Massive scalp hematoma: An unusual presentation of valproic acid toxicity
A 15-year-old boy with mental retardation and epilepsy, on regular antiepileptic medication, presented with history of fall from bed 1 week prior to admission. He had a progressively increasing diffuse scalp swelling. He had no loss of consciousness, vomiting, seizures or aural, nasal or oral bleed. On examination, the patient was conscious (GCS- E4V5M6) and vitals were stable. He had a bilateral fronto-temporo-parietal diffuse scalp hematoma with bilateral periorbital swelling (Raccoon eyes sign) []. He had pallor but no focal neurological deficits. Laboratory investigations revealed anemia (hemoglobin-5 gm%) with normal leukocyte, platelet counts and liver function tests. Bleeding time was normal. Coagulation profile revealed International Normalised Ratio (INR) of 1.7 with normal activated partial thromboplastin time (APTT). Noncontrast computed tomography showed diffuse scalp hematoma with no skull fracture or intracranial bleed [Figure –].\nOn a review of medications, it was noted that the patient (body weight-30 kg) was on phenytoin (PHT) 200 mg (7 mg/kg), 0.5 mg of clonazepam and 2400 mg of VPA (80 mg/ kg) daily. The VPA dose was increased to the current dosage 6 months before, when the patient had increase in frequency of seizures after a bout of bacterial meningitis. He did not have any further seizures. The serum level of VPA was found to be 119.54 mg/ mL (normal range 50–100 mg/mL). Packed cell blood 2 units and fresh frozen plasma 2 units were transfused. A total of 1050 mL of blood was removed by aspiration of subgaleal hematoma followed by a pressure bandage. He required another aspiration 1 week later when 100 mL was aspirated. Dosage of VPA was gradually decreased from 2400 mg/day to 1200 mg/day (40 mg/kg). The patient did not have any seizure during this time. The patient was discharged in a satisfactory condition and is currently doing well with no fresh seizure.