CASE REPORT Bali Medical Journal (Bali MedJ) 2021, Volume 10, Number 2: 507-509 P-ISSN.2089-1180, E-ISSN: 2302-2914 Acute subdural hemorrhage accompanied with rupture of the inferior vena cava: a case report

Published by Bali Medical Journal Marsal Risfandi1, Sayed Musyari2, Celia3*

ABSTRACT

Introduction: One of the main causes of mortality and morbidity with physical and mental disabilities is traumatic brain injury (TBI). Apart from that, TBI also causes huge socio-economic burdens around the world. About 60% of TBI cases reported are caused by traffic accidents. Acute subdural hemorrhage (ASDH) is the main clinical finding in TBI cases. Blunt abdominal trauma associated with TBI accounts for 14% of cases. Inferior vena cava (IVC) injury is the most common vessel injured in a blunt (0.6-1%) and penetrating abdominal trauma (0.5-5%). Injury of the IVC can lead to a very high mortality rate. Case description: Male patient, 15 years old, presented to the emergency department 30 minutes after a traffic accident with decreased consciousness with the Glasgow Coma Scale score of 11. The patient’s chest was clear, abrasions were found 1Neurosurgeon, Putri Bidadari Hospital, on the left hypochondrium. Head CT scan represented acute subdural hemorrhage in the left frontotemporoparietal region Langkat, Indonesia; was accompanied by midline shift more than 0,5cm. Hemicraniectomy decompression was performed. After decompression 2General surgeon, Putri Bidadari was done, the patient was unstable, blood pressure down to 70/50 mmHg and weak peripheral pulses with 140 beats per Hospital, Langkat, Indonesia; minute. Fluid and blood resuscitation have been performed but not responding. The patient remained hemodynamically 3 Neurosurgeon, Atmajaya Hospital, unstable with minimal urine output. Physical examination reveals a tense abdomen. Diagnostic peritoneal lavage (DPL) was Jakarta, Indonesia. performed, blood was obtained. Exploration laparotomy was done by a midline incision, and IVC injury was found. The blood was removed, then packing on IVC with gauze, observation, and no blood comes out. The packing was opened, the patient *Corresponding author: Celia; stable, the operation was complete. Neurosurgeon, Atmajaya Hospital, Conclusion: Case of severe head injury with acute SDH, then a craniectomy was performed, in the abdomen had a ruptured Jakarta, Indonesia; inferior vena cava, an exploratory laparotomy was done. Currently, the patient has recovered well without deficits. [email protected] Keywords: acute subdural hemorrhage, inferior vena cava injury, traumatic brain injury. Received: 2021-04-18 Cite This Article: Risfandi, M., Musyari, S., Celia. 2021. Acute subdural hemorrhage accompanied with rupture of the inferior Accepted: 2021-06-19 vena cava: a case report. Bali Medical Journal 10(2): 507-509. DOI: 10.15562/bmj.v10i2.2393 Published: 2021-06-26

INTRODUCTION outcomes, such as the patient’s age, followed by the RHIVC (19%), SRIVC associated brain injuries, time lag between (18%), PRIVC (17%), and SHIVC as the One of the main causes of mortality and injury and surgical care, and the patient’s least likely segment to be injured. Several morbidity with physical and mental level of consciousness on admission.5 factors reported that may be predictive disabilities is traumatic brain injury Blunt abdominal trauma associated with to patient’s mortality are patient’s (TBI). Apart from that, TBI also causes TBI contributes to 14% of cases.6 hemodynamic status on arrival, level of huge socio-economic burdens around the Inferior vena cava (IVC) injury is the the IVC where the injury occured, amount world. About 60% of TBI cases reported most common vessel injured in a blunt of associated injuries, blood that have been are caused by road traffic accidents, which (0.6-1%) and penetrating abdominal loss since the injury occured, and blood make it the most common and important 7 1,2 trauma (0.5-5%). Injury of the IVC transfusion requirements. One recent cause of TBI. can lead to a very high mortality rate. study by Huerta et al. described GCS as an Acute subdural hemorrhage (ASDH) Mortality rates for IVC injuries reported independent predictor of mortality in IVC is the main clinical finding in TBI cases. in the literature range from 34% to 70%.8 trauma.8 Neurosurgeons find it as a common A rapid and uncontrollable hemorrhage We present a severe head injury with clinical entity and usually have a poor can be produced by the shear forces on acute SDH accompanied with rupture of prognosis. ASDH represents One-third of the blood vessels induced by deceleration. the IVC containing traumatic para-renal severe head injuries. The mortality rate of 3 Anatomically, the IVC is divided into rupture of the IVC, which performed the cases increased up to 60%. According segments, which are supra-renal (SRIVC), successfully with surgical intervention. to the report in the western countries, retro-hepatic (RHIVC), infra-renal although the mortality rate may be better, (IRIVC), para-renal (PRIVC), and supra- CASE DESCRIPTION ASDH still carries substantial mortality hepatic (SHIVC). IRIVC is the most 4 A 15-year-old male patient presented in death under 45 years old. Many frequently injured segment (39%), then prognostic factors may influence patients’ to the emergency department 30

