American Journal of Clinical Neurology and Neurosurgery

Vol. 1, No. 2, 2015, pp. 77-80

http://www.aiscience.org/journal/ajcnn

* Corresponding author

E-mail address: duttaguru2002@yahoo.com (G. D. Satyarthee)

Intraoperative Contralateral Massive Extradural Hematoma Development During Decompressive Craniectomy and Evacuation of Traumatic Acute Subdural Hematoma Causing Brain Bulge: Management

Guru Dutta Satyarthee*, A. K. Mahapatra

Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India

Abstract

Sequential development of extradural hematoma (EDH) during decompressive craniotomy and evacuation for acute subdural

hematoma (ASDH) causing massive brain bulge is rare, it may represent to be first indication of hematoma development.

About thirty seven cases are published in the form of isolated case report till date. Management is debated, as first to carry out

exploratory burr-hole or necessity of getting CT scan head or intraoperative ultrasonography imaging to ascertain the diagnosis.

Authors report a 40-year male, who developed EDH on contralateral side during evacuation of traumatic acute subdural

hematoma during intraoperative period, wound was closed, patient was directly shifted to CT scan suit and got CT scan

revealed ED, underwent evacuation of EDH by retuning back with good outcome. Awareness of occurrence of EDH

development as a cause of massive intraoperative brain - bulge, which is not getting relieved on routine anaesthetic measure,

may need urgent CT scan or at least intraoperative ultrasonography imaging is to diagnose early and provide appropriate

management.

Keywords

Intraoperative, Extradural Hematoma, Brain Bulge, Decompressive Craniectomy

Received: July 6, 2015 / Accepted: July 26, 2015 / Published online: August 5, 2015

@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license.

http://creativecommons.org/licenses/by-nc/4.0/

1. Introduction

Development of extra-axial haematoma on contralateral

hemisphere during craniotomy surgery for evacuation of

traumatic ASDH presenting with brain bulge is a potential

life threatening complication, if existence of such occurrence

not suspected. [1-8] It may present as extradural, subdural or

intracerebral hematoma. However, development of ASDH is

well reported in literature [3, 9]. However, incidence of EDH,

freshly developing is extremely rare, with paucity of

literature, only reported in the form of isolated case report [1,

4-8]. Intraoperative brain bulge can be commonly caused due

to formation ipsilateral enlargement of hematoma volume or

intra-parenchymal bleed, hydrocephalus enlargement or

rarely but important causes are formation of ASDH, EDH on

contralateral side. Authors report an interesting case of severe

head injury with ASDH, who developed acute brain bulge

intraoperatively during decompressive craniectomy, NCCT

head revealed massive extradural hematoma, located on

contralateral cerebral hemisphere associated with fracture of

overlying calvarium to the surgical procedure, which

necessitated emergency evacuation. Current study

emphasizes getting immediate CT scan directly from

operating room and return back to carry out urgent

evacuation of hematoma can be a life saving measure without

wasting of valuable time and providing golden opportunity

78 Guru Dutta Satyarthee and A. K. Mahapatra: Intraoperative Contralateral Massive Extradural Hematoma Development During

Decompressive Craniectomy and Evacuation of Traumatic Acute Subdural Hematoma Causing Brain Bulge: Management

for good neurological recovery.

2. Case Report

A-40-year male was brought in altered consciousness

following trauma six hour back to our emergency services.

Examination on arrival, vital stable with a G.C.S. Score of 8,

with papillary asymmetry, immediately intubated and kept on

ventilatory support. NCCT head showed thick left sided

ASDH causing with effacement of basal cisterns with

midline shift and significant mass effect (fig-1).

He underwent left frontotemporoprarieal scalp flap and

decompressive craniectomy. Brain was lax after hematoma

evacuation, however suddenly brain bulge noticed just prior

to beginning of dural closure, all routine measure was taken

to reduce he intracranial pressure, but no relief, so

development of hematomas was possibility as it was not

responding to routine anaesthetic measure. Hence a decision

to get CT scan head after rapid wound closure was planned

and shifted to CT scan suit and back to O.T. following NCCT

head, which showed thick right sided parietal EDH with

gross mid line shift. Decompressive craniectomy with EDH

evacuation was carried out. He needed electively ventilated

for five days. He was discharged on tenth postoperative day

with GCS score of 14). (Fig-2). Subsequently he underwent

split autologus cryogenic preserved skull flap cranioplasty at

six months following first surgery (fig-3).

Fig. 1. Initial CT scan head showing thick acute subdural hematoma in left

frontotemporo-parietal region causing effacement of basal cistern, subfalcine

herniation and significant mass effect.

Fig. 2. Post-operative CT scan head showing complete evacuation of

extradural and subdural hematoma.

Fig. 3. CT scan with bone window showing cranioplasty utilizing autologus

split cryogenic preserved skull flap.

3. Discussion

Development of extra-axial haematoma in opposite

hemisphere in a sequential manner during craniotomy

surgery for evacuation posttraumatic ASDH can be caused by

epidural or subdural hematoma. Such occurrence is

extremely rare but presents a challenge for accurate and rapid

a diagnostic and surgical management.

