History
This is a 45 years old female black Ethiopian newly diagnosed type 1 DM patient who first presented with diabetic ketoacidosis which was diagnosed in a routine investigations done for a compliant of sever global headache of 1 month duration following a 1 month prior history of trivial trauma she sustained to her head. The headache was sever and persistent for the whole duration of one month but get worsened & unbearable for 1 week before current visit. In association, she had history of intermittent vomiting of ingested matter of week duration. For the above complaints, she visited multiple health facility and received pain killer medications though there was no improvement. Otherwise, she has no weakness, abnormal body movement and loss of consciousness. She also had no the classic presentation of DM and DKA as well. No known precipitants identified for her DKA except the trivial trauma history she had. Apart from the trivial trauma history, she did not have risk factors for CSDH, including history of use of medications that increase bleeding risk. No previous surgery & other comorbidities. No family history of chronic medical illnesses including diabetes mellitus.
Physical finding
She looked acutely sick looking from due to sever global headache she was suffering from. She had tachypnea and tachycardia which was presumed to be due to the severe headache. She was afebrile and had normal blood pressure limit. Buccal mucosa was dry. Air entry to the lung fields was good bilaterally. Neurologic exam was also unremarkable.
Laboratory
Her basic lab investigations including CBC, RFT, LFT, serum electrolytes and her coagulation profiles were with normal range. But, her fasting blood sugar was 530mg/dl with +2 ketonuria and +3 glucosuria, hence the diagnosis of type 1 DM with DKA was diagnosed.
Imaging
Non contrast brain CT scan was obtained with possible impression of extra axial collection as she had trivial trauma history as a risk factor for the cause of headache before the commencement of treatment for DKA.
Accordingly, the brain CT showed a bilateral fronto-parietal subdural hypodense extra-axial collection with a maximum thickness of 9.86mm & 7.65 mm on the right and left side respectively. In addition, there is global effacement of hemispheric sulci, sylvian fissure, basal cisterns & ventricles. The gray white matter differentiation is also poor and the intracranial fosses appear crowded. There is no significant midline shift however (<3mm). A likely diagnosis of chronic subdural hematoma with DDX of subdural hygroma was made based on the preoperative imaging (See figure 2 for the CT scan of the patient below at different levels of sections in the image from ‘a to g’).
Diagnosis
Based on the lab and imaging evidences, the diagnosis of CSDH + R/O subdural hygroma + newly diagnosed Type 1 DM with DKA + cerebral edema 20? (Mass effect from CSDH +? /DKA induced) was made.
Treatment
Since our patient had both medical and neurosurgical problem, multidisciplinary team was involved it her management. Accordingly, both medical & neurosurgical treatment was given by the respective team of physicians.
1. Medical management:
Accordingly, the fluid deficit, potassium deficit and the hyperglycemia was corrected using normal saline, potassium replacement and regular insulin administration as per diabetic keto-acidosis management protocol. Patient then followed with an hourly basis of RBS and ketone urine with clinical response of the patient. The patient became ketone free after 6hours of management with the level of hyperglycemia reduced to 250-300mg/dl. Despite our patient had metabolic response, her headache persisted and didn’t improve with the medical management.
2. Surgical management:
Once the patient was stabilized metabolically &/medically, neurosurgical intervention was decided to be made as the patient has tight brain which is disproportionate for the thickness of the extra-axial collection as detailed in the CT finding.
Written informed consent was obtained for her to undergo surgery and for her case summary can be published for educational purpose. Patient was then taken to the operating room and positioned supine. Patient put on intranasal oxygen, and sedation with both pethidine and diazepam achieved. Then hair was shaved and local anesthesia using 2% lidocaine administered at the surgical site. Surgical field cleaned with alcohol first which then painted with providone iodine. Proper prepping and draping then done. A 3cm sized skin incision at the epicenter (maximal thickness) of the extra-axial collection done; which is at the coronal suture and 5cm off of midline and burr hole was made using manual bur. Bone dust thoroughly irrigated. Dural vessels cauterized with bipolar cautery forceps and dura opened in a cruciate fashion on the right side first and left side then after. Dural lips opened in a cruciate fashion tucked up with a bipolar cautery. Upon opening the dura a xanthocromic CSF appearing fluid come out with moderate pressure bilaterally (more on right). There was no characteristic dark motor oil appearing hemolyzed blood expected to be seen in CSDH. Copious irrigation with saline done; after which subdural drain left bilaterally and skin closed in a locking fashion bilaterally. Meticulous hemostasis secured with bipolar cautery in each step of the procedure. Patient transferred with stable vital signs to post anesthesia recovery unit and final postoperative diagnosis of Type 1 DM with DKA + Subdural hygroma likely from CSDH + DKA induced cerebral edema was made.
Follow-up & treatment response
Patient postoperatively was put on analgesics and sliding scale of insulin management. Her headache responded well after the surgical management was done. She was also followed with random blood sugar & urine ketone evaluation every 6 hours and never returned back to DKA in the postoperative period. Drain removed after 24 hours. Patient then was discharged improved on her 3rd postoperative day after the patient was linked to medical side for comprehensive diabetic care.