Nontraumatic Spontaneous Chronic Subdural Hematoma with Mass Effect and Midline Shift in an Adolescent

Abstract

Chronic subdural hematoma (CSDH) is predominantly a disease of the elderly; it rarely occurs in the pediatric and adolescent population. Nontraumatic CSDH in young individuals presents unique diagnostic and therapeutic challenges due to its rarity and atypical presentation. This is a case of a 16-year-old female who presented with headache, vomiting, and no history of trauma. Noncontrast computed tomography revealed a large chronic subdural hematoma causing midline effect. Laboratory investigations were within normal limits. The patient underwent craniotomy and showed complete recovery with no neurological deficits. She was enrolled in regular follow-up in the pediatric outpatient department.

INTRODUCTION

Chronic subdural hemorrhage is commonly seen in the elderly population.[1] In the pediatric population, it usually occurs secondary to head trauma or any bleeding dyscrasias.[2] Chronic subdural hematoma (SDH) is uncommon in the pediatric population, accounting for 3%–5% of all SDHs of age group.[3] Children usually have greater intracranial compliance due to open sutures, which might delay the presentation.[4,5] The classic triad of SDH includes headache, neurological deficits, and altered mental status, although presentation might vary.[6] Radiological investigations such as non-contrast computed tomography (NCCT) and magnetic resonance imaging (MRI) are essential to evaluate the bleed and midline shift. Management of SDH typically involves surgical intervention to prevent further deterioration with perioperative anti epileptics and anti-edema medications, and postoperative physiotherapy. This is a case report of an adolescent female with spontaneous SDH without any history of trauma or bleeding disorder who was successfully treated by craniotomy and postoperative care, resulting in complete recovery.

CASE REPORT

A 16-year-old female presented to the emergency department with complaints of occipital headache and neck pain for 1 week. The headache was progressive and associated with multiple episodes of projectile vomiting and diplopia. There was no history of recent head trauma or any bleeding manifestations. There was a history of hypertension in the father, who is currently on antihypertensives.

On examination, the patient was irritable with a Glasgow Coma Scale score of 15/15. Vital signs revealed pulse rate of 62/min, blood pressure of 110/70 mmHg, with (Respiratory rate)RR-20/min. General physical examination showed no abnormalities, and systemic examination was normal.

Ophthalmological evaluation revealed early disc edema changes suggestive of raised intracranial pressure.

NCCT showed a chronic SDH measuring 25–30 HU (Hounsfield units) along the right frontoparietal temporo-occipital region. The hematoma caused mass effect on the adjacent brain parenchyma with a midline shift of 11 mm toward the left. The suprasellar cistern appeared effaced, suggestive of impending transtentorial descending herniation [Figure 1]. MRI + magnetic resonance angiography showed the left transverse sinus appeared hypoplastic [Figure 2].

Figure 1.

Noncontrast computed tomography showing a curvilinear collection noted along the right cerebral hemisphere, mainly along the frontoparietal region, causing mass effect in the form of effacement of adjacent sulci, right lateral ventricle, and midline shift of 11 mm toward the left side - suggestive of subdural hematoma

Figure 2.

Magnetic resonance imaging films showing subdural hematoma on the right cerebral hemisphere in fronto temporo parieto occipital area, causing mass effect with midline shift. The hematoma is noted to be hypointense in T1 and T2 sequences. (a) T2 imaging, (b) flair, (c) Susceptibility weighted imaging (SWI) and (d) T1 imaging

Laboratory investigations, including complete blood count along with peripheral blood smear, coagulation profile and bleeding and clotting factors, were within normal limits, ruling out bleeding disorders. Echocardiography done by a cardiologist showed a normal cardiac structure with no evidence of structural abnormalities. A multi-disciplinary approach was adopted involving neurosurgery team.

After obtaining informed consent, burr-hole craniotomy was performed under antibiotic cover along with anti-seizure medication and anti-edema measures.

Postoperatively, the patient was shifted to the pediatric intensive care unit for close monitoring. She remained hemodynamically stable, and postoperative repeat NCCT scan showed near-complete resolution of the chronic SDH with a significant reduction in midline shift from 11 mm to 1.8mm with a reduction in mass shift [Figure 3].

Figure 3.

Noncontrast computed tomography postoperative films with resolution of midline shift, along with burr-hole defects

Postoperative care included antibiotics, antiepileptics, anti-edema measures, and supportive care with analgesics. The patient showed no signs of neurological deficits.

Subsequent NCCT showed complete resolution, and she was enrolled in regular follow-up in the pediatric and neurosurgery outpatienvt department for monitoring any potential complications.

DISCUSSION

Chronic SDH is predominantly a disease of the elderly. Its incidence in the pediatric and adolescent population is low, accounting for only 3%–5% of all SDHs, making our case of a 16-year-old female particularly noteworthy.[2]

Only around 20 cases of spontaneous chronic subdural hemorrhage without predisposing factors have been reported in the literature, highlighting its rarity and the importance of early diagnosis and intervention.

Clinical presentation of CSDH in adolescents is often non-specific, often leading to delayed diagnosis. Radiological evaluation remains the cornerstone of CSDH diagnosis and surgical planning. NCCT is the main diagnostic evaluation for evaluation of the severity of the bleed and any possibility of herniation.[7]

MRI provides anatomical causes for the hematoma. This study shows a left hypoplastic transverse sinus, which was an incidental finding but not a direct cause of the bleed.

Surgical management is the definitive treatment for symptomatic CSDH with significant mass. The primary surgical approach would be burr-hole craniotomy.[8,9]

Postoperative management in the intensive care setting allows for close neurological monitoring and early detection of complications such as rebleeding, infection, or cerebral edema, and optimization of intracranial pressure. The patient’s smooth postoperative course with rapid clinical improvement and excellent neurological recovery is consistent with the generally favorable prognosis reported in pediatric CSDH cases.[4,10] Recurrence rates in the pediatric population are reported to be lower than in adults, ranging from 9% to 33%.[10] Regular follow-up is essential to detect early signs of recurrence. Complete resolution of symptoms shows an excellent prognosis in children.

CONCLUSION

This case highlights the rarity of spontaneous SDH with no prior history of trauma or bleeding disorders, which makes it a diagnostic challenge. Timely recognition and prompt surgical intervention are crucial to prevent neurological deficits. The excellent outcome in the patient emphasizes that early intervention can lead to complete recovery and a favorable prognosis in pediatric patients.

Patient perspective

The patient and relatives were frightened by the sudden onset of symptoms and diagnosis of subdural hemorrhage without any known predisposition. They were relieved following successful surgery and excellent recovery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.