Scientific letter
Acute epidural haematoma as a presentation of hepatocellular carcinoma: Case report and literature review
Hematoma epidural agudo como presentación de carcinoma hepatocelular: a propósito de un caso y revisión de la literatura
Ana Delgado Maroto
, María del Moral Martínez, Carmelo Diéguez Castillo, Francisco Javier Casado Caballero
Corresponding author
Unidad de Gestión Clínica de Digestivo, Hospital Universitario San Cecilio, Granada, Spain
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Osteolytic cranial vault lesion of a probable metastatic aetiology.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 59-year-old Thai woman living in Spain for the past 20 years with a personal history of a partial nephrectomy and hysterectomy, who was not taking any regular medication. She attended our hospital's emergency department having suffered from general malaise, abdominal distension, jaundice and choluria over the course of two weeks, with her symptoms worsening in the second week. While having her history taken, she mentioned that she had received a blood transfusion in the 1980s. She said she did not take any medicines, herbal products or have tattoos. She travelled often, having visited Thailand and Switzerland in the last year. She had consumed 16<span class="elsevierStyleHsp" style=""></span>g of alcohol per day for the past five years. During the physical examination, she presented jaundiced skin and mucous membranes and painless hepatosplenomegaly. Her laboratory tests revealed a previously unknown coagulopathy and abnormal liver parameters: total bilirubin 8.11<span class="elsevierStyleHsp" style=""></span>mg/dl, direct bilirubin 5.85<span class="elsevierStyleHsp" style=""></span>mg/dl, GOT 368<span class="elsevierStyleHsp" style=""></span>U/l, GPT 137<span class="elsevierStyleHsp" style=""></span>U/l, GGT 625<span class="elsevierStyleHsp" style=""></span>U/l, AP 190<span class="elsevierStyleHsp" style=""></span>U/l, CRP 14.39<span class="elsevierStyleHsp" style=""></span>mg/dl and prothrombin activity of 53%. Twenty-four hours after admission, she presented a sudden-onset intense holocranial headache and a rapid decline in consciousness (Glasgow Coma Score [GCS] of 5), with no focal neurological deficit. The patient was transferred to intensive care, where she underwent orotracheal intubation and a computed tomography (CT) scan of the head with intravenous contrast. The CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) revealed the presence of a left-sided frontoparietal acute epidural haematoma (AEH) measuring 85<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>42<span class="elsevierStyleHsp" style=""></span>mm, with associated intracranial expansion and hypertensive hydrocephalus in the contralateral ventricle, probably secondary to an osteolytic cranial vault lesion, suggesting a metastatic aetiology. She underwent emergency neurosurgery, with a left frontotemporal craniotomy, evacuation of the haematoma and tumour resection.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The patient presented poor clinical progress, maintaining a GCS score of 3–4 as well as anuria. From a gastrointestinal point of view, an abdominal ultrasound was performed, showing liver cirrhosis with a focal heterogeneous lesion in segment II measuring 4<span class="elsevierStyleHsp" style=""></span>cm, a partial portal vein tumour thrombus with a hepatofugal flow and mild ascites. Her blood work up tested positive for the hepatitis C virus (HCV) antigen and antibody, with raised alpha-fetoprotein (2476<span class="elsevierStyleHsp" style=""></span>ng/ml). According to both clinical and analytical data, she presented a Child-Pugh score of C14 and a MELD score of 24. An anatomical pathology study of the skull lesion (bone and epidural) revealed the presence of epithelial tumour cells with abundant eosinophilic cytoplasm, prominent nuclei and a trabecular structure, compatible with hepatocellular carcinoma (HCC) metastases. In the end, the patient died four days after surgery.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The incidence of HCC is less than 5% and it is typically located in the lungs (34–70%) and lymph nodes (16–40%). Bone metastases make up 1.6–16%, generally in the vertebrae, pelvis and ribs, being rare in the skull (0.4–1.6%).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">An AEH usually develops secondary to a traumatic brain injury, but may arise spontaneously in the context of neoplastic diseases, infections, vascular malformations or coagulation disorders. Intracranial haemorrhage secondary to metastasis is rare, with an incidence of 0.9–11%. They usually occur within a tumour or the brain itself, and very rarely in the epidural area.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–8</span></a> The formation of an AEH secondary to a HCC metastasis is very rare. In the literature reviewed, we found just eight published cases, as set out in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2–9</span></a> According to this review, they generally affect Asian males, with or without a history of known liver disease, who present with a headache and sharp mental decline. AEH is diagnosed by CT, although bone lesions are only observed in half of cases. All patients undergo surgery and the prognosis is poor, either due to the AEH itself or liver failure. It should be noted that this is the first case reported in a female.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The literature review performed by Hsieh et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> gathers a total of 68 cases of skull metastases due to HCC. The most common form of presentation is a subcutaneous mass, although 10% of patients present intracranial haemorrhagic events. It is not known why these types of metastasis cause AEH, although the most widely accepted hypothesis posits that it is due to the breakdown of vessel structures in the peritumoral tissue, secondary to tumour growth.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1,9</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, we should consider the existence of skull metastases in patients with HCC, particularly if they present with neurological signs and/or symptoms. We should also keep in mind the risk of fulminating AEH.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Delgado Maroto A, del Moral Martínez M, Diéguez Castillo C, Casado Caballero FJ. Hematoma epidural agudo como presentación de carcinoma hepatocelular: a propósito de un caso y revisión de la literatura. Gastroenterol Hepatol. 