Combined epidural and intracerebral hematomas after evacuation of bilateral chronic subdural hematoma

Remote bifrontal epidural hematoma following hemispheric glioma resection. A rare life-threatening postoperative complication

Background:

Postoperative acute epidural hematoma (EDH) is a well-known serious complication that usually occurs at the operated site after cranial surgery. However, epidural bleeding, distant from the site of the previous craniotomy, is relatively rare and may sometimes cause significant neurological morbidity or even mortality. We report such a case.

Case Description:

A 35-year-old woman, previously healthy, was operated on for a left temporo-parieto-fronto-insular anaplastic astrocytoma. Between 2 and 4 h after the surgery, the patient had trouble waking-up following the general anesthesia. Emergent computed tomography (CT) scan revealed an acute bifrontal EDH away from the initial surgical field. The patient underwent an immediate reoperation, a decompressive bifrontal craniotomy, and the evacuation of the hematoma. Despite the neurologic improvement, she died 24 days after the surgery due to severe sepsis caused by pulmonary infection with pseudomonas aeruginosa.

Conclusion:

The pathophysiology of postoperative remote EDH is poorly understood, although various hypotheses have been suggested including the loss of tamponade effect, the vasomotor mechanisms, and the coagulopathy. As seen in the present case report, we suspected that the intensive use of perioperative mannitol may also promote this complication. In the early postoperative period, every patient with neurological deterioration should have a rapid cranial CT-scan because early detection and removal of postoperative acute EDH can be life-saving.

Intraparenchymal Hemorrhage After Evacuation of Chronic Subdural Hematoma: A Case Series and Literature Review

BACKGROUND

Intraparenchymal hemorrhage (IPH), possibly due to reperfusion, after evacuation of a cranial chronic subdural hematoma (cSDH) is a known phenomenon. However, it is sparingly reported and not well understood.

METHODS

An illustrative case series is presented. A literature review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify all previously reported cases.

RESULTS

A total of 48 cases were analyzed. Males were 85.4% of the population, and the mean age was 67.5 years. Pre-existing head trauma and hypertension were the most common comorbidities. Headache was a presenting symptom in 60.4% of cases. Midline shift was explicitly stated in 54.2% of cases. Initial burr hole alone was performed 75.0% of the time, whereas craniotomy alone was performed in 16.7% of cases. Any initial craniotomy patients were associated with a modified Rankin Scale score of 5 (P = 0.03). The IPH was located in the cerebral hemisphere in 62.5% of cases and more likely to occur ipsilateral to a unilateral cSDH (P = 0.02). The IPH occurred a mean 1.9 days after surgery, and 50.0% occurred within 24 hours of initial intervention. The median modified Rankin Scale at discharge was 2. The mortality rate was 25%. Lastly, a multifactorial reperfusion pathophysiology was proposed.

CONCLUSION

IPH after cSDH evacuation is associated with significant morbidity and mortality. Prompt recognition, regulating blood pressure, controlling the amount and rate of extra-axial fluid drained, and a meticulous surgical technique are critical to optimize the care of patients with cSDH and reduce the rate of postoperative IPH.

Bilateral Oculomotor Palsy After Surgical Evacuation of Chronic Subdural Hematoma

BACKGROUND

Chronic subdural hematoma is a common neurosurgical disease and the most benign form of intracranial hematoma. Most patients are successfully treated with simple burr hole evacuation and external drainage with good outcome and low rate of complications. Brainstem hemorrhage is a rare cause of severe disability in these patients, and cannot be ignored.

CASE DESCRIPTION

We report the first case of bilateral oculomotor palsy due to a midbrain hemorrhage after evacuation of a unilateral chronic subdural hematoma. The relevant literature is also reviewed to better understand the causes of this rare but disabling occurrence and how it can be prevented during and after surgery.

CONCLUSIONS

Neurosurgeons must have awareness of remote intracerebral hemorrhage after burr hole evacuation of chronic subdural hematoma, and take measures to avoid it during surgery. Our experience and the review of the relevant literature demonstrate that preoperative computed tomography can provide information to identify the patients at major risk.

