Spontaneous subdural haematoma in a paediatric patient on anticoagulant therapy

Abstract

DescriptionA 5-year old girl with congenital mitral and subaortic stenosis on anticoagulant therapy since her mechanical mitral valve replacement, and a remote history of idiopathic intrahepatic cholestasis requiring liver transplantation presented with jaundice and pruritus. She was found to have elevated transaminases, and an echocardiogram revealed significantly increased right ventricular pressures concerning for pulmonary hypertension. Subsequently, the patient needed to be intubated for respiratory insufficiency and poor cardiac output. After several days in the intensive care unit (ICU), she was noted to be bradycardic and have a dilated right pupil. A stat CT of the head demonstrated a large mixed density right-sided subdural haematoma with mass effect, midline shift and early uncal and transtentorial herniation, as well as a small subdural haematoma on the left (figure 1). The mixed density of the haematoma on CT scan was likely a result of multiple haemorrhages over the previous several days and/or hyperacute blood product accumulation in the setting of a coagulopathy.The patient was taken to the operating room for emergent decompressive craniectomy and evacuation of subdural haematoma. Prior to surgery, her coagulopathy was reversed with protamine, decreasing her PTT from 150 to 37 s. The patient was also given mannitol and hyperventilated as temporising measures while the operating room was being prepared. A large right frontotempoparietal craniectomy was performed in standard fashion. Removal of the bone flap revealed impressive swelling and tense dura with a blue tint. The dura was then opened progressively to avoid herniation of brain tissue or hypotension. Extensive mixed density clot was evacuated to reveal markedly swollen brain parenchyma with a mottled appearance, likely due to a combination of cerebral contusions from the mass effect of the haematoma as well as the patient's underlying venous hypertension (figure 1). After a satisfactory and uneventful decompression, an ICP monitor was placed, the bone flap was left off and the skin was closed in routine fashion. The patient was kept intubated and transported back to the ICU for further management. Figure 1 CT of the head showing right-sided subdural haematoma with mass effect, midline shift and a small subdural haematoma on the left and swollen brain parenchyma with mottled appearance after evacuation of subdural haematoma and decompressive craniectomy. Learning points

Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients

“…33 SSH has been reported in patients using anticoagulants after cardiac surgery. 34 In our patient series, of 19 patients, 1 had acute myeloid leukemia, 1 had a history of anticoagulant use due to past ventricular septal defect/tetralogy of Fallot, and 1 had a coagulability disorder. Of these patients, two had SDH at their initial admittance, and they were later diagnosed with acute myeloid leukemia and vitamin K deficiency, respectively.…”

“…Vinchon et al reported that pediatric SDHs can occur spontaneously but remain extremely rare. 9 Previous studies on pediatric SDH patients have shown that the most common causes are abuse, 11,18,19 arachnoid cysts, 15,16,29 use of anticoagulants/bleeding diathesis, 17,34 and external hydrocephalus. 37 Other underlying causes include a history of previous surgery, birth trauma, macrocephaly, arachnoidomegaly, meningeal sarcoma, and infantile tremor syndrome.…”

“…Extracerebral hemorrhages have also been found in patient groups taking anticoagulant medications 33 . SSH has been reported in patients using anticoagulants after cardiac surgery 34 . In our patient series, of 19 patients, one had acute myeloid leukemia, one had a history of anticoagulant use due to past ventricular septal defect/Tetralogy of Fallot, and another had a coagulability disorder.…”

“…anticoagulants/bleeding diathesis 17,34 , and external hydrocephalus 37 . Other underlying causes include a history of previous surgery, birth trauma, macrocephaly, arachnoidomegaly, meningeal sarcoma, and infantile tremor syndrome 9,39,40 .…”