PublishedOpen access: by Baliwww.balimedicaljournal.org Medical Journal | Bali Medical Journal 2021; 10(2): 507-509 | doi: 10.15562/bmj.v10i2.2393 507 CASE REPORT

was seen with active bleeding; the primary Injury of the IVC can lead to a very high suture was performed, the bleeding mortality rate. A rapid and uncontrollable stopped. After that, the identification of hemorrhage can be produced by the shear hollow organs was carried out. There was forces on the blood vessels induced by a laceration in the transverse colon at the deceleration. Anatomically, the IVC is border of the serosa, and a primary suture divided into segments, which are supra- was performed. The passage test was good. renal (SRIVC), infra-renal (IRIVC), para- The solid identification of other organs renal (PRIVC), supra-hepatic (SHIVC), within normal limits was carried out. and retro-hepatic (RHIVC). The most The next identification is thefrequently injured segment is IRIVC (39%), identification of the oral cavity. Pallatum and SHIVC is the least likely segment to molle rupture is visible, size 5 cm, then be injured. Several factors reported that repair was performed. The gingival may be predictive to patient’s mortality are fractures of the upper and lower incisors patient’s hemodynamic status on arrival, Figure 1. Head CT scan showing acute were shown, fixation and immobilization level of the IVC where the injury occured, subdural hematoma (ASDH) in with thread no. 1. Operation done. He has amount of associated injuries, blood that the left frontotemporoparietal being transfused 500 ml of packed red cells have been loss since the injury occured, region accompanied with (PRC) and 1 L of plasma intraoperatively and blood transfusion requirements. midline shift. and postoperatively. He remained in Because the patient is shifted early to the the intensive care unit for the first three hospital and the intraabdominal bleed postoperative days; then, he was shifted of hematoma tamponade effect can be minutes after a traffic accident with to the general ward. Postoperatively, the controlled, he can survive. The other decreased consciousness with a GCS patient’s chief complaint was the pain reason he can survive is that the segment score of 11. The patient’s chest was at the wound site, which was managed involved is the PRIVC. clear, abrasions were found on the accordingly. There was no significant Control of hemorrhage is the main left hypochondrium. Head CT scan clinical event from the first day until the intervention needed in IVC injuries represented acute subdural hemorrhage last day of his stay at the hospital. He was because active bleeding may affect the in the left frontotemporoparietal region discharged after ten days of stay in the disease prognosis badly.13 In our case, a was accompanied by midline shift more hospital and remained stable on successive tamponade effect on IVC is produced than 0,5cm (Figure 1). Hemicraniectomy follow-up. by retroperitoneal hematomas, stopping decompression was performed. further bleeding and increasing the survival After decompression was done, the DISCUSSION probability. One study showed that patients patient was unstable, blood pressure down with retroperitoneal tamponade have a to 70/50 mmHg, and weak peripheral Because of its high mortality and 91% survival rate compared to patients pulses with 140 beats per minute. Fluid and morbidity, ASDH has become a critical without tamponade with a 93% mortality blood resuscitation has been performed entity representing about 30% of brain rate.14 Multiple cases have reported that but not responding. The patient remained injuries.9 Until the 1990s, the mortality rate retroperitoneum exploration may start hemodynamically unstable with minimal of ASDH was reported to be around 60%, profuse bleeding due to the patient’s urine output. Physical examination reveals and it decreased to be around 20-40% in hematoma tamponade effect removal.15 a tense abdomen. Diagnostic peritoneal the last decade.10 The functional recovery The uncontrollable bleeding after the lavage (DPL) was performed, blood was rate ranges between 19-45% in traumatic tamponade effect released is reported to be obtained. ASDH.11 Mechanisms that can cause the cause of death of 40% of the patients, Exploration laparotomy was done by ASDH are cortical surface vessel damage, as shown in a study done by Huerta et midline incision. As much as 1.500 cc bleeding from underlying parenchyma al.16 Hence, exploration or no exploration blood discharge with 500 cc blood clots injury, and tearing of bridging veins remains debatable. A study done by were found intraoperatively. Then packing from cortex to dural venous sinuses.12 In Okyere et al. concluded that a conservative was done in 5 places. Identification order to decrease intracranial pressure, approach might be chosen instead of of bleeding originated from the right hematoma evacuation and decompressive exploration in the presence of a contained retroperitoneal zone 1 and 2, and there craniectomy were performed. Many hematoma that can cause tamponade.13 was a rupture of the inferior vena cava prognostic factors may influence patients’ IVC repairment can be accomplished in the para-renal (PRIVC) segment outcomes, such as the patient’s age, by using different techniques that have accompanied by a blood clot on the wall. associated brain injuries, time lag between been published, including primary repair Temporary tamponade and suturing the onset of injury and the medical-surgical by direct suturing, i.e., venorrhaphy, were performed on the retroperitoneal care, and the level of consciousness of the ligation, atriocaval shunting, venacaval tear. After 30 minutes, the tampon was patient on admission.5 transposition, and others.16 opened, the impression that the bleeding Blunt abdominal trauma associated was stopped. Furthermore, spleen rupture with TBI contributes to 14% of cases.6

