An 18-Year-Old Man with Delayed Progressive Epidural Hematoma in 4 Days after Injury

Keywords

delayed epidural hematoma - linear fracture - coagulopathy

Introduction: Epidural hematoma, usually caused by tearing of middle meningeal artery, is associated with hematoma expansion and rapid deterioration within first 24 hours. Nevertheless, hematoma size enlargement later than 3 days after injury rarely occurs. This case will outline a delayed progressive epidural hematoma patient who eventually deteriorated at fourth day after injury because of hematoma expansion.

Methodology/Description: An 18-year-old male patient with a history of motorcycle accident was referred to our hospital. Initial computed tomography (CT) scan showed right temporal bone linear fracture, small epidural hematoma at right temporal lobe, and subarachnoid hemorrhage. On admission, the Glasgow Coma Scale (GCS) was 10, pupils were equal and reactive bilaterally, and no signs of lateralization. Initial laboratory results show elevated level of D-Dimer (13.1 mg/L), leukocyte (27,800/µL), and blood glucose (222.6 mg/dL). Mannitol was administered, and patient was treated conservatively in neurology ward, then GCS level increases to 12. At day4, right pupil became dilated and had sluggish reaction to light. Subsequent CT scan shows enlargement of epidural hematoma size, and craniotomy was done. Concurrently, there were slight elevated fibrinogen levels (578.7 mg/dL), but decreased level of D-Dimer (0.4 mg/L) and leucocyte (12.510/µL), as compared with initial. At day8, patient improved and discharged from hospital with good recovery.

Conclusion: Epidural hematoma typically tends to progress acutely soon after injury. However, rare cases indicate a delayed progressive hematoma expansion. Therefore, identification of delayed hematoma expansion in the presence of risk factors (linear fracture, coagulopathy, decreased ICP) and close monitoring in epidural hematoma patients is essential, even after 3 days post injury.

• References

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• 2 Ahmad T, Imran S, Sarfraz K. Risk factors of progressive epidural hematoma in patients with head trauma.. Rawal Med J 2015; 40: 303-306