2019;42:177–179.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 763 "Ancho" => 800 "Tamanyo" => 31345 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Head CT: left-sided frontoparietal acute epidural haematoma. Osteolytic cranial vault lesion of a probable metastatic aetiology.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AEH: acute epidural haematoma; HCC: hepatocellular carcinoma.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Authors and year of publication \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Origin \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Signs and symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Known history of HCC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CT findings \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical findings \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Clinical course \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nakagawa et al,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> 1992 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and sharp mental decline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Haemorrhagic bone tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died two months later due to liver failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nakao et al,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">3</span></a> 1992 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and painful scalp mass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and epidural mass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chronic epidural haematoma and bone tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died six months later due to liver failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hayashi et al,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> 2000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and left-sided hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lentiform nucleus hyperintensity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died two months later due to liver failure and pneumonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">McIver et al,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> 2001 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and left-sided hemiparesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteolytic lesion and acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No neurological deficit and treatment with palliative chemotherapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kanai et al.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a>, 2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache, sharp mental decline and scalp mass \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteolytic lesion and acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died three weeks later due to liver failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Woo et al.,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">South Korea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and sharp mental decline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour, epidural and subdural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died five days later due to multiple organ failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kim et al,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> 2010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">South Korea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Sharp mental decline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone and dural tumour, and epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Vegetative state \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kim et al,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> 2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">South Korea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache, sharp mental decline and vomiting \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteolytic lesion and acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and acute and chronic epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died four months later due to liver failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">This case \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Thailand \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Headache and sharp mental decline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Osteolytic lesion and acute epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bone tumour and epidural haematoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Died four days later due to multiple organ failure \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1987563.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Summary of published cases of patients with a spontaneous AEH due to HCC metastasis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Skull metastasis from hepatocellular carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.T. 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|---|---|---|---|
| 2024 November | 3 | 0 | 3 |
| 2024 October | 21 | 3 | 24 |
| 2024 September | 22 | 1 | 23 |
| 2024 August | 27 | 4 | 31 |
| 2024 July | 26 | 2 | 28 |
| 2024 June | 15 | 5 | 20 |
| 2024 May | 12 | 1 | 13 |
| 2024 April | 17 | 4 | 21 |
| 2024 March | 24 | 3 | 27 |
| 2024 February | 38 | 1 | 39 |
| 2024 January | 32 | 1 | 33 |
| 2023 December | 37 | 4 | 41 |
| 2023 November | 17 | 1 | 18 |
| 2023 October | 48 | 2 | 50 |
| 2023 September | 6 | 1 | 7 |
| 2023 August | 15 | 1 | 16 |
| 2023 July | 26 | 2 | 28 |
| 2023 June | 25 | 1 | 26 |
| 2023 May | 37 | 1 | 38 |
| 2023 April | 25 | 0 | 25 |
| 2023 March | 41 | 1 | 42 |
| 2023 February | 34 | 3 | 37 |
| 2023 January | 46 | 7 | 53 |
| 2022 December | 29 | 4 | 33 |
| 2022 November | 85 | 3 | 88 |
| 2022 October | 33 | 24 | 57 |
| 2022 September | 21 | 12 | 33 |
| 2022 August | 14 | 10 | 24 |
| 2022 July | 9 | 6 | 15 |
| 2022 June | 14 | 7 | 21 |
| 2022 May | 16 | 6 | 22 |
| 2022 April | 9 | 7 | 16 |
| 2022 March | 20 | 7 | 27 |
| 2022 February | 8 | 7 | 15 |
| 2022 January | 25 | 8 | 33 |
| 2021 December | 19 | 8 | 27 |
| 2021 November | 29 | 10 | 39 |
| 2021 October | 12 | 7 | 19 |
| 2021 September | 10 | 10 | 20 |
| 2021 August | 8 | 3 | 11 |
| 2021 July | 17 | 8 | 25 |
| 2021 June | 22 | 0 | 22 |
| 2021 May | 18 | 5 | 23 |
| 2021 April | 46 | 11 | 57 |
| 2021 March | 30 | 10 | 40 |
| 2019 November | 1 | 0 | 1 |
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