508 Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 507-509 | doi: 10.15562/bmj.v10i2.2393 CASE REPORT

In our patient, surgical intervention REFERENCES Survey of Head Injuries. Acta Neurochir like grafting or shunting of the IVC was (Wien). 1999;141(3):223–36. Available 1. Dewan MC, Rattani A, Gupta S, from: http://dx.doi.org/10.1007/ impossible due to inadequate facilities, Baticulon RE, Hung Y-C, Punchak M, lack of required equipment, and also lack s007010050292 et al. Estimating the global incidence 10. Ryan CG, Thompson RE, Temkin NR, of specialized vascular surgeons. Direct of traumatic brain injury. J Neurosurg. Crane PK, Ellenbogen RG, Elmore JG. repair of IVC was preferred instead of 2019;130(4):1080–97. Available from: Acute traumatic subdural hematoma. J ligation. It is because the para-renal part http://dx.doi.org/10.3171/2017.10. Trauma Acute Care Surg. 2012;73(5):1348– of IVC was accessible, and the lumen jns17352 54. Available from: http://dx.doi. diameter looked wide enough. This proved 2. Gururaj G. Epidemiology of traumatic org/10.1097/ta.0b013e31826fcb30 to be a better choice in concordance with brain injuries: Indian scenario. Neurol Res. 11. Tallon JM, Ackroyd-Stolarz S, Karim SA, other studies that preferred direct repair 2002;24(1):24–8. Available from: http:// Clarke DB. The epidemiology of surgically dx.doi.org/10.1179/016164102101199503 treated acute subdural and epidural instead of ligation. Our patient also 3. GODLEWSKI B, PAWELCZYK A, had visceral injuries that need surgical hematomas in patients with head injuries: PAWELCZYK T, CERANOWICZ K, a population-based study. Can J Surg. intervention. WOJDYN M, RADEK M. Retrospective 2008;51(5):339–45. Analysis of Operative Treatment of a 12. Prahaladu P, Prasad KS, Rajasekhar CONCLUSION Series of 100 Patients With Subdural B, Reddy KS. Clinical study of acute Hematoma. Neurol Med Chir (Tokyo). Case of severe head injury with acute subdural haematoma – a level I trauma 2013;53(1):26–33. Available from: http:// care centre experience. Int J Res Med SDH, then a craniectomy was performed, dx.doi.org/10.2176/nmc.53.26 Sci. 2017;5(3):857. Available from: in the abdomen had a ruptured inferior 4. Hyder AA, Wunderlich CA, http://dx.doi.org/10.18203/2320-6012. vena cava, an exploratory laparotomy was Puvanachandra P, Gururaj G, Kobusingye ijrms20170625 done. Currently, the patient has recovered OC. The impact of traumatic brain injuries: 13. Okyere I, Yorke J, Agbeko EA, Forson well without deficits. A global perspective. NeuroRehabilitation. PK, Bonney