Subdural Hygroma- A Case Report

Introduction: An accumulation of Cerebrospinal fluid in subdural spaces is known as subdural hygroma. It is encountered in all age-groups but overall, most common in elderly. The exact pathogenesis of Subdural Hygroma is still unclear. Presentation of Case: A 03 months old female child was brought to Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha, Maharashtra, India on date 02/10/2020 with the complaints of breathing difficulty, elevated body temperature, excessive enlargement of head with bulged and tense fontanel, high pitch shrill cry, restlessness, nausea and vomiting. On physical examination, it is found that head circumference was 44 cm, head size was enlarged, bulged anterior fontanel, angular cheilitis, pale conjunctiva as well as peripheral cyanosis were present. The child was diagnosed at birth and child was brought to Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha for surgical management of subdural hygroma. Intervention: The treatment of patients was started immediately after admission.Burr-Hole Evacuation was done on 4th October 2020 and the patient was discharged on 08th October 2020. Conclusion: In this report, we mainly focus on expert surgical management and excellent nursing care helped in managing the complicated case very nicely. The patient response was positive to conservative and nursing management. The patient was discharged without postoperative complications and satisfactory with recovery. Case Study Rodge et al.; JPRI, 33(42B): 1-5, 2021; Article no.JPRI.71988 2


INTRODUCTION
Subdural hygroma is a collection of cerebrospinal fluid that in subdural spaces that can occur in the postnatal period as consequences of either a traumatic rupture of arachnoid membrane with cerebrospinal fluid leakage in the subdural space or disturbance of cerebrospinal fluid circulation [1].
The subdural hygroma was first introduced by Rudolph Virchow in 1856. Subdural hygroma in infants are rare and rather implicate a delayed and nonacute process, subdural hygroma may develop rapidly or be delayed [2].
The head trauma, infections and spinal procedures are the most prevalent causes of subdural hygroma, which can occur in combination with brain atrophy, severe dehydration, excessive spinal leaking, or any other condition that causes a decrease in intracranial pressure [3].
Subdural hygromas pathophysiology is not fully known. The most typical explanation is a rip in the arachnoid layer that creates a ball-valve aperture that allows CSF to flow one way into the subdural area. Although this explanation is simple, it may not necessarily represent an accurate representation of the underlying mechanisms. It has been claimed that subdural hygromas are significant subdural effusions caused by a separation of the dural border cell layer with fluid accumulation. There is unquestionably a link between subdural hygromas and acute, chronic, and recurrent subdural hematomas [4].
There is as yet no accurate report to date on the incidence of subdural hygroma in infants [5].
Here we report a case of 03 months old female child with subdural hygroma.

Patient Information
A 3 months old female child was referred to Pediatric outpatient department at AVBR Hospital, Sawangi (Meghe), Wardha on 2nd of October 2020 with complaints about breathing difficulty, elevated body temperature, excessive enlargement of head with bulged and tense fontanel, high pitch shrill cry, restlessness, nausea and vomiting.

Medical/Surgical History
The patient had known case of subdural hygroma since birth. As narrated by the patient's mother, she was diagnosed with Subdural Hygroma with Cystic Atrophy by prenatal ultrasonography. After birth, the patient was referred to Govt. Hospital, Yavatmal, from Adilabad for further management and from there the case was referred to A.V.B.R. Hospital, Sawangi (Meghe), Wardha for surgical management.

Birth History
The patient was born at 36 weeks of gestation by Lower Segment Cesarean Section. The child did not cry immediately after birth and had history of Neonatal Intensive Care Unit stay due to respiratory distress after birth. At 28 days of a life, Neuroultrasonogram (NUSG) was done which was suggestive of prominent lateral ventricle with bilateral subdural hygroma with atrophy of cerebral hemispheres.

Immunization History
Immunizations were not administered to the patient in accordance with the national immunization schedule as prescribed by the doctor.

Anthropometry measurement of child
The child general anthropometric measurements, length of child was 59 cm (27.67 percentile), weight was 5 kg (11.12 percentile), head circumference was 44 cm (increased), mid upper arm circumference was 13 cm and chest circumference was 36 cm.

