Spontaneous bilateral subdural hematoma in a patient with a prosthetic valve and association with plasmodium vivax malaria: A rare case report.

Introduction and importance: Bilateral subdural hematoma (SDH) is a very rare condition which can occur without any apparent etiology. It's characterized by a lower frequency of focal neurological impairments, which could delay the diagnosis and postpone treatment. The reported incidence of an acute spontaneous subdural hematoma (SSH) varies between 2% and 6.7% of all acute SDH. SDH following Plasmodium vivax (P. vivax) infection are uncommon to our knowledge, only two cases of SDH linked with P. vivax infection have been documented in the literature. Case presentation: We describe a case of a 31-year-old male with a history of mitral mechanical valve replacement on anti-coagulant presented with spontaneous bilateral subdural hematoma in the presence of malaria. The patient had a limited vague symptom, which delayed a prompt diagnosis of his disease. Clinical discussion: Spontaneous subdural hematoma has only a few documented cases. Hypertension, infections, vascular malformations, ruptured aneurysms, thrombocytopenia caused by hematological and oncological illnesses, acquired or inherited types of coagulopathies, and drug abuse are all risk factors. Also, SDH has been documented in the literature as a consequence of Plasmodium infection. In addition to that this patient was on anti-epileptic medicines which might potentiate vitamin K antagonists. Numerous factors were thought to have contributed to this significant bleeding.
Conclusion: Patients on anticoagulants who exhibit nebulous symptoms, including a mild headache, should be subjected to a thorough history and examination. And any factor delaying an accurate diagnosis should be eliminated. This will complement the patient's plan and management.

Introduction

Spontaneous subdural hematoma (SSHs) are uncommon, with only a few case reports in the medical literature. The reported incidence of an acute SSH varies between 2% and 6.7% of all acute subdural hematoma [1]. In patients with mechanical heart valves, subdural hematoma (SDH) was responsible for 50% of anticoagulant-related intracranial hemorrhages [2]. Several cases have been reported in the literature of spontaneous subdural hematomas in association with Plasmodium falciparum malaria [3,4]. However, incidence of SDH following Plasmodium vivax (P. vivax) infection is rare, as per our knowledge only two cases with isolated plasmodium vivax infection has been reported [5,6].

We present here a of a 31-year-old male with a history of mitral mechanical valve replacement who presented with spontaneous bilateral subdural hematoma in the setting of Malaria.

Case presentation

A 31-year-old male presented to the outpatient department of cardiology complaining of a mild headache and tiredness associated with a mild temperature in five days. Three years prior he had prosthetic mitral valve replacement for rheumatic mitral valve stenosis. He has no significant family history. His history also revealed hypertension and epilepsy. Two days prior to presentation, the patient received a Plasmodium vivax (P. vivax) diagnosis in another healthcare facility. There was no history of projectile vomiting or convulsions, no blurred or double vision, no weight loss or weakness, and no other neurological abnormalities. The patient had not reported any trauma or falling history recently. There has been no history of any symptoms that may indicate a bleeding issue, such as easy bruising, significant bleeding from minor wounds, or inexplicable nosebleeds. His current medical treatments included warfarin 2 mg once every 4 days, lamotrigine 100 mg, phenytoin 100 mg, valsartan plus hydrochlorothiazide 160/12.5, and arthemeter lumefantrine 20/120 mg. He was vitally stable and oriented to time, place, and person; memory was intact; pupils responded equally to light; all limbs were powered five out of five; intact cranial nerves examination; and normal gait. The sound of prosthetic valves was heard clearly. An international normalized ratio (INR) of 2.08 (the target range for patients with MVR is 2.5–3.5), and a prothrombin time (PT) of 27 (11–16 sec). Other laboratories were normal. His symptoms were assumed to be related to the recent diagnosis of uncomplicated malaria, and at that time, a CT scan was not done and he was consulted to complete the anti-malaria treatment.

After the headache persisted for four days, the patient came to the emergency department complaining of a throbbing severe headache, which he scored 8 out of 10. The following were his initial vital signs: blood pressure was 125/85, heart rate was 82 minutes, temperature 38 °C, respiratory rate was 16 breaths per minute, and SaO2 was 98% on ambient air. The results of the full blood count were within normal limits. The platelet function tests were normal. Coagulation tests revealed INR of 5.9, PT of 79, and partial thromboplastin time of 165 (23–35 sec). All other routine investigations were normal. His Glasgow Coma Scale was 15, with no neurological deficit. Due to a history of severe headaches, a history of warfarin use, and an abnormal coagulation profile, a head CT scan was ordered, which showed acute subdural hematoma in both cerebral hemispheres, the deepest area measured 3 cm (Fig. 1). He was transferred to a high dependency ward in our hospital under close follow up of his neurological assessment and coagulation profile. On trans-thoracic echocardiography, the mechanical prosthetic valve was found in the mitral position with proper opening and closing. The forward flow gradient was 10 mmHg on average.

