Diagnostic dilemma of hemophilia B causing re-exploration and evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency: a case report
6 affiliations
- 1Department of Neurosurgery, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
- 2Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- 3Department of Internal Medicine, Kathmandu Medical College and Teaching Hospital, Kathmandu, Nepal
- 4Department of Anesthesiology, Nepal Medical College and Teaching Hospital, Kathmandu, Nepal
- 5Department of Neurosurgery, College of Medicine, University of Warith Al-Anbiyaa, Karbala, Iraq
- 6Department of Neurosurgery, College of Medical Sciences, Bharatpur, Nepal
Abstract
Introduction and importance:: Acute subdural hemorrhage itself is a lethal condition, and unknown hemophiliacs results in a poor prognosis. Delayed diagnosis of a blood disorder, as well as the need for multiple operative interventions such as re-exploration, is rare. We present such a case of an unknown hemophiliac who required multiple neurosurgical operations.
Case presentation:: A 41-year-old man had a frontotemporoparietal subdural hematoma. He underwent symptomatic management then presented the same night to our hospital with worsening headache and a Glasgow Coma Scale of 14, so he underwent decompressive craniectomy with removal of the subdural hematoma and lax duraplasty. An immediate hemophilia panel was sent as his history suggested a bleeding tendency for 3 days with minor cuts while shaving. The postsurgical phase was complicated by significant bleeding in the form of high-volume drainage and hypertension. Re-exploration to remove the hematoma was carried out. A blood transfusion was performed. The factor assay resulted only after a 7-day delay and confirmed factor IX deficiency, consistent with mild hemophilia B (factor IX activity, 6%); factor IX concentrate was then administered, which further managed the underlying coagulopathy. He was stable and discharged with a Glasgow Outcome Scale (GOS) score of 5.
Clinical discussion:: Evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency in a case of hemophilia B is rare. This case highlights that a normal initial coagulation screen does not exclude an inherited bleeding disorder, that unexplained or excessive postoperative bleeding should prompt a high index of suspicion for an underlying coagulopathy, and that early multidisciplinary collaboration is central to a favorable outcome when definitive hematological results are delayed.
Conclusion:: It was hard for us to manage two surgeries when the status of hemophilia B was unknown; however, timely treatment and a multidisciplinary approach led to a good outcome for the patient. Still, the diagnostic dilemma due to delays in reporting at a tertiary care center like ours is a lesson underscoring the need for prompt diagnosis and management to avoid unnecessary surgery.
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BibTeX
@article{shrestha2026diagnostic,
title = {{Diagnostic dilemma of hemophilia B causing re-exploration and evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency: a case report}},
author = {Sushan Shrestha and Kashif Qureshi and Bibechana Pradhan and Prashanti Prasai and Murtaja Satea and Bipin Chaurasia},
journal = {International Journal of Surgery Case Reports},
year = {2026},
month = oct,
doi = {10.1097/rc9.0000000000001112},
url = {https://doi.org/10.1097/rc9.0000000000001112},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Diagnostic dilemma of hemophilia B causing re-exploration and evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency: a case report
AU - Sushan Shrestha
AU - Kashif Qureshi
AU - Bibechana Pradhan
AU - Prashanti Prasai
AU - Murtaja Satea
AU - Bipin Chaurasia
PY - 2026
DA - 2026/10/21
JO - International Journal of Surgery Case Reports
DO - 10.1097/rc9.0000000000001112
UR - https://doi.org/10.1097/rc9.0000000000001112
AB - Introduction and importance:: Acute subdural hemorrhage itself is a lethal condition, and unknown hemophiliacs results in a poor prognosis. Delayed diagnosis of a blood disorder, as well as the need for multiple operative interventions such as re-exploration, is rare. We present such a case of an unknown hemophiliac who required multiple neurosurgical operations. Case presentation:: A 41-year-old man had a frontotemporoparietal subdural hematoma. He underwent symptomatic management then presented the same night to our hospital with worsening headache and a Glasgow Coma Scale of 14, so he underwent decompressive craniectomy with removal of the subdural hematoma and lax duraplasty. An immediate hemophilia panel was sent as his history suggested a bleeding tendency for 3 days with minor cuts while shaving. The postsurgical phase was complicated by significant bleeding in the form of high-volume drainage and hypertension. Re-exploration to remove the hematoma was carried out. A blood transfusion was performed. The factor assay resulted only after a 7-day delay and confirmed factor IX deficiency, consistent with mild hemophilia B (factor IX activity, 6%); factor IX concentrate was then administered, which further managed the underlying coagulopathy. He was stable and discharged with a Glasgow Outcome Scale (GOS) score of 5. Clinical discussion:: Evacuation of subdural hematoma following traumatic brain injury and hypertensive emergency in a case of hemophilia B is rare. This case highlights that a normal initial coagulation screen does not exclude an inherited bleeding disorder, that unexplained or excessive postoperative bleeding should prompt a high index of suspicion for an underlying coagulopathy, and that early multidisciplinary collaboration is central to a favorable outcome when definitive hematological results are delayed. Conclusion:: It was hard for us to manage two surgeries when the status of hemophilia B was unknown; however, timely treatment and a multidisciplinary approach led to a good outcome for the patient. Still, the diagnostic dilemma due to delays in reporting at a tertiary care center like ours is a lesson underscoring the need for prompt diagnosis and management to avoid unnecessary surgery.
SN - 2210-2612
ER -