Chronic subdural hematoma

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. There is lack of uniformity in the treatment of CSDH amongst surgeons in terms of various treatment strategies. Clinical presentation may vary from no symptoms to unconsciousness. CSDH is usually diagnosed by contrast-enhanced computed tomography scan. Magnetic resonance imaging (MRI) scan is more sensitive in the diagnosis of bilateral isodense CSDH, multiple loculations, intrahematoma membranes, fresh bleeding, hemolysis, and the size of capsule. Contrast-enhanced CT or MRI could detect associated primary or metastatic dural diseases. Although definite history of trauma could be obtained in a majority of cases, some cases may be secondary to coagulation defect, intracranial hypotension, use of anticoagulants and antiplatelet drugs, etc., Recurrent bleeding, increased exudates from outer membrane, and cerebrospinal fluid entrapment have been implicated in the enlargement of CSDH. Burr-hole evacuation is the treatment of choice for an uncomplicated CSDH. Most of the recent trials favor the use of drain to reduce recurrence rate. Craniotomy and twist drill craniostomy also play a role in the management. Dural biopsy should be taken, especially in recurrence and thick outer membrane. Nonsurgical management is reserved for asymptomatic or high operative risk patients. The steroids and angiotensin converting enzyme inhibitors may also play a role in the management. Single management strategy is not appropriate for all the cases of CSDH. Better understanding of the nature of the pathology, rational selection of an ideal treatment strategy for an individual patient, and identification of the merits and limitations of different surgical techniques could help in improving the prognosis.

Chronic subdural haematoma management: an iatrogenic complication. Case report and literature review

The authors report the case of a 45-year-old woman who presented to our institution with 10 days history of confusion and signs of progressive raised intracranial pressure as a result of a minor head injury occurred 4 weeks before. A brain CT-scan showed a large right hemispheric chronic subdural haematoma which was, as routinely, treated by burr-hole craniostomy and closed-drainage. Although the procedure was uneventful, the next day the patient developed a mild left hemiparesis associated to a slight global status worsening. A brain CT scan showed an intracerebral position of the drain with diffuse brain oedema and midline shift. Following drain removal the patient developed a serious neurological deterioration dropping the Glasgow coma scale to 8/15 as the result of an intracerebral and intraventricular haemorrhage along the removed drain trajectory. The clinical features of this iatrogenic complication are reported analysing also globally chronic subdural haematoma management and discussing pertinent literature.

Influence of cranial morphology on the location of chronic subdural haematoma

BACKGROUND

The purpose of the present study was to evaluate the relationship between cranial morphology and location of a chronic subdural haematoma (CSDH) in patients with and without intracranial vault asymmetry.

METHOD

The study was conducted in 110 consecutive adult patients who underwent surgery for CSDH. The relationship between the following variables and CSDH was studied: sex, age, past medical history, history of trauma, interval between head injury and symptoms, clinical presentation, location of the CSDH, symmetry of the frontal and occipital intracranial vault on the CT scan and/or MR images, surgical treatment and outcome. Throughout the analysis, p < 0.05 was considered statistically significant.

FINDINGS

The frontal cranial vault was symmetrical in 48 patients (43.6%) and asymmetrical in 62 patients (56.4%). CSDH was more commonly bilateral in patients with a symmetrical frontal cranial vault than those with an asymmetrical shape (41.7% vs 17.7% and this difference is statistically significant (p = 0.01). In 62 patients with an asymmetric frontal skull vault, the CSDH was bilateral in 11 patients. In the remaining 51 patients, the CSDH was located on the same side of the most curved frontal convexity in 34 patients and on the side of the less curved frontal convexity in 17 patients. The occipital cranial vault was symmetrical in 44 patients (40%) and asymmetrical in 66 patients (60%). CSDH was more commonly bilateral in patients with a symmetrical occipital cranial vault than those with an asymmetrical one (40.9% vs 19.7%) and this difference was also statistically significant (p = 0.019). In 66 patients with an asymmetric occipital skull vault, the CSDH was bilateral in 13 patients. In the remaining 53 patients, the CSDH located on the same side of the most curved occipital convexity in 39 patients and on the side of the less curved occipital convexity in 14 patients.

CONCLUSIONS

Frontal and occipital intracranial vault morphology provides valuable information about location of CSDH. Bilateral CSDH is common in patients with symmetrical frontal and occipital cranial vault. In asymmetrical cranium, CSDH usually locates on the same side of the most curved frontal or occipital convexity. Identification of this relationship can be very useful to elucidate the origin and the pathogenesis of CSDH.