Contralateral hemispherical evolution of ASDH development

during surgery is reported literature [3, 9,11]. However, EDH

evolution during craniotomy or decompressive craniectomy

surgery for traumatic SDH evacuation is still rarer. [1, 4, 6, 7]

In a review by Shen et al, found only 32 published cases,

who developed contralateral EDH during craniotomy for

traumatic acute SDH evacuation in 2013 [4]. However, exact

American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 2, 2015, pp. 77-80 79

mechanism of contralateral epidural hematoma development

remains unknown. Various postulates are put forward to

explain the intraoperative development of EDH, causing

significant mass effect and brain bulge. Tomycz et al

postulated rapid brain shift caused by craniotomy lead to

shear stress on bridging veins of contralateral side, which

may got torn leading to formation of EDH and ongoing

collection of blood over time, may enlarge to cause brain

bulge during surgery, which is unresponsive to anaesthetic

mediation [9]. According to Takeuchi et al, early initial CT

scan is usually done within few hours following injury and

these scan may miss such hematoma development, which

may represent as natural course of evolution [4]. However,

Feuerman et al tried to define intraoperative hematoma as

occurrence of hematoma, which are not observed during

initial CT scan, but developing slowly following surgical

evacuation either during surgery or in the immediate

postoperative period [1].

According to chronology of evolution, such hematoma may

manifest either in the period after completion of surgery or

during intraoperatively. Former can present in the form of

delay reversal from anaesthesia or development of fresh

neurological deficit after recovery from surgery during

convalescence in the postoperative period. Further,

intraoperative development of EDH is much rarer, but can

occur during any stage of surgical procedure of intracranial

surgery i.e. bone flap elevation or following dura opening or

during evacuation of hematoma phase, may present with

catastrophic brain bulge as occurred in the current case.

Various factors have been incriminated to promote the

evolution of epidural hematoma formation are usage of

osmotic dehydrating agent during intraoperative period,

hyperventilation, CSF rhinorrhoea, otorhorea, and presence

of fracture of skull and may act either alone or in

combination causing loss of temponade causing enlargement

of EDH and leading to mass effect and rise in intracranial

pressure. Authors also reported an interesting case, who

developed contralateral epidural hematoma without overlying

calvarial fractures as the source of EDH, was bleeding from

superior saggital sinus [3]. In current case, fracture of

overlying calvarium, compression and temponade effect of

left sided ASDH with midline shift probably prevented

contralateral extradural hematomas from developing but

following evacuation of first hematoma led to decrease in

intracranial tension, loss of temponade effect, increase

intracranial circulation flow aggravated stripping of dura

promoting arterial bleed causing attainment of massive size

leading to intraoperative malignant brain bulge. Huang et al.

observed remote EDH development in patients, who

underwent unilateral decompressive hemicraniectomy for

trauma, presence of remote skull fracture and absent

contusion are independent risk factors and further observed

such remote EDH development is devastating, timely CT

scan head and urgent evacuation of hematoma are efficient

and important factors determinig neurological outcome [2].

If acute brain bulge noticed intraoperatively, which fails to

respond well to the anaesthetic maneuver routinely practiced

i.e. head elevation, infusion of osmotic agent, diuretics,

maintaining air way patency, avoidance of over-rotation of

head, hyperventilation, switching over to total intravenous

anaesthetic agent anaesthesia and in such resistant brain bulge.

Routine intraoperative neurosurgical manoeuvre should be

applied first to control further brain bulge, cisternal CSF

release, ventricular tapping to release CSF are surgical adjunct.

Another important indicator of remote bleeding during

craniotomy is progressive brain bulge with recurrent oozing or

venous bleeding in the surgical cavity causing repetitive failure

to secure hemostasis. But in few cases, brain continue to bulge

and not responding favourably to either surgical or anaesthetic

maneuver, a possibility of remote hemorrhage should be kept.

Awareness of such remote hematoma occurrence is very

essential for neurosurgeons.

Ascertaining the causes of brain bulge and providing

appropriate remedial measure is very important requiring

urgent neuro-imagings. It can be diagnosed with

intraoperative ultrasonography or CT scan or exploratory

burr hole placement without imaging study or getting CT

scan first and planning of subsequent surgery depends on

immediate availability of CT scan or Ultrasound machine.

However, CT scan of head is time consuming in addition

requires shifting out and in off the operating room unless or

institution having Intraoperative mobile CT scanner.

Management depends upon mass effect, size of hematoma,

rate of progression of mass effect, effect of anaesthetic

measure. A large acute EDH requires evacuation; however

small contralateral EDH collection developing or detected in

postoperative period can be monitored however, our case

needed urgent surgical intervention. Singh et al advocated

intraoperative anaesthetic measure, rapid closure of scalp

wound without placing bone and getting immediate CT scan

head and immediately shifting to operating room without

delay and craniotomy with evacuation of extradural

hematoma [5].

4. Conclusion

Acute brain budge during surgery may be first indication of

developing contralateral extraxial collections or parenchymal

contusions in severe head injury. Authors advocate getting

rapid imaging is paramount importance, either intraoperative

ultrasonography or urgent CT scan for proper diagnosis is

important.

80 Guru Dutta Satyarthee and A. K. Mahapatra: Intraoperative Contralateral Massive Extradural Hematoma Development During

Decompressive Craniectomy and Evacuation of Traumatic Acute Subdural Hematoma Causing Brain Bulge: Management

References

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[2] Huang YH, Lee TC, Lee TH, Yang KY, Liao CC. Remote epidural haemorrhage after unilateral decompressive hemicraniectomy in brain-injured patients. J Neurotrauma. 30(2): 96-101, 2013

[3] Sarkari A, Satyarthee GD, Mahapatra AK, Sharma BS. Delayed opposite frontal epidural hematoma due to bleeding from superior saggital sinus with no cranial fracture - a case report Indian J Neurotrauma 9:133-135, 2012

[4] Shen J, Pan JW, Fan ZX, Zhou YQ, Chen Z, and Zhan RY. Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review. Acta Neurochir (Wien). 155 (2):335-41, 2013

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