Physical Examination
The patient had a mild fever, looked undernourished, and had an enlarged head, a bulged anterior fontanel with head circumference of patient was 44 cm, peripheral cyanosis, angular cheilitis, and pale conjunctiva on physical examination.
On Central Nervous System: Normal tone and power in all four limbs. Plantar reflex were extensor on the both side.

Management
There is no specific medical management for Subdural Hygroma. Symptomatic treatment with surgical intervention was given to the patient.

Symptomatic Treatment
The symptomatic treatment was listed in Table 1.

Surgical Management
Surgery was the only option for the patient with subdural hygroma. On the patient, surgery was performed on the Right and Left Frontal Turbinates, And Suction Evacuation of the Subdural Hygroma. The surgery was done under general anesthesia on 4th October 2020.

Ineffective Cerebral Tissue Perfusion related to increased ICP (Intracranial Pressure).
Goal: Enhance tissue perfusion

Goal:
To maintain normal body temperature.
Intervention: Monitored vital signs and provide medication as prescribed by doctors.

Goal: To prevent from infection
Intervention: Assess the site of surgical incision, monitored vital signs, hand wash before and after providing the care to patient and provide medication as prescribed by doctors.

Nursing Management
As per criteria, the nursing care was given to maintain the health status and to prevent further complications.
 Provided comfortable position to the child.  Monitored vital signs of the patient.  Administered all the prescribed medications to the child.  Monitored intake and output of the patient.  Assisted parents while doing the daily activity of the patient.  Health education given to the parents regarding feeding, medication administration, disease condition and prognosis as well as how to take care at home and follow up.

Therapeutic Diet Plan
Provide high caloric formula milk or breast milk to the infant with kotari spoon.

Prognosis
On the patient, surgery was performed on the right and left frontal turbinates, and suction evacuation of the subdural hygroma. The parents were informed about the need of giving medication regularly as prescribed by doctors. At the time of discharge, the patient's condition was satisfactory. The child was an infant with a special ailment, the parents were educated about the disease's prognosis as well as follow-up.

DISCUSSION
An accumulation of Cerebrospinal fluid in subdural spaces is known as subdural hygroma [1]. Most commonly followed by head injury or decompressive cranieotomy [6]. In our case, the patient had breathing difficulty, elevated body temperature, excessive enlargement of head with bulged and tense fontanel, high pitch shrill cry, restlessness, nausea and vomiting. The exact etiology of subdural hygroma is mostly considered as idiopathic.
Subdural hygroma can be seen on CT; however, the differentiation form subdural hematoma or cerebral atrophy is not always possible. Contrast enhanced MRI is useful for differentiating the two entities [6]. In our case MRI (both Plain and Contrast) was done to make clinical diagnosis.
Most of the subdural hygroma resolve spontaneously and do not require surgical intervention [7]. However, a subset of patients who develop compression symptoms will require surgical intervention to avoid permanent neurological sequel [6]. In our case, the patient was diagnosed of Subdural Hygroma with Cerebral Atrophy. The patient was treated with antibiotics, antacid, antiemetic and anticonvulsant drugs. They had performed Right and Left Frontal Turbinate Burr-Hole and Suction Evacuation of Subdural Hygroma.
The decision of choice to perform surgical procedure is emphasized by clinical and radiological finding. For making therapeutic intervention, the combination of structural functional imaging in the form of scan Technetium-99m Ethyl Cysteinate Dimer (99m Tc-ECD) of brain and Single Photon Emission Computed Tomography (SPECT) of the brain may be highly beneficial [6]. In our case, the MRI Brain (both Plain and Contrast) was done to make a diagnosis. Subdural hygroma in infants and children is a condition that compresses the developing brain; relief of the pressure allows the brain to re-expand, resulting in normal development and a good outcome. Because this condition is distinct from other disease entities that resolve spontaneously without treatment, an accurate diagnosis is critical and it is essential [8].

CONCLUSION
In recent years, an increasing number of studies on prenatal diagnosis and management have been published.
This case report is a contribution to the knowledge of rare malformation of brain.

CONSENT
While preparing case report and for publication parental informed consent has been taken from parents.

ETHICAL APPROVAL
As per international standard or university standard written ethical approval has been collected and preserved by the author(s).