Warfarin-Associated Fetal Subdural Hematoma Causing Severe Neurodevelopmental Delay: A Case Report

Abstract

Fetal subdural hematoma is an antenatal finding associated with significant morbidity and mortality. It can occur due to maternal or fetal risk factors, and its management varies based on the underlying cause and the anticipated long-term outcomes. We present a case of warfarin-associated fetal subdural hematoma resulting in a live birth and severe neurodevelopmental delay by 10 years of age. In conclusion, counseling regarding the risk of fetal intracranial hemorrhage and the potential neurodevelopmental delay is essential in women who require anticoagulation with warfarin. In addition, close antenatal follow-up with fetal sonography and strict INR monitoring are essential preventative measures.

Keywords: Case report; Critical care; Neonatology; Subdural hematoma; Warfarin.

Fig. 1.

a, b Antenatal ultrasound: antenatal ultrasound on the day of delivery showing crescent hyperechoic collection suggestive of SDH 8 × 1.2 cm (dotted lines 1 and 2).

Fig. 2.

First brain ultrasound: brain ultrasound on day 1 of life showing crescent shape hypoechoic collection in the left frontoparietal region measuring 5 × 0.7 cm suggestive of SDH with overlying echogenic area probably denoting layering of the hematoma. An echogenic focus was seen in the falx measuring 1.7 × 0.8 cm which could be clotted blood. No midline shift or ventricular dilatation was noted.

Fig. 3.

Testes ultrasound: testes ultrasound on day 1 of life showing large turbid fluid collection in the right scrotal sac, most probably hemorrhagic fluid measuring around 25 × 15 mm. Normal appearance and perfusion of both testes are seen.

Fig. 4.

a–f Head computed tomography (CT) scan: head CT on day 2 of life showing significant bilateral SDH surrounding almost the whole left hemisphere with extension to the tentorium and posterior interhemispheric fissure as well as the occipital horn of the right lateral ventricle. Also, linear hyperdense lesions are seen extending along the cerebral cortical sulci likely representing associated subarachnoid hemorrhage. Diffuse hypodense area involving both hemispheres almost entirely, suggesting diffuse brain edema with shifting of the midline structures at least 6 mm to the right.

Fig. 5.

a–c Brain ultrasound at 20 days of life: brain ultrasound on day 20 of life showing large subacute/chronic SDH overlying the left cerebral hemisphere with the largest pocket measuring 5.9 × 2.8 (cross dotted black lines) with midline shift to the right side. Large cystic changes involving both cerebral hemispheres suggestive of severe PVL and changes suggestive of cephalomalacia and dilated lateral ventricles were observed.

Fig. 6.

a, b Head MRI: head MRI at day 24 of life showing large bilateral acute on subacute SDH. Features of extensive encephalomalacia changes are noted involving the cerebral hemispheres with small areas being spared in the basal ganglionic region and in the frontotemporal area. The posterior fossa structures are also noted to be spared.