Fig. 1

Acute subdural hematoma in both cerebral hemispheres the deepest area measures 3cm.

Because the INR was above the intended therapeutic range (2.5–3.5) for MVR and a second bleed was anticipated, warfarin was discontinued. Vitamin K injections and 4 units of fresh blood were used to try to reverse bleeding diathesis. Also, the patient was anticoagulated with unfractionated heparin with APTT monitoring.

A multidisciplinary discussion involving cardiologists, neurologists, and neurosurgeons took place. Due to patient's little neurological deficit, abnormal coagulation parameters surgical intervention was considered both high risk and undesirable and they suggested to be treated conservatively. His INR was reduced to 2.9, PT of 38.6 sec, and partial thromboplastin time of 109 sec.

After one day of follow-up in the intensive care unit, the patient's condition deteriorated and he had a drop in sensorium, GCS 8, necessitating mechanical intubation. A repeat CT brain revealed a crescent-shaped homogeneously hypertense subdural collection in bilateral cerebral hemispheres and along the right tentorial leaflet, as well as re-expansion of the subdural hematoma with bilateral bi-convex extradural hematoma (Fig. 2A&B). The patient's clinical state deteriorated, with no evidence of neurologic improvement, and he passed away three days later. The case has been reported in line with the SCARE criteria [18].

Fig. 2

A&B Crescent-shaped homogeneously hyperdense subdural hematoma bilateral cerebral hemispheres (2a) and along with Bi-convex hyperdense collection under the skull (extradural) in bilateral occipital, right side measures 3 × 1.5 cm and left side measures 4 × 2.5 cm (2b).

Discussion

Subdural hematoma is attributed by a collection of blood between the dura mater and the arachnoid membrane. The most prevalent cause is trauma, which causes traction of the bridging veins as a result of fast acceleration or deceleration of the head [7].

Spantenous subdural hematoma have only a few documented cases. Hypertension, infections, vascular malformations, ruptured aneurysms, thrombocytopenia caused by hematological and oncological illnesses, acquired or inherited types of coagulopathy, and drug abuse are all risk factors [1,8]. Anticoagulation is linked to an increased risk of bleeding. With an international normalized ration (INR) > 4.8, the risk of hemorrhagic problems increases in patients who have a mechanical valve and are on anticoagulation [9]. SDH has been documented in the literature as a consequence of Plasmodium falciparum infection [3,4]; however, SDH after Plasmodium vivax infection is uncommon; to our knowledge, only two cases of isolated plasmodium vivax infection have been reported [5,6]. Interactions between warfarin and other drugs mainly induce a change in the international normalized ratio (INR), but they can also cause bleeding and/or thromboembolic events [10,11]. The interaction of warfarin and phenytoin isn't completely understood [12]. Anticoagulation decisions in persons with epilepsy are complicated, because each of these patients has unique risk profiles for thrombotic/bleeding events [13].

Our patient was on a vitamin K antagonist with an INR target of 2.5–3.5, and numerous factors were suspected to have played a part in this major bleeding, including Plasmodium Vivax and anti-epileptic drugs.

Surgical evacuation of chronic SDH is linked to a positive outcome [2]. However, the result in patients with acute SDH is not always favorable. Failure to reverse anticoagulation before to surgery may be linked to a bad outcome [14]. An INR of at least 1.4 or less is recommended as the ideal coagulation parameter for neurosurgical operations [15,16]. Our case was treated conservatively because he had an acute subdural hematoma with few symptoms and the anticoagulants had not been reversed in a timely manner.

The therapeutic management of hemorrhagic patients on anticoagulant medication in patients with mechanical heart valve prostheses was extremely problematic; restarting treatment could result in bleeding recurrence, but suspending or halting treatment could result in prosthesis thrombosis [17]. Despite all efforts to reverse the anticoagulation using FFP and vitamin K injections, the goal range was not reached in our reported case, which could be related to many factors leading to bleeding diathesis, which were present in this instance.

In conculsion for patients using anticoagulants, any misinterpretation of variables affecting drug pharmacodynamics and pharmacokinetics should be explored. This will contribute in the patient's plan and pave the way for the other management strategy.

Funding resources

We declared that we have not received any financial support.

Registration of research studies

Name of the registry: Not Applicable

Unique Identifying number or registration ID: Not Applicable

Hyperlink to your specific registration (must be publicly accessible and will be checked): Not Applicable

Ethics approval

Based on the regulations of the review board of the Mogadishu Somali Turkish Training and Research Hospital, institutional review board approval is not required for case reports.

Consent for publication

Written informed consent was obtained from the patient's brother for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contributions

All authors performed substantial contributions to the case sections. Took part in drafting the case or revising it critically for important intellectual content and gave final approval of the version to be published.

Guarantor

Ishak Ahmed Abdi.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Declaration of competing interest

The authors declare that there is no competing interest related to the study, authors, other individuals, or organizations.