Abstract: A 37 yo men, with history of cranioplasty with titanium mesh 11 years ago due to complicated subdural empyema, presented to the Acute and Emergency Department, after awakening with numbness and pin and needles sensation to the left side of his face, tongue and left arm. The symptoms were more intense at the perioral region and were accompanied by pulsatile right-sided headache. The patient had been submitted to capillary implants 6 hours before the symptoms started. At presentation, he had moderate central facial paresia, decreased sensitivity to pain and touch on his left face and arm, and finger-to-nose dysmetria, with no other findings on the physical examination. Laboratory results showed Hb 15.1g/dL, increased white cell count (19,800/uL) with left axis deviation (84% neutrophils) and mildly increased C-Reactive Protein (5 times the upper normal limit). Platelet count was normal, INR 0.97. Kidney function, electrolytes and hepatic markers were normal. The head computed tomography (CT) scan showed right frontal, temporal and parietal craniectomy with cranioplasty, below which an extensive parenchymatous encephaloclastic lesion was seen. Within this space, several acute cerebral bleeds could be detected (Figure – day 1). There was no midline or ventricular acute changes. The patient was admitted for monitoring and image control. Whilst in hospital, he suffered a tonic-clonic seizure and was started on parenteral anti-convulsive medication, with no further episodes. After 72h, he was discharged to the outpatient neurosurgery clinic, with improved symptoms and overlapping CT findings. On follow-up, despite further epileptic seizures with need for medication titration, blood reabsorption was documented (Figure – days 6 and 11).
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