A CASE OF CEREBROVASCULAR PATHOLOGY IN A CHILD RESULTING IN EPIDURAL HEMATOMA
Regional Clinical Hospital,
Altay Regional Bureau of Forensic Medicine,
Barnaul, Russia
Intracranial hemorrhage takes one of the leading places among all causes of death and is one of the main causes of disability in the population [1]. As one knows, intracranial bleedings are associated both with traumatic and non-traumatic origin. Despite of significant amount of dedicated studies, differential diagnostics of traumatic and vascular intracranial hemorrhage is still associated with significant difficulties for clinicians and forensic experts.
Non-traumatic bleedings are divided into primary bleedings as result of arterial hypertonia, and secondary ones as result of vasculitis, coagulopathy, ruptured arterial venous malformations (AVM) and aneurysm, tumoral bleedings. Epidural hematomas (EH) are considered as traumatic in most cases, and, as a rule, are accompanied by injuries to cranial bones [2, 6, 7, 8].
Objective – to give an example of a rare case of cerebral vascular pathology resulting in EH, which was improperly interpreted by clinicians as traumatic one.
MATERIALS AND METHODS
During the investigation of a criminal case of infliction of a bodily injury in the citizen V., age of 12, the fact was confirmed that on September, 2013, in one of the schools of Altay region a classmate had given a blow (with her palm) to the girl (to her left cheek). There were no faint or falling. The victim was excited and she went home. In two hours sharp headache and multiple vomiting events appeared. The child was admitted to the hospital. The state at admission: without consciousness, coma of II-III degrees, right hemiplegia and meningitis symptoms. The diagnosis was confirmed: “Closed traumatic brain injury. Brain contusion and compression by an intracranial hematoma to the left. Dislocation syndrome. Coma III”. An emergent operation was initiated (decompressive cranial trepanation to the left). During the operation EH was found in the left parietotemporal region in view of liquid blood and clots (70 ml), without cranial fractures. Dura mater was opened in embowed shape for revision of subdural space. A massive venous arterial bleeding from dura mater vessels was found. It created significant difficulties and was arrested with vascular coagulation. The cerebral mater was without changes.
24 hours after the surgical intervention the state of the child was severe: coma of degree III, artificial lung ventilation. The control computer tomography showed focal changes in subcortical nuclei to the left and the evident cerebral edema to the left. During the following 3 weeks a tracheostoma and a gastrotome were installed. The child was shifted to independent breathing. A month after disease appearance, with consideration of state stabilization, the child was transferred to the pediatric regional hospital. Magnetic resonance imaging (MRI) with contrast magnification was carried out. It showed lacunar infarcts in the basal ganglia and in the midbrain to the left, chronical focal changes in cortical departments of the left parietal, temporal and occipital lobes. One could observe selective accumulation of the contrast media in dura mater in the left parietooccipital region. After realized treatment the patient’s state improved (little consciousness). There was a persistent syndrome of motion disorders (akinesia). The neurosurgeons and the neurologists confirmed the diagnosis: “Subacute period of traumatic brain injury, secondary ischemia of the stem and basal ganglions of the brain…”. The appropriate treatment was prescribed.
Henceforth, the patient received rehabilitation: 4 months, with good outcomes (the girl was in clear consciousness, could speak, with limited active motions in the right extremities).
In the end of January, 2014, the girl entered the planned rehabilitative treatment in the neurology department. Here after 14 days, at the background of satisfactory general state, labored breathing and unconsciousness with respiratory and cardiac failure appeared.
The forensic medical investigation of the child’s dead body showed the signs of significant cerebral edema with focuses of softening in the left temporal lobe and in the subcortical space, with development of dislocation syndrome. For the investigative authorities it was recommended to assign the expertise involving clinicians to investigate the issues of the epidural hemorrhage and the death of the child 4.5 months after the surgery and EH removal.
RESULTS AND DISCUSSION
After detailed analysis of all medical documents, materials of the case and results of the pathologic examination the expert commission noted the following significant moments:
- the discrepancy between the external impaction and the characteristics of the pathologic changes in the brain;
- acute beginning of the disease at the background of complete health;
- massive arterial venous bleeding from dura mater vessels during the surgical intervention, despite of absence of direct injury to the soft tissues, cranial bones and dura mater in this region; it is uncommon for traumatic hemorrhage over brain tunic;
- according to cerebral MRI, accumulation of contrast media in dura mater in the left parietooccipital region which is uncommon.
Due to the combination of above-mentioned factors the expert commission could objectively and reliably estimate the presence of pathology in dura mater vessels, namely AVM in the left parietooccipital region with complications in view of disruption and bleeding with formation of EH.
Cerebral arteriovenous malformation is a pathologic connection between veins and arteries resulting in direct shunting of the blood from arterial basin into venous system, and it leads to chronical insufficiency of cerebral perfusion. One of the serious complications of this pathology is rupture of pathologically changed vessels: acute development of thin varicose veins or arterial aneurysm feeding a malformation. The incidence of intracerebral, subarachnoid and intraventricular types of bleeding is significantly higher. Arteriovenous malformation of dura mater is extremely rare (1 % of all cases with AVM).
If complications are absent, such vascular pathology usually proceeds without symptoms. Therefore, it is almost impossible to suspect its presence. There are no screening diagnostic methods for AVM. Unlike intracerebral AVM, dural AVM commonly do no present a compact node resulting in difficult diagnostics, even with contrast MRI [3]. Appropriate diagnostics is possible only with cerebral angiography with separate catheterization and contrast enhancement for external and internal carotid arterial systems in a special neurosurgery department [4]. After malformation ruptures the mortality achieves 30 %. The half of patients becomes disabled after hemorrhage from a malformation. Within one year the risk of recurrent bleeding appears in 26.9 % of patients. Even with timely surgical treatment for AVM (endovascular embolization, stereotactic clipping of an afferent vessel, radiosurgical intervention et al.), the possibility of a lethal outcome is high during surgery and in short term period after it because of intrasurgical bleeding, recurrent postsurgical hemorrhage including appearance of blood in ventricular system, venous thrombosis, brain stem ischemia etc. [5].
Therefore, after the appropriate analysis of the results the expert commission has confirmed that the death is related to cerebral vascular disease – chronical insufficient cerebral perfusion caused by arteriovenous shunting in view of secondary disorders of blood circulation in the cerebral structures (subcortical nuclei, midbrain), ischemic changes in cortical departments of the left occipital, temporal and parietal lobes, with development of edema and brain dislocation. The triggering moment for development of chronic insufficiency of left cerebral perfusion is partial diathermocoagulation of pathologic vessels of dura mater during the surgical intervention which resulted in changing cerebral flow.
The possibility of EH development as result of trauma was excluded, and the investigative authorities closed the criminal case about infliction of the injuries in the citizen V.
CONCLUSION
The given case indicates significance of proper, in-depth investigation of all medical documents, which allow (with combination of minute particulars) to perform differential diagnostics of cerebral injury and disease during realization of medical assistance. In this case the mistaken orientation to an injury, with consideration of only anamnesis data, resulted in improper diagnosis. The operating physicians did not pay attention to massive arterial venous bleeding from dura mater vessels, and did not interpret EH without cranial bone fractures. During the subsequent medical assistance in the regional facility and consultations from the leading specialists of the region the diagnosis by the physicians of primary medical aid was not disputed, the results of contrast MRI (selective accumulation of contrast media in dura mater vessels in the parietooccipital region to the left) were not estimated that resulted in lengthening the sequence of incorrect comments about the state of the patient. Timely cerebral angiography would allow identifying the network of pathologic dura mater vessels in the left parietooccipital region.