Delayed Traumatic Intracerebral Hematoma: Case Report and Review of Literature

Abstract

Delayed traumatic intracerebral hematoma is an uncommon serious complication of severe head injury that is associated with a high mortality. By definition, it arises in an area of the brain where intracerebral hematoma had been noted on a computed tomographic (CT) scan performed in the early postinjury period. The lesion was originally described a century ago by Bollinger [1]; however, Morin and Pitis [2] found only 24 cases reported in the literature before 1970. Baratham and Dennyson [3] in 1972 reported 21 cases out of 7886 cases of head injury seen during a ten-year period. It was only after the advent of CT that it was possible to confirm the de novo occurrence of hemorrhage in areas of the brain shown to be normal on an initial scan [4][5][6][7]. Currently, the reported incidence represents between 1.5 and 7% of the cases of severe head injury [8,9]. However, French and Dublin [10] could find only one case among their 1000 consecutive cases of head injury.Because delayed traumatic intracerebral hematoma frequently occurs in patients with cerebral contusion, a deteriorating neurological state in such patients may erroneously be attributed to edema around a preexisting cerebral contusion causing an increase in mass effect [6]. Thus, correct diagnosis and treatment are not infrequently delayed, with irreversible neurological damage as the outcome. The value of repeated CT scanning as part of the clinical management of severe head injury patients cannot be overemphasized.In our prospective study of 120 patients with a severe head injury (with a Glasgow Coma Scale [GCS] of 8 or below) who were seen over a one-year period, we found only one had a solitary delayed traumatic intracerebral hematoma, and this case forms the basis of our report, along with a brief review of the literature. Case ReportA 35-year-old Omani male was admitted with a GCS of 6 (i.e., no eye opening to pain, flexion withdrawal to pain, no verbal response to pain) following a road traffic accident. He had stable vital parameters (pulse, 90 bpm; blood pressure, 130/90 mm Hg; respiration, normal) and no focal neurological deficits. There were no injuries to the chest, abdomen, or limbs. Plain x-ray studies of the skull showed no fracture and CT scan done 16 hours after the accident showed no abnormality (Figure 1). With symptomatic management, his level of consciousness improved to a GCS of 11 (i.e., spontaneous eye opening, localizing to pain, voicing noise on pain). On the fourth postinjury day, a rapid-onset left hemiplegia developed and he became restless. However, his vital signs remained stable and an urgent CT scan (Figure 2) was performed that revealed a moderate-sized right posterior frontal intracerebral hematoma with surrounding edema, producing slight mass effect. He was treated conservatively, and this consisted of mannitol and dexamethasone therapy along with nursing care and physiotherapy. Over three weeks, his level of consciousness improved to a GCS of 15, and the left hemiplegia abated to a power grade of 4-5/5. Repeat CT sca...

Delayed Intracerebral Hematoma

“…

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.

…”