Successful conservative management of a large acute epidural hematoma in a patient with arrested hydrocephalus: A case report
- Division of Neurosurgery, Department of Neuroscience, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Philippines.
Kevin Ivan Peñaverde Chan, Department of Neuroscience, Philippine General Hospital, Manila, Philippines.
DOI:10.25259/SNI_982_2021Copyright: © 2022 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Kevin Ivan Peñaverde Chan, Jose Francisco Abawag Aguilar, Kathleen Joy Ong Khu. Successful conservative management of a large acute epidural hematoma in a patient with arrested hydrocephalus: A case report. 19-Aug-2022;13:366
How to cite this URL: Kevin Ivan Peñaverde Chan, Jose Francisco Abawag Aguilar, Kathleen Joy Ong Khu. Successful conservative management of a large acute epidural hematoma in a patient with arrested hydrocephalus: A case report. 19-Aug-2022;13:366. Available from: https://surgicalneurologyint.com/surgicalint-articles/11811/
Background: Arrested hydrocephalus is a condition wherein congenital hydrocephalus spontaneously ceases to progress due to a balance between production and absorption of cerebrospinal fluid. These patients rarely present with pressure symptoms so conservative treatment may be instituted. There are, however, little data on the long-term outcomes of these patients and how they present in the presence of other intracranial pathologies as they transition into adulthood. We aim to add to the growing knowledge about the management of patients with arrested hydrocephalus who have sustained traumatic hematomas.
Case Description: To the best of our knowledge, we present the only reported case of a 34-year-old female with arrested hydrocephalus who sustained an acute epidural hematoma secondary to a fall and underwent a conservative management. She was asymptomatic except for mild headache that started on the 3rd day postinjury and was thus treated conservatively with favorable outcomes. A review of literature showed that adults with arrested hydrocephalus may develop intracranial hematomas after head injuries despite them manifesting with little or no symptoms. The hydrocephalus may have provided them with a form of internal decompression thus delaying symptomatology.
Conclusion: Clinicians should be vigilant as these patients will present with either delayed or completely without neurologic symptomology. Tailored and individualized management of other intracranial pathologies should be adapted in this subset of patients.
Keywords: Acute epidural hematoma, Arrested hydrocephalus, Traumatic brain injury, Untreated congenital hydrocephalus
Hydrocephalus is a complex neurologic disorder characterized by an increased amount of cerebrospinal fluid (CSF), enlargement of the cerebral ventricles, and raised intracranial pressure.[
There are little data on the long-term outcomes of patients with arrested hydrocephalus.[
Here, we present a unique case of an adult woman with arrested hydrocephalus who had a large acute epidural hematoma from a blunt head injury that was managed conservatively and had a good outcome.
A 34-year-old female was admitted for traumatic brain injury. She slipped on the bathroom floor and fell, resulting in loss of consciousness. She regained consciousness after a few minutes but did not seek consult. She was initially well but started to complain of intermittent right-sided headache 3 days postinjury, prompting consult at a general clinic. Cranial CT scan showed a large acute epidural hematoma on the right temporal area, measuring 41 cc in volume and resulting in a midline shift of 0.4 cm. The lateral and third ventricles were enlarged but did not exhibit transependymal effusion, and the cerebral sulci were effaced. There was also a linear and nondisplaced right temporal bone fracture [
Axial (a-c) and sagittal (d) day 3 postinjury plain cranial CT scan showed a right temporal acute epidural hematoma measuring 8.5 × 3.1 × 3.1 cm (41 cc), obstructive hydrocephalus without transependymal effusion and with an Evan’s Index of 0.5, absent septum pellucidum, tectal beaking, and a small posterior fossa cyst; day 5 postinjury cranial CT scan (e) showed no progression of the hematoma; and 3-week postinjury cranial CT scan (f) showed the resolving hematoma.
Her medical history was significant for a diagnosis of congenital hydrocephalus from aqueductal stenosis, but she did not undergo surgery. She was also an epileptic maintained on phenobarbital, with the last seizure episode occurring about 15 years ago. She had a recent history of mild COVID-19 infection 5 months prior. Despite having hydrocephalus, she did not exhibit developmental delays as a child and underwent schooling at the proper age. She finished high school at the top of her class, earned a bachelor’s degree at age 20, and is currently pursuing a master’s degree while employed full time.
On examination, the patient had a Glasgow Coma Scale (GCS) of 15 with equal and briskly reactive pupils. She was slightly macrocephalic, and her head circumference of 59 cm was in the upper 97th percentile when plotted against her height.[
Because the patient was asymptomatic except for mild headache and was already on the 5th postinjury day, it was decided to treat the patient conservatively with analgesics and close clinical monitoring at the neurosurgical ward. The patient’s headache resolved and she did not develop any deficits; thus, she was sent home on the 8th day postinjury.
A repeat cranial CT scan [
The patient’s latest follow-up was at 10-month postinjury. She continued to be well and asymptomatic and did not have any new complaints.
This is a report of a patient with arrested hydrocephalus who was found to have a large acute epidural hematoma after sustaining a blunt head injury after a fall. Despite the large size of the hematoma, which would usually cause symptoms and require surgical evacuation,[
A few case reports of patients with arrested hydrocephalus and traumatic intracranial hematomas have been reported in the literature. They included a 34-year-old male who became symptomatic from a 700 cc subdural hematoma 10 weeks after a fall;[
Neurologic symptomatology or deterioration usually occurs within the first 24 h of injury.[
If the postulated mechanism was true, patients with arrested hydrocephalus should be aware of the possibility of developing clinically asymptomatic hematomas if they sustain traumatic brain injuries. As such, the Canadian Head CT Rule, which guides clinicians in the emergency department on the indications for ordering cranial imaging after minor head trauma,[
In fact, the authors still believe that surgical evacuation is still the gold standard for large traumatic hematomas even in the present of arrested hydrocephalus. It should be emphasized that a conservative management was indeed illustrated by the above case, but larger retrospective or prospective studies are required to fully recommend the similar management.
This case report adds to the growing knowledge about the management of traumatic hematomas in patients with arrested hydrocephalus. Tailored and individualized management of other intracranial pathologies should be adapted in this subset of patients.
Clinicians should be vigilant as patients with arrested hydrocephalus may present with either delayed or completely without neurologic symptomology. The patient’s hydrocephalus may have provided them with a form of internal decompression. Individualized management of other intracranial pathologies should be adapted in patients with arrested hydrocephalus.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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