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Acenocoumarol/amlodipine Spontaneous subacute subdural haemorrhage and haematoma: case report

A middle-aged adult woman [exact age not stated] developed spontaneous subacute subdural haemorrhage and haematoma during treatment with acenocoumarol and amlodipine [dosages, routes and time to reactions onset not stated]. The post-menopausal woman presented to the emergency room with 2-weeks history of an intense left-sided parieto-occipital pulsatile headache, with progressive worsening in the previous 2 days and minimal response to paracetamol [acetaminophen]. The neurological examination was normal. She was hypocoagulated with acenocoumarol due to previous deep vein thrombosis. Additionally, she had been receiving amlodipine for chronic hypertension. Head CT-scan showed a subacute left hemisphere and tentorial subdural hemorrhage with 17mm of maximum width and signs of acute hemorrhage in the frontal region, as well as a left frontal dural-based lesion, well-demarcated, spontaneously hyperdense, and partially calcified, measuring 15 × 18mm in diameter, causing surrounding oedema and mass effect, inducing a 10mm midline shift. Bone window revealed hyperostosis, overlying the lesion. Of note, blood tests were normal, with no signs of infection. She was then admitted to the neurosurgery ward. A head MRI revealed extra-axial left frontal lesion, with adjacent dural enhancement after intravenous contrast. An MR-angiogram excluded cerebral aneurysms or any other vascular malformations. The woman underwent a small left frontal craniotomy using neuronavigational guidance. The dural opening revealed subacute subdural hemorrhage and a yellowish rounded lesion, very well delimited, that was carefully separated from the cortical surface, preserving the arachnoid membrane, and removed with the adjacent dural thickening. The subdural haemorrhage was drained, and a soft drain was left in the subdural space. Duraplasty was made with the dural substitute. Bony hyperostosis was drilled, and the bone flap was regularised. Histology demonstrated an underlying transitional meningioma, infiltrating the adjacent dura mater. Along side some areas of fibrosis and necrosis, a few areas of internal haemorrhage were identified. The adjacent dura mater showed signs of fibrovascular proliferation and hemosiderin deposits, both intra and extracellularly. The subdural drain was removed at 24h following surgery. Steroids (unspecified) were slowly weaned postoperatively over the course of days, and seizure prophylaxis was continued for 1 month. Postoperative head CT showed satisfactory imaging result, with total subdural haematoma evacuation. After the surgery, she noticed significant headache relief and needed no analgesics at discharge, maintaining a normal neurologic evaluation. Postoperative head MRI demonstrated complete lesion removal. During the last follow-up appointment at 2 years after surgery, she remained asymptomatic. Matos D, et al. Meningioma-related subacute subdural hematoma: A case report. Surgical Neurology International 11: N