Skip to main content
Erschienen in: Journal of Medical Case Reports 1/2014

Open Access 01.12.2014 | Case report

Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): a case report

verfasst von: Lucas Crociati Meguins, Gustavo Botelho Sampaio, Eduardo Cintra Abib, Rodrigo Antônio Rocha da Cruz Adry, Richam Faissal El Hossain Ellakkis, Filipe Webb Josephson Ribeiro, Ângelo Luiz Maset, Dionei Freitas de Morais

Erschienen in: Journal of Medical Case Reports | Ausgabe 1/2014

download
DOWNLOAD
print
DRUCKEN
insite
SUCHEN

Abstract

Introduction

Decompressive surgery for acute subdural hematoma leading to contralateral extradural hematoma is an uncommon event with only few cases previously reported in the English medical literature.

Case presentation

The present study describes the case of a 39-year-old White Brazilian man who had a motorcycle accident; he underwent decompressive craniectomy for the treatment of acute subdural hematoma and evolved contralateral extradural hematoma following surgery.

Conclusion

The present case highlights the importance of close monitoring of the intracranial pressure of severe traumatic brain injury, even after decompressive procedures, because of the possible development of contralateral extradural hematoma.
Hinweise

Electronic supplementary material

The online version of this article (doi:10.​1186/​1752-1947-8-153) contains supplementary material, which is available to authorized users.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

LCM, GBS, ECA, RE and FR participated on the surgeries of the patient. All authors helped to draft the manuscript. All authors read and approved the final manuscript.

Introduction

Traumatic brain injury (TBI) represents an important life-threatening disease. In 2009, the US Centers for Disease Control and Prevention estimated that at least 2.4 million emergency department visits, hospitalizations, or deaths were related to a TBI, either alone or in combination with other injuries[1]. Posttraumatic intracranial mass lesions are commonly seen after severe TBI and are usually involved in the pathophysiology of intracranial hypertension. They may vary from extra-axial mass lesions (acute subdural hematomas, [ASDHs], and extradural hematomas, [EDHs]) to intraparenchymal mass lesions (contusions and intracerebral hematomas)[25]. However, EDH following decompressive surgery for ASDH is an uncommon situation with only few cases previously reported in the English medical literature[610].
The present report describes the case of a Brazilian man who evolved EDH following decompressive surgery for ASDH. We review similar cases previously published.

Case presentation

A 39-year-old White Brazilian man was admitted to our Emergency Department after a motorcycle accident on a highway. Although he was hemodynamically stable, a neurological assessment revealed a Glasgow Coma Scale (GCS) of six points and right eye mydriasis. No clotting dysfunction was detected by laboratory test. Computed tomography (CT) of his brain revealed right side ASDH, hemispheric edema and midline shift of 15.7mm with compression of his right lateral ventricle (Figure 1). He was immediately transferred to the Operating Room and a right decompressive craniectomy was performed. He was kept under sedation and his intracranial pressure (ICP) was continuously monitored in the intensive care unit. On the first postoperative day, he started to present elevated ICP refractory to hyperventilation and osmotic therapy. A new CT was then obtained and showed a large contralateral EDH (Figure 2) and frontal hemorrhage associated with catheter insertion. He was taken again to the Operating Room and surgical evacuation of the hematoma was performed. A brain CT following the second operation, revealed no residual EDH (Figure 3). He evolved hemodynamically unstable within the first 48 hours and no neurological improvement was observed after weaning sedation. He died on the ninth postoperative day.

