Corticosteroid treatment for traumatic acute subdural haematoma, maybe not such a good idea.

Demailly D, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-220344 Description An 86-year-old woman with acute blunt head trauma (the patient’s head was hit by a car) 10 days ago, associated with a right occipital fracture and an acute subdural haematoma (treated in the department of neurosurgery by oral prednisone 80 mg once a day) (figure 1), presented with focal left arm motor seizures. At that time, CT and MRI showed right cortical venous thrombosis (figure 1), absent on initial CT imaging. Corticosteroids were stopped and antiepileptic drugs and anticoagulation (warfarin) started. Three weeks later, CT showed complete resolution of the cortical venous thrombosis and spontaneous resorption of the subdural haematoma. Blood analyses in search of a prothrombotic state were negative in the absence of other blood test abnormalities (including normal metabolic profile). Despite the lack of evidence-based efficacy, steroids are sometimes used in the non-surgical treatment of chronic (and sometimes also acute) subdural haematoma. Venous sinus thrombosis is relatively frequent after blunt head trauma (described in up to 16% of patients with acute blunt trauma), especially in the presence of skull fracture (associated with a risk of 20% for venous sinus thrombosis). The recommended treatment by anticoagulation of these post-traumatic venous sinus thrombosis patients is unclear because of frequently associated traumatic intracranial haemorrhage. The exact underlying pathophysiological mechanism of these trauma-related venous sinus thromboses is unknown. In our patient, other risk factors for venous sinus thrombosis might have also played a role, for example, intracranial hypotension due to a traumatic dural tear (although radiological abnormalities often seen in intracranial hypotension lacked) or pre-existing dehydration (often present in elderly patients, although dehydration-related blood abnormalities lacked in our patient). In conclusion, corticosteroid treatment (with its possible associated prothrombotic effect) has to be used with caution in traumatic acute subdural haematoma.