Delayed Intracerebral Hematoma

Abstract

of the Annals of Saudi Medicine by Sharma et al [1]. While its possible development cannot be overlooked as a cause of deterioration in the course of treatment of head-injured patients, nevertheless it is worth pointing out that in some cases it could be silent despite its multiplicity and therefore, its presence does not necessarily preclude other reasons for the deterioration.We would like to draw attention to that point through this illustrative case:A 36-year-old Saudi male was brought to the emergency room after a car accident. He had sustained a head injury with a 3-inch right temporoparietal scalp laceration but no underlying skull fracture. In addition, he suffered both pelvic fracture and a left knee ligament rupture. His admission Glasgow Coma Scale (GSC) score was 10/15 and he had a focal left hemiparesis. His initial computerized tomographic (CT) scan was almost normal except for his mild right hemispheric contusion. After resuscitation and stabilization (left knee immobilized in above-knee plaster and suture of the scalp laceration) he was ventilated in the intensive care unit. Forty-eight hours later his PO 2 dropped from 101 mm Hg to 63 on consistent CMV at a rate of 15/m, a tidal volume of 700 and FIO 2 of 35%. His PO 2 improved partially on increasing the oxygen flow, tidal volume and respiratory rate. Positive end-expiratory pressure (PEEP) of 5 had to be added to attain acceptable values of his PO 2 . His clinical picture was consistent with an acute respiratory distress syndrome (ARDS) which was later controlled. A follow-up scan after the institution of the PEEP clearly showed the development of two areas of delayed intracerebral hematoma in both the right frontal and left temporal lobes. The patient responded well to conservative treatment and he was extubated after fully recovering his level of consciousness. Over the subsequent week his left hemiparesis resolved, however, he had a transient episode of post-traumatic psychosis which responded well to haloperidol. The second follow-up CT scan of the brain showed the total resolution of the delayed intracerebral hematomas.In an earlier study on our head-injured patients there was a less than favorable expected outcome in patients with an initial GSC score of seven or less, particularly so in those who had a combination of acute intracerebral and subdural hematomas (78% died) [2]. The importance of follow-up CT scan in head-injured patients cannot be overemphasized, particularly so with evidence of deterioration during the course of treatment. The reported incidence of 1.5% and 7% [3,4] relates to those delayed intracerebral hematoma which become evident clinically, however, the incidence of the silent ones could conceivably be higher than those quoted. It is worth pointing out that the deterioration in our patient was likely due to the development of ARDS which preceeded the onset of the delayed intracerebral hematomas. A factor which may have hastened its formation is the use of PEEP which may well be an additional factor in the pathogenesi...