Discussion

Posttraumatic intracranial mass lesions are commonly seen after severe TBI and are usually involved in the pathophysiology of intracranial hypertension. ASDH is frequently associated with other intracranial abnormalities, and only 30% to 40% of all ASDHs requiring surgery are isolated lesions[11, 12]. The most frequently associated intracranial lesions are contusions and intracerebral hematomas, associated EDHs are noted in 6% to 14% of patients[12, 13]. However, EDH following decompressive surgery for ASDH is an extremely uncommon situation with only 38 cases previously reported in the English medical literature[610].
Several neurosurgical procedures have been reported to be associated with contralateral EDH, such as ventriculoperitoneal shunt insertion and evacuation of acute and chronic ASDH[610, 14, 15]. Shen et al.[6], in 2013, estimated that the percentage of occurrence of EDH contralateral to the site of drainage of ASDH was 2.4% according to the published data. Most of the patients were male, with an average age of 35 years and with a main mechanism of traffic accident[6]. The present report describes the case of an adult who had a motorcycle accident who was admitted to our Emergency Room showing signs of severe neurological damage, with GCS of six points and anisocoria.
Many signs have been proposed as alert hints to the detection of contralateral EDH following drainage of ipsilateral ASDH, such as intra-operative brain swelling, postoperative neurological deterioration, pupillary dilation contralateral to the site of ASDH, grand mal seizure and intractable elevated ICP[8, 14, 15]. In our case, the patient was admitted in poor neurological status and was continuously sedated. ICP monitoring revealed increased ICP from the first postoperative day and was refractory to all initial clinical maneuvers. A postoperative CT showed the presence of a large contralateral EDH. As already highlighted by other authors, on the presentation of “red flags” immediate CT is recommended because it may lead to urgent evacuation surgery of these life-threatening mass lesions[7, 16].
The pathophysiology involved in the formation of delayed contralateral EDH following decompressive surgery is not fully understood, but may include loss of tamponade effect, vasomotor mechanisms, and coagulopathy, with the main cause appearing to be the upsetting of the equilibrium of the damaged vessels and the reactive ICP[17]. In the present case, although a linear fracture ipsilateral to the ASDH had been identified on the admission CT, no other structural abnormality was found during drainage of contralateral EDH, making us believe that the main mechanism involved in our case was the loss of tamponade effect following decompressive surgery and microvascular ruptures in the virtual epidural space.

Conclusions

In conclusion, the present case highlights the importance of close monitoring of the ICP of patients who have severe TBI, even after decompressive procedures, because of the possible development of contralateral EDH. Although most instances of increased ICP after ASDH drainage seem to be associated with brain swelling, these phenomena should raise the suspicion of evolution of contralateral hematoma.
Written informed consent was obtained from the patient’s next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

LCM, GBS, ECA, RE and FR participated on the surgeries of the patient. All authors helped to draft the manuscript. All authors read and approved the final manuscript.

Unsere Produktempfehlungen

e.Med Interdisziplinär

Kombi-Abonnement

Für Ihren Erfolg in Klinik und Praxis - Die beste Hilfe in Ihrem Arbeitsalltag

Mit e.Med Interdisziplinär erhalten Sie Zugang zu allen CME-Fortbildungen und Fachzeitschriften auf SpringerMedizin.de.

© Springer Medizin

Bis 11. April 2024 bestellen und im ersten Jahr 50 % sparen!

e.Med Allgemeinmedizin

Kombi-Abonnement

Mit e.Med Allgemeinmedizin erhalten Sie Zugang zu allen CME-Fortbildungen und Premium-Inhalten der allgemeinmedizinischen Zeitschriften, inklusive einer gedruckten Allgemeinmedizin-Zeitschrift Ihrer Wahl.

© Springer Medizin

Bis 11. April 2024 bestellen und im ersten Jahr 50 % sparen!

