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Título

CHRONIC EPIDURAL HEMATOMA WITH ATYPICAL EVOLUTION POST TRAUMATIC BRAIN INJURY: CASE REPORT

RESUMO

Case presentation: Patient, male, 27 years old, with hemiparesis and grade 4 motor strength - on the right, with a history of severe traumatic brain injury (TBI) and neurosurgical approach with left decompressive craniectomy and later cranioplasty, at age 19. A control cranial tomography revealed a passive epidural hematoma of resorption, which was chosen for a conservative approach. During the subsequent 7 years, there was no clinical worsening, but with gradual growth of the hematoma evidenced on CT. In 2022, CT showed a heterogeneous left frontoparietotemporal formation, predominantly hyperattenuating, measuring 8.7 x 8.6 x 6.3, with a midline deviation of 1.8 cm, dilatation of the ventricular system and CSF transudation, suggestive of Chronic Epidural Hematoma (CEH). A reapproach was decided, with preoperative MRI showing a lesion measuring 9.3 x 9.3 x 7.2 cm. During the procedure, the presence of fibrosis in the dura mater was noted, as well as a heterogeneous hematoma with no apparent origin of the bleeding, with an aspect of “hard clay” next to the “motor oil” aspect. In the postoperative period, the patient evolved with a bulging wound. surgery and exteriorization of serous secretion, without exudate or foci of bleeding, with a diagnostic hypothesis of dural cerebrospinal fluid fistula Discussion: The precise definition of CEH is not clearly defined, it is known, however, that it is more common in young men, associated with TBI and the source of bleeding is usually venous. Most reports state that only 15% of patients did not present clinical signs suggestive of CEH, as in this case. It is understood that a cerebrospinal fluid redistribution in the lateral ventricles could allow the creation of space for the hematoma to grow, not leading to clinical involvement, which may be the anatomopathological basis of this report. In addition, most cases have a mean time between CT and diagnosis. months, with few descriptions with more than years after the TBI, in this case the evolution of 8 years. In addition, the literature describes that CEH is isodense, corroborating the predominantly liquid presentation of CEH on surgical inspection, but with little association with the “hard clay” appearance. Final comments: We present an CEH with a poorly documented chronological evolution and whose pathophysiology has not yet been elucidated. Its heterogeneous appearance, together with postoperative evolution, raises the diagnostic hypothesis of a dural CSF fistula.