Mild hemophilia A presaged by recurrent postoperative hemorrhagic complications in an elderly patient

Abstract

Background: Mild hemophilia without spontaneous bleeding can remain undiagnosed for a lifetime. However, intracranial hemorrhage is one of the most serious complications for patients with hemophilia. In addition, hemorrhagic complications after emergency surgery tend to arise from coagulopathy.

Case description: An 80-year-old man was admitted with left hemiparesis and disturbed consciousness. He had no history of trauma, fever, or drug and alcohol intake. Computed tomography imaging upon admission disclosed a hemispheric subdural hematoma with a midline shift. No vascular abnormalities were identified as a source of the hemorrhage. The hematoma was removed on an emergency basis with external decompression. However, a large subcutaneous hematoma was again evident on the following day. Insufficient hemostatic maneuvers during surgery were considered the cause of this hemorrhagic complication. A second operation was performed to achieve hemostasis of the subcutaneous and muscle tissue. Thereafter, he was rehabilitated without treatment for hemophilia as he had no bleeding episodes. Cranioplasty proceeded using artificial bone at 40 days after the first operation. However, epidural hematoma developed again on postoperative day 1. His neurological status did not worsen so a repeat procedure was unnecessary. Close scrutiny uncovered a diagnosis of mild hemophilia A.

Conclusions: Accurate diagnosis is important for the management of postoperative hemorrhagic complications caused by pathologies of the coagulation system. Sufficient hemostasis of hemorrhage from subcutaneous and muscle tissue is essential even during emergency surgery to avoid postoperative complications. A diagnosis of hemophilia should be considered in the face of prolonged activated partial thromboplastin time (APTT).

Keywords: Activated partial thromboplastin time; acute subdural hematoma; diagnosis mild hemophilia A; postoperative complication.

Figure 1

Initial CT imaging findings. Subdural hematoma with obviously shifted midline structure to the contralateral side

Figure 2

CT imaging findings immediately after the first surgery. Complete removal of the hematoma

Figure 3

CT imaging findings after first and second surgeries. A large subcutaneous hematoma again appears with midline deviation on postoperative day 1 after the first surgery (a). Complete removal of the hematoma (b)

Figure 4

CT imaging findings after cranioplasty. A small amount of air is the sole abnormal finding immediately after cranioplasty (a). Epidural hematoma is evident under artificial bone at 22 hours after cranioplasty (b)