J. Inferior vena cava injury: 2007;22(5):341–53. Available from: http:// survival of a rare case. Ghana Med J. FUNDING dx.doi.org/10.3233/nre-2007-22502 2019;53(2):181. Available from: http:// 5. Marmarou A, Lu J, Butcher I, McHugh dx.doi.org/10.4314/gmj.v53i2.14 None. GS, Murray GD, Steyerberg EW, et al. 14. MILLIKAN JS, MOORE EE, COGBILL Prognostic Value of The Glasgow Coma TH, KASHUK JL. Inferior Vena Cava CONFLICT OF INTEREST Scale And Pupil Reactivity in Traumatic Injuries—A Continuing Challenge. Brain Injury Assessed Pre-Hospital And J Trauma Inj Infect Crit Care. All authors stated no conflict of interest on Enrollment: An IMPACT Analysis. 1983;23(3):207–12. Available from: http:// regarding this report. J Neurotrauma. 2007;24(2):270–80. dx.doi.org/10.1097/00005373-198303000- Available from: http://dx.doi.org/10.1089/ 00005 AUTHOR CONTRIBUTION neu.2006.0029 15. Buckman RF, Pathak AS, Badellino 6. Mehta N, Babu S, Venugopal K. An MM, Bradley KM. Injuries of the All authors contributed to the concept, Experience with Blunt Abdominal inferior vena cava. Surg Clin North design, definition of intellectual content, Trauma: Evaluation, Management and Am. 2001;81(6):1431–47. Available literature research, clinical studies, data Outcome. Clin Pract. 2014;4(2):34–7. from: http://dx.doi.org/10.1016/s0039- analysis, manuscript preparation, review, Available from: http://dx.doi.org/10.4081/ 6109(01)80016-5 and also served as guarantor of this study. cp.2014.599 16. Huerta S, Bui TD, Nguyen TH, Banimahd Marsal Risfandi and Celia also contributed 7. Millikan JS, Moore EE. Critical factors in FN, Porral D, Dolich MO. Predictors of determining mortality from abdominal Mortality and Management of Patients to the statistical analysis and manuscript aortic trauma. Surg Gynecol Obstet. editing. with Traumatic Inferior Vena Cava 1985;160(4):313–6. Injuries. Am Surg. 2006;72(4):290– 8. Cheaito A, Tillou A, Lewis C, Cryer H. ETHICAL STATEMENT 6. Available from: http://dx.doi. Management of traumatic blunt IVC org/10.1177/000313480607200402 injury. Int J Surg Case Rep. 2016;28:26– All authors declare that they have obtained 30. Available from: http://dx.doi. written informed consent to publish the org/10.1016/j.ijscr.2016.09.003 details relating to the patient in this case 9. Murray GD, Teasdale GM, Braakman R, report. Cohadon F, Dearden M, Iannotti F, et al. The European Brain Injury Consortium

Published by Bali Medical Journal | Bali Medical Journal 2021; 10(2): 507-509 | doi: 10.15562/bmj.v10i2.2393 509