Spontaneous Recurrent Chronic Subdural Hematoma in a Young Woman
Received: 20 August 2018
Accepted: 06 September 2018
22 August 2019 (eFirst)
Spontaneous chronic subdural hematoma (CSH) is rare and is mostly seen in elderly persons. Only a few case reports have reported it in young individuals. We report an interesting rare case of spontaneous CSH in a young woman and the problems faced in its management. This case report also highlights the occasional but important role of magnetic resonance imaging (MRI) in managing multiseptated CSH.
A 23-year-old woman, laborer by profession, presented with complaints of headache for past 30 days with intermittent vomiting for past 5 days. The patient was fully conscious and oriented, with no neurologic deficits. Computed tomographic (CT) scan of the head showed left side frontoparietal iso- to hypodense collection in subdural location with mass effect and midline shift, suggestive of CSH ([Fig. 1]). There was no history of any trauma to the head, bleeding disorder, or intake of any anticoagulants. There was history of right-sided CSH 6 years earlier, which was drained by a burr hole in another hospital. The patient was completely normal in intervening period. Her coagulation parameters were within normal range. The hematoma was drained by frontal and parietal double burr hole technique evacuating nearly 100 cc of motor oil colored fluid and clots. Her symptoms rapidly relieved, and she was discharged on postoperative day 3. Twenty days after discharge, she presented with similar symptoms of headache, vomiting, and a new-onset right-sided hemiparesis. CT scan showed a large subdural collection in left frontoparietal region ([Fig. 2]). MRI of the brain showed presence of multiple septae within the hematoma that was not apparent in CT scan ([Fig. 3]). A formal frontoparietal craniotomy was done with excision of capsule and evacuation of hematoma ([Fig. 4]). Postoperative CT scan showed complete removal of the hematoma ([Fig. 5]). On follow-up of the patient after 6 months, there were no fresh complaints and the CT scan was absolutely normal ([Fig. 6]).
Chronic subdural hematoma is basically a disease of the elderly, and most of them are caused by trivial trauma. Spontaneous onset CSH in young persons is very rare.      Because of its rarity in young population and the nonspecific nature of symptoms, CSH is often diagnosed late and sometimes undertreated and neglected. Even in young population group, trauma remains the most common cause of such hematoma; however, some other causes have been reported. Coagulopathy, arteriovenous malformation, and aneurysm have been reported to cause spontaneous CSH. Intracranial hypotension and middle fossa arachnoid cyst have also been implicated as the predisposing factors for CSH. This case did not have any coagulation abnormality or any vascular pathology. Aneurysms can cause acute subdural hematoma due to their previous arachnoid adhesions and subsequent rupture into the subdural space, which gradually converts into a chronic collection. Wang et al reported an interesting case of spontaneous CSH in a flute trainer, which they thought to be caused by increased intravenous pressure induced by repeated blowing of air (Valsalva's maneuver). Similar role of repeated Valsalva's maneuver in causing subdural hematoma has been reported by Brennan et al in a marathon runner and Jacome and Yanez in a heavyweight lifter. Intracranial hypotension secondary to systemic hypotension or exercise can cause spontaneous subdural hematoma.
The investigation of choice in subdural hematomas is CT scan. However, rarely, as in this case, the cause of recurrent subdural hematoma could only be elicited by MRI of the brain, which showed multiseptated nature of the collection. CT scan did not show any internal septae within the collection.
The exact cause of CSH could not be revealed in this case. Multiple factors such as intracranial hypotension and straining due to labor work (Valsalva's factor) could have played a role in pathogenesis of such rare hematoma. This case is also exclusive in that it stresses the rare but important role of MRI in knowing the internal architecture of hematoma, which plays an important role in further management. Overall, the CSH should be considered in the differential diagnosis of headache in young healthy persons without any history of trauma, as a rare but easily treatable cause.
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