Abstract
We present a rare case of infected subdural hematoma (ISH) in a patient with pancreatic head adenocarcinoma and severe cholangitis. A 78–year–old woman with pancreatic cancer and liver metastases presented one day after a fall, complaining of impaired mobility. She had poorly controlled diabetes (HbA1c 10.1%) and was scheduled for chemotherapy. On arrival, her Glasgow Coma Scale score was E3V4M6, with no focal deficits. Blood tests revealed leukocytosis (WBC 2.6×104/μL), elevated CRP (16.8 mg/dL), thrombocytopenia (Plt 9.0×103/μL), and liver ⁄ kidney dysfunction. Head computed tomography (CT) showed a right acute subdural hematoma with slight midline shift. Abdominal CT revealed bile duct dilatation due to pancreatic cancer, and she was diagnosed with severe cholangitis. Due to bleeding risk and impaired consciousness likely related to cholangitis, conservative management was selected for the hematoma, and cholangitis treatment was prioritized.
On the second day after head trauma, endoscopic retrograde cholangiopancreatography revealed distal bile duct stenosis, and a biliary stent was placed. Escherichia coli was detected in blood and bile cultures, and antibiotics were adjusted accordingly. Her condition improved, and she was transferred to a rehabilitation hospital on day 17 with a Glasgow Outcome Scale (GOS) score of 4.
However, on day 21, she developed decreased consciousness and left hemiparesis. Inflammatory markers had re–elevated, and head CT revealed hematoma enlargement with marked midline shift. Emergency burr hole drainage yielded brownish, purulent fluid. Escherichia coli was identified from the abscess culture, supporting the diagnosis of ISH. Antibiotic therapy was adjusted accordingly. The patient showed clinical improvement, and follow–up CT confirmed resolution of the abscess. She was transferred back to rehabilitation on day 52 with a GOS score of 3.
This case highlights the importance of considering ISH in patients with underlying conditions complicated by systemic infection.
