Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport 71103, Louisiana, United States.
J Stroke Cerebrovasc Dis. 2020 Aug;29(8):104872. doi: 10.1016/j.jstrokecerebrovasdis.2020.104872. Epub 2020 May 18.
Acute, recurrent subdural hematoma (SDH) is a rare entity in the absence of trauma. Atraumatic SDH may be due to vascular disorders, coagulopathies, or intracranial hypotension. It is a rare complication of disseminated intravascular coagulation (DIC), with no prior reports in patients with intracranial metastatic colon cancer (MCC). Rapid resolution of the initial acute SDH with contralateral recurrence has not yet been reported in the literature. We present a case of rapidly resolving and recurrent, contralateral acute SDH from DIC secondary to MCC.
A 77-year-old woman with MCC presented with severe, acute onset headache. She progressed to unresponsiveness, dilated right pupil, and Glasgow Coma Scale (GCS) score of 4T. Initial computed tomography (CT) of the head demonstrated a right, 17-mm SDH with a right-to-left midline shift. Repeat CT head 8 hours later revealed resolution of the right SDH. She was extubated with notable clinical improvement. Laboratory examination showed international normalized ratio of 3.4, leukocytosis, and thrombocytopenia. The next morning, she became lethargic, GCS score of 3, with bilateral fixed pupils and dilated to 5-mm, and she was then reintubated. Repeat CT head demonstrated a new left SDH with bilateral uncal herniation. A small hyperdense focus in the left parietal region was suspicious for intraparenchymal hematoma versus a hemorrhagic metastatic focus. Shortly after, she was extubated due to do not resuscitate status, and she then passed away.
To our knowledge, this is the first case illustrating rapidly resolving and recurrent, contralateral acute SDH from DIC in a patient with MCC. Clinical recognition of this phenotypic pattern should raise the question of an underlying coagulopathy.
在没有外伤的情况下，急性、复发性硬膜下血肿（SDH）是一种罕见的情况。非创伤性 SDH 可能是由于血管疾病、凝血障碍或颅内低血压引起的。它是弥散性血管内凝血（DIC）的罕见并发症，在颅内转移性结肠癌（MCC）患者中尚无先前报道。文献中尚未报道 DIC 继发于 MCC 的双侧急性 SDH 迅速消退并再次出现的情况。我们报告了一例因 MCC 继发 DIC 而迅速消退和再次出现的双侧急性 SDH 病例。
一名 77 岁女性因 MCC 出现严重、急性发作的头痛。她病情进展为无反应、右侧瞳孔扩大和格拉斯哥昏迷量表（GCS）评分为 4T。头部初始 CT 显示右侧 17mm SDH 伴右侧至左侧中线移位。8 小时后重复头部 CT 显示右侧 SDH 消退。她在明显的临床改善后被拔管。实验室检查显示国际标准化比值为 3.4、白细胞增多和血小板减少。第二天早上，她变得昏昏欲睡，GCS 评分为 3，双侧瞳孔固定且扩大至 5mm，随后再次插管。重复头部 CT 显示新的左侧 SDH 伴双侧小脑幕疝。左顶叶的一个小高密度病灶疑似为脑实质内血肿而非出血性转移性病灶。不久后，由于不复苏状态，她被拔管，随后去世。
据我们所知，这是首例在 MCC 患者中描述由 DIC 引起的迅速消退和再次出现的双侧急性 SDH 的病例。这种表型模式的临床认识应引起对潜在凝血障碍的质疑。
