Acute extradural haematoma occurring during twistdrill craniostomy for chronic subdural haematoma

Acute epidural hemorrhage following burr-hole irrigation for chronic subdural hematoma: A possible association with the diploic veins

A 50-year-old man presented with headache and left hemiparesis. No noticeable preceding head trauma was observed. Computed tomography (CT) scans revealed a compressive chronic subdural hematoma (CSDH). The patient underwent burr-hole irrigation, during which he was considerably restless. In addition, extensive avulsion was found in the parietal dura mater posterior to the burr hole. CT performed immediately after the surgery revealed the emergence of a thick epidural hematoma (EDH) located posterior to the burr-hole. During emergency craniotomy for the EDH, there was no identifiable injury to the dura mater or the meningeal vessels. However, a review of the CT scans confirmed well-developed diploic spaces just above the center of the EDH, with connecting channels between the diploic spaces and extracranial sites. Based on these observations, we assumed that the diploic vein might have caused the EDH. Diploic veins can cause AEDH after burr hole irrigation for CSDH. Appropriate intraoperative sedation and protective irrigation maneuvers can reduce the risk of such AEDH.

Complications Following Burr Hole Craniostomy and Closed-System Drainage for Subdural Lesions

Objective

Burr hole craniostomy and closed-system drainage (BCD) is a common surgical procedure in the field of neurosurgery. However, complications following BCD have seldom been reported. The purpose of this study was to report our experiences regarding complications following BCD for subdural lesions.

Methods

A retrospective study of all consecutive patients who underwent BCD for presumed subdural lesions at one institute since the opening of the hospital was performed.

Results

Of the 395 patients who underwent BCD for presumed subdural lesions, 117 experienced surgical or nonsurgical complications. Acute intracranial hemorrhagic complications developed in 14 patients (3.5%). Among these, 1 patient died and 5 patients had major morbidities. Malposition of the drainage catheter in the brain parenchyma occurred in 4 patients, and opposite-side surgery occurred in 2 patients. Newly developed seizures after BCD occurred in 8 patients (2.0%), five of whom developed the seizures in relation to new brain lesions. Eighty-eight patients (22.3%) suffered from nonsurgical complications after BCD. Pulmonary problems (7.3%) were the most common nonsurgical complications, followed by urinary problems (5.8%), psychologic problems (4.3%), and cognitive impairments (3.8%).

Conclusion

The incidence of complications after BCD for subdural lesions is higher than previously believed. In particular, catastrophic complications such as acute intracranial hematomas and surgical or management errors occur at rates that cannot be ignored, possibly causing medico-legal problems. Great caution must be taken during surgery and the postoperative period, and these complications should be listed on the informed consent form before surgery.

Is there a way to avoid surgical complications of twist drill craniostomy for evacuation of a chronic subdural hematoma?

BACKGROUND

Although twist drill craniostomy for evacuation of a chronic subdural hematoma is a rapid and minimally invasive procedure, it carries the risk of complications because it is a 'blind' technique. Our aim was to analyse the complications in a series of patients treated by this technique in order to identify methods of avoidance by modifications in the surgical technique.

METHOD

Thirty-nine patients with a chronic subdural hematoma underwent twist drill craniostomy between November 2002 and December 2005 in our clinic. When a surgical complication happened we modified our surgical technique to see if this avoided it in future patients.

FINDINGS

Surgical complications happened in 7 patients (17.9%) including inadequate drainage, brain penetration, acute epidural hematoma and catheter folding. After preventive modifications these complications did not recur.

CONCLUSIONS

Modifications in the technique of twist drill craniostomy are described in this paper which may minimise the occurrence of surgical complications.

Contralateral acute epidural haematoma following evacuation of a chronic subdural haematoma with burr-hole craniostomy and continuous closed system drainage: a rare complication

Chronic subdural haematoma (CSDH) is one of the most frequent causes for neurosurgical intervention. Although the prognosis is generally good and treatment modalities are well established, some devastating intracranial haematomas can complicate its evacuation. The authors report here a case of an acute epidural haematoma occurring after evacuation of a contralateral chronic subdural haematoma (CSDH) with burr-hole craniostomy and continuous closed system drainage without irrigation. Since this is a rare, but potentially life-threatening, complication, clinicians should suspect its occurrence when an unexpected postoperative course is demonstrated.