“Rabbit Ear” scalp deformity caused by massive subdural effusion in infant following bilateral burr-hole drainage
This 10-month-old male infant, presented at our neurosurgical emergency services with a history of depressed sensorium for 2 days. This followed a road traffic accident 10 days ago in which he was sitting at the rear seat of car and was the sole survivor. On physical examination, his pulse rate was 158/min and blood pressure 68/40 mm Hg. On neurological assessment at admission, he was arousable, moving limbs spontaneously with good cry. His anterior fontanelle was tense. Pupils were mid dilated and non-reacting to light. Hematological and biochemistry profiles were within the normal limits. Computerized tomography (CT) scan of the head done immediately after accident revealed presence of thin subdural hygroma in both frontoparietal regions with compression of adjacent brain []. Ophthalmologist evaluation for vision showed doubtful presence of vision. He was being managed with cerebral decongestant with regular visual assessment and monitoring under ophthalmologist. Repeat CT scan and magnetic resonance imaging (MRI) done after 10 days, following depression of sensorium revealed enlargement of bilateral SDE [] and fundoscopy revealed presence of bilateral papilledema. Patient was shifted to operating room for emergency evacuation of SDE. Right parietal and left parietal burr-holes were placed with drainage of subdural hygroma; the fluid collection was xanthochromic and under raised pressure. The post-operative period was uneventful except rapid bulging of scalp wound at burr-hole site seen bilaterally. He was put on acetazolamide and furosemide with spironolactone for 2 weeks. Despite these, scalp swelling continued to increase rapidly on both burr-hole sites with impending rupture of wound at burr-hole site. The bulging of scalp mimicked bilateral ‘rabbit ear’ appearance []. CT scan showed the presence of massive SDE causing mass effect []. So he was again taken to operation theatre and under general anesthesia a right sided subduro-peritoneal shunt was carried out. Subdural fluid sample was sent for cytopathology, biochemistry and aerobic, anaerobic, fungal and mycobacterial tuberculosis culture. In the post-operative period, subduro-peritoneal shunt was working well with complete resolution of subdural fluid collection. He was discharged on fifth post-operative day following shunt surgery.\nAt the last follow-up 6 months after surgery, he regained significant visual recovery and MRI carried out at follow-up showed a mild hydrocephalus with no residual subdural collection [Figure –]. He was regularly followed-up in pediatrics and the observed developmental milestones were corresponding to the child's age.