Seizure and aspiration complicating acute expanding epidural hematoma in a tuberous sclerosis adolescent: a case report of clinical and surgical emergency

Epidural hematoma (EDH) is a life-threatening neurosurgical emergency characterized by rapid neurological decline, often after a transient lucid interval. Tuberous sclerosis complex (TSC), a neurocutaneous disorder associated with cortical tubers and vascular abnormalities, predisposes patients to seizures and may exacerbate trauma-related complications. A 16-year-old male with known TSC sustained minor head trauma in a road traffic accident. Initial CT revealed a small right temporoparietal EDH (12 cc) without midline shift, and observation was planned. Four hours later, he developed a generalized tonic-clonic seizure with tongue biting and aspiration, necessitating emergency intubation. Repeat CT demonstrated hematoma expansion to 140 cc. Emergency craniotomy with hematoma evacuation was performed. Postoperatively, he received levetiracetam for seizure prophylaxis, mannitol for raised intracranial pressure, and structured neurorehabilitation. EEG and MRI at 6 months were normal, and antiepileptic therapy was discontinued after a seizure-free follow-up. This case highlights the catastrophic potential of small EDHs progressing to massive hematomas. The combination of seizure, aspiration, and rapid hematoma expansion underscores the need for early repeat neuroimaging, vigilant monitoring, and timely surgical intervention. To our knowledge, this is among the rare reported cases of seizure and aspiration complicating EDH in a TSC adolescent.