1. Abstract Chronic subdural hematoma generally occurs in elderly patients. Anti-coagulation is also a frequent risk factor for this disease. The objective of thisreport was to present the rare case of a right hemispheric subdural hematoma associated with a COVID-19 lung infection in an 81years old female patient, both diagnoses confirmed with imaging and biological work-up. On admission, she presented with an altered general state as well altered state of consciousness, chest pain and left side motor deficit. The management of the subdural hematoma was surgical while the COVID-19 pneumonia was managed using a medical protocol which included curative anticoagulation. The post-operative course was marked by re-bleeding of the subdural hematoma. This case report thus brings out the ambiguity regarding the possible association of COVID-19 infection and chronic subdural hematoma on one hand, and the risk-benefit effect of using anticoagulants in COVID-19 patients presenting a high risk of bleeding, on the other hand [1-5].
Keywords: Anti-Coagulation; COVID-19; Hypercoagulability
2. Case Presentation We report the case of an 81years old woman presenting with subacute subdural hematoma associated with COVID-19 pneumonia. It was a female married Cameroonian housewife; hypertensive for over 3years, followed up but not compliant to treatment. She had an ischemic stroke 2 years ago with no sequalae but not documented. She is also known to have a cardiopathy with atrial fibrillation.She was brought to the Yaoundé Emergency Centre (YEC) for behavioral changes and left side motor deficit of progressive evolution over 2weeks prior to consultation [6-10]. There was no notion of head trauma. Otherwise, she had chest pains. Physical examination revealed: • Altered general state with asthenia; • Altered state of consciousness with a GCS of 13/15; • Left hemiparesis at 3/5; • Lung and heart exams were unremarkable; • Vital parameters were within normal limits; • The rest of physical examination was normal.
3. Introduction With regards to this clinical picture of a sub-acute right hemispheric subdural hematoma with mass effect and altered conscious state, as well as a COVID-19 pneumonia, the management strategy developed was first to treat the subdural hematoma, then the COVID-19 infection. A trepanation was done with washing and drainage of the subdural hematoma under local anesthesia and sedation. She was installed in the supine position, head turned towards the left. A 5cm linear right frontal-parietal incision was done following the superior temporal line and a borehole was created behind the coronal suture. Per operative finding was a dark fluid with an “engine oil” aspect mixed with some blood clots. Abundant washing of the subdural space was done using isotonic normal saline and closure was done in two planes after placing a non-aspirate redon drain. The intervention was well tolerated. Post-operative treatment comprised of analgesics and prophylactic antibiotics at meningeal doses. The patient was then transferred to the COVID-19 treatment unit of the Yaoundé Central Hospital (YCH) [11-13]. On Admission, she complained of fatigue and had an acute respiratory distress syndrome. She was placed on a management protocol for COVID-19 comprising; high concentration mask oxygen therapy, Azithromycin, Amoxicillin-clavulanic acid, Vitamin C, Vitamin D, Zinc, a bolus of Methylprednisolone, curative dosage of Enoxaparin. The evolution a few days later was marked by the progressive improvement in the state of consciousness, as well as regression of the left hemiparesis and respiratory difficulties notably with amelioration of the oxygen saturation leading to the withdrawal of oxygen on post-operative day 8. A control COVID-19 rapid diagnostic test was negative. On post-operative day 10, the patient presented with a rapidly progressive alteration in her state of consciousness within about 12hours with her GCS moving from 13 to 11/15. A control brain CT-scan done (Figure 3) showed a bilateral pan hemispheric subdural hygroma, marked at the right with re-bleeding at the site of trepanation, without mass effect to the adjacent parenchyma. Management was conservative with Tranexamic acid, Etamsylate, Vitamin K, Methylprednisolone and Enoxaparin at prophylactic doses. The evolution 4days later was favorable with amelioration of consciousness with a GCS of 14/15. The patient was discharged on post-operative day 18, and during the follow up two weeks later, she had a good general state, normal state of consciousness and an improvement in muscular force of the left side.
4. Discussion It is the rare case of a female 81years old hypertensive patient, non-compliant to treatment, also having a cardiopathy with atrial fibrillation. She presented with a sub-acute subdural hematoma with mass effects associated with COVID-19 pneumonia. The hematoma was treated with surgery and pneumonia treated at a specialized COVID-19 treatment center. The anticoagulation at curative doses administered in the treatment plan would have been a risk factor for the occurrence of re-bleeding at the hematoma site in the post-operative period (Figure 1). Administration of a short course pro-thrombotic treatment protocol associated with corticosteroids led to the control of the re-bleeding and amelioration of the neurological condition of the patient [14-17]. The doses of anticoagulants to be administered for prophylaxis in the treatment plan of moderate to severe forms of COVID-19 infections has to follow a rigorous evaluation of the risk of bleeding in patients. This also has to take into consideration the clinical state of the patient, the past history and comorbidities, especially intracranial hematoma. Moreover, the cause and effect relationship between COVID-19 infection and the occurrence ofspontaneous subdural hematoma in our patient could be the hypothesis and point of interest for further research (Figure 2 and 3).
5. Conclusion The hypercoagulability of blood and thrombo-embolic events observed in patients with COVID-19 infections justified the systematical empiric use of anticoagulants in the management of these patients generally. Considering the fact that our patient presented with a severe form of COVID-19, using curative doses of anticoagulation seemed justified. However, the probable contribution of this anticoagulation to the re-bleeding of the subdural hematoma brings to light the necessity of a judicious evaluation of the risk-benefit effects as well as a consideration of the appropriate dosage before initiating an anti-thrombotic protocol in the treatment of COVID-19.
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Aubin Sandio. Sub-Dural Hematoma and COVID-19 Infection: Re-Bleeding Following Anti-Coagulation. Annals of Clinical and Medical Case Reports 2022