Diagnostic dilemma of hemophilia B causing re-exploration and evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency: a case report
Sushan Shrestha, Kashif Qureshi, Bibechana Pradhan, Prashanti Prasai, Murtaja Satea, Bipin ChaurasiaIntroduction and importance:
Acute subdural hemorrhage itself is a lethal condition, and unknown hemophiliacs results in a poor prognosis. Delayed diagnosis of a blood disorder, as well as the need for multiple operative interventions such as re-exploration, is rare. We present such a case of an unknown hemophiliac who required multiple neurosurgical operations.
Case presentation:
A 41-year-old man had a frontotemporoparietal subdural hematoma. He underwent symptomatic management then presented the same night to our hospital with worsening headache and a Glasgow Coma Scale of 14, so he underwent decompressive craniectomy with removal of the subdural hematoma and lax duraplasty. An immediate hemophilia panel was sent as his history suggested a bleeding tendency for 3 days with minor cuts while shaving. The postsurgical phase was complicated by significant bleeding in the form of high-volume drainage and hypertension. Re-exploration to remove the hematoma was carried out. A blood transfusion was performed. The factor assay resulted only after a 7-day delay and confirmed factor IX deficiency, consistent with mild hemophilia B (factor IX activity, 6%); factor IX concentrate was then administered, which further managed the underlying coagulopathy. He was stable and discharged with a Glasgow Outcome Scale (GOS) score of 5.
Clinical discussion:
Evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency in a case of hemophilia B is rare. This case highlights that a normal initial coagulation screen does not exclude an inherited bleeding disorder, that unexplained or excessive postoperative bleeding should prompt a high index of suspicion for an underlying coagulopathy, and that early multidisciplinary collaboration is central to a favorable outcome when definitive hematological results are delayed.
Conclusion:
It was hard for us to manage two surgeries when the status of hemophilia B was unknown; however, timely treatment and a multidisciplinary approach led to a good outcome for the patient. Still, the diagnostic dilemma due to delays in reporting at a tertiary care center like ours is a lesson underscoring the need for prompt diagnosis and management to avoid unnecessary surgery.