. Only Koppen et al. have reported a rapid resolution time of 4 h which is less than the present case.
Rapid resolution of hematoma is a rare phenomenon and only a few case reports exist in the English literature. The entity was first reported in 1986 and several mechanisms have been put forward to explain the pathogenesis of the same. Hematoma washout by cerebrospinal fluid (CSF) following a breach of subarachnoid space is a commonly accepted theory and it was suggested both by Nagao and Niikawa. They proposed that due to the mixing of CSF with hematoma, it is diluted, redistributed, and eventually washed out. This hypothesis is supported by Kato et al. who proposed that presence of a low-density band within a hematoma is a pointer toward mixing of CSF with blood and that rapid resolution of SDH occurs via redistribution. A later retrospective study; however, found no statistical difference for the presence of a low-density band when they compared rapid and nonrapid resolution of SDH in 154 patients. Acute brain swelling has also been proposed as a contributing factor toward rapid resolution and it has been postulated that in addition to redistribution, the swollen brain compresses the hematoma toward the cranial vault and assists in dilution and redistribution.
In the author’s opinion, dilution and redistribution played a part in the resolution of hematoma in our case. A hypodense area was noted inside the hematoma in our patient [Figure 3] and although it has been regarded as statistically insignificant by a few authors, the sign has been described in most case reports and series on this rare entity. Also, the study which downplays this sign is not free from retrospective bias.
|Figure 3: Showing presence of hypodensity inside the hyperdense clot (arrow)|
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Decision-making forms an essential and integral part of management strategy and is based on the clinical condition of the patient and radiology. In our case, neither the clinical condition nor the initial CT brain warranted surgery, and thus, a decision to closely monitor the patient and repeat the scan was taken. Although it has been deemed necessary to evaluate the progression of injury, there is no universal guideline/consensus on the timing of a repeat CT brain. In actual practice, repeat scans range from 1 h to 23 h, with a median interval time of 6 h. In our patient, a decision to repeat the scan early was taken keeping in mind the presence of hypodensity in the clot. The hypodensity could have been suggestive either of a hyperacute bleed or a connection with subarachnoid space and clarity on the same was needed to avoid prognostic uncertainty. Also, during that period, there was clinical improvement seen which gave a clue toward a better CT scan picture. Thus, early decision making is of paramount significance and decisions should be made based on the clinical condition of the patient supported by radiological evidence.
The case report is useful in making the neurosurgeon cognizant of the entity, make early decisions based on clinical condition and radiology, and also, possibly save the patient from the stress of surgery. Authors would stop short of recommending pathogenesis based on a single case report and a bigger, double-blind prospective study is the need of hour to define the variables for easy recognition of such patients. However, as the incidence of this entity is rare, it might be difficult to randomize the patients prospectively.
| Conclusion|| |
The case report is useful in making the neurosurgeon cognizant of the entity, make early decisions based on clinical condition and radiology, and also, possibly save the patient from the stress of surgery. Being forewarned is being forearmed.
Ethics approval and consent to participate
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (name of institute/committee) and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
Consent for publication
Taken they proposed a lower rate of comorbidities and prehospital anticoagulation as significant variables which contribute to rapid resorption of SDH. Both these variables were previously unrecognized and further research needs to affirm the same.
Availability of data and material
P.P. conceived and designed the study. A.C. helped in drafting the article. S.G. collection of data and final review.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Limitations of study
The study has the following limitations which mandate future studies:
- -Small sample size
- -Lack of control group
- -Single center study.
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[Figure 1], [Figure 2], [Figure 3]