Anhänge

Authors’ original submitted files for images

Literatur
1.
Zurück zum Zitat Centers for Disease Control and Prevention (CDC): CDC grand rounds: reducing severe traumatic brain injury in the United States. MMWR Morb Mortal Wkly Rep. 2013, 62 (27): 549-552. Centers for Disease Control and Prevention (CDC): CDC grand rounds: reducing severe traumatic brain injury in the United States. MMWR Morb Mortal Wkly Rep. 2013, 62 (27): 549-552.
2.
Zurück zum Zitat Udoh DO: Bilateral post-traumatic acute extradural hematomas: a report of four cases and review of literature. Niger J Clin Pract. 2012, 15 (1): 104-107. 10.4103/1119-3077.94111.CrossRefPubMed Udoh DO: Bilateral post-traumatic acute extradural hematomas: a report of four cases and review of literature. Niger J Clin Pract. 2012, 15 (1): 104-107. 10.4103/1119-3077.94111.CrossRefPubMed
3.
Zurück zum Zitat Le TH, Gean AD: Neuroimaging of traumatic brain injury. Mt Sinai J Med. 2009, 76 (2): 145-162. 10.1002/msj.20102.CrossRefPubMed Le TH, Gean AD: Neuroimaging of traumatic brain injury. Mt Sinai J Med. 2009, 76 (2): 145-162. 10.1002/msj.20102.CrossRefPubMed
4.
Zurück zum Zitat Zammit C, Knight WA: Severe traumatic brain injury in adults. Emerg Med Pract. 2013, 15 (3): 1-28. Epub 2013 Feb 20PubMed Zammit C, Knight WA: Severe traumatic brain injury in adults. Emerg Med Pract. 2013, 15 (3): 1-28. Epub 2013 Feb 20PubMed
5.
Zurück zum Zitat Gabrielian L, Helps SC, Thornton E, Turner RJ, Leonard AV, Vink R: Substance P antagonists as a novel intervention for brain edema and raised intracranial pressure. Acta Neurochir Suppl. 2013, 118: 201-204.PubMed Gabrielian L, Helps SC, Thornton E, Turner RJ, Leonard AV, Vink R: Substance P antagonists as a novel intervention for brain edema and raised intracranial pressure. Acta Neurochir Suppl. 2013, 118: 201-204.PubMed
6.
Zurück zum Zitat Shen J, Pan JW, Fan ZX, Zhou YQ, Chen Z, Zhan RY: Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review. Acta Neurochir (Wien). 2013, 155 (2): 335-341. 10.1007/s00701-012-1569-9.CrossRef Shen J, Pan JW, Fan ZX, Zhou YQ, Chen Z, Zhan RY: Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review. Acta Neurochir (Wien). 2013, 155 (2): 335-341. 10.1007/s00701-012-1569-9.CrossRef
7.
Zurück zum Zitat Saberi H, Meybodi AT, Meybodi KT, Habibi Z, Mirsadeghi SM: Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: a case report. Cases J. 2009, 2: 6282-10.4076/1757-1626-2-6282.CrossRefPubMedPubMedCentral Saberi H, Meybodi AT, Meybodi KT, Habibi Z, Mirsadeghi SM: Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: a case report. Cases J. 2009, 2: 6282-10.4076/1757-1626-2-6282.CrossRefPubMedPubMedCentral
8.
Zurück zum Zitat Su TM, Lee TH, Chen WF, Lee TC, Cheng CH: Contralateral acute epidural hematoma after decompressive surgery of acute subdural hematoma: clinical features and outcome. J Trauma. 2008, 65 (6): 1298-1302. 10.1097/TA.0b013e31815885d9.CrossRefPubMed Su TM, Lee TH, Chen WF, Lee TC, Cheng CH: Contralateral acute epidural hematoma after decompressive surgery of acute subdural hematoma: clinical features and outcome. J Trauma. 2008, 65 (6): 1298-1302. 10.1097/TA.0b013e31815885d9.CrossRefPubMed
9.
Zurück zum Zitat Mohindra S, Mukherjee KK, Gupta R, Chhabra R, Gupta SK, Khosla VK: Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two cases and review of literature. Br J Neurosurg. 2005, 19 (6): 490-494. 10.1080/02688690500495216.CrossRefPubMed Mohindra S, Mukherjee KK, Gupta R, Chhabra R, Gupta SK, Khosla VK: Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: a report of two cases and review of literature. Br J Neurosurg. 2005, 19 (6): 490-494. 10.1080/02688690500495216.CrossRefPubMed
10.
Zurück zum Zitat Boviatsis EJ, Korfias S, Kouyialis AT, Sakas DE: Epidural haematoma after evacuation of contralateral subdural haematoma. Ir J Med Sci. 2004, 173 (4): 217-218. 10.1007/BF02914555.CrossRefPubMed Boviatsis EJ, Korfias S, Kouyialis AT, Sakas DE: Epidural haematoma after evacuation of contralateral subdural haematoma. Ir J Med Sci. 2004, 173 (4): 217-218. 10.1007/BF02914555.CrossRefPubMed
11.
Zurück zum Zitat Massaro F, Lanotte M, Faccani G, Triolo C: One hundred and twenty-seven cases of acute subdural haematoma operated on. Correlation between CT scan findings and outcome. Acta Neurochir (Wien). 1996, 138 (2): 185-191. 10.1007/BF01411359.CrossRef Massaro F, Lanotte M, Faccani G, Triolo C: One hundred and twenty-seven cases of acute subdural haematoma operated on. Correlation between CT scan findings and outcome. Acta Neurochir (Wien). 1996, 138 (2): 185-191. 10.1007/BF01411359.CrossRef
12.
Zurück zum Zitat Servadei F, Nasi MT, Giuliani G, Cremonini AM, Cenni P, Zappi D, Taylor GS: CT prognostic factors in acute subdural haematomas: the value of the ‘worst’ CT scan. Br J Neurosurg. 2000, 14 (2): 110-116. 10.1080/02688690050004525.CrossRefPubMed Servadei F, Nasi MT, Giuliani G, Cremonini AM, Cenni P, Zappi D, Taylor GS: CT prognostic factors in acute subdural haematomas: the value of the ‘worst’ CT scan. Br J Neurosurg. 2000, 14 (2): 110-116. 10.1080/02688690050004525.CrossRefPubMed
13.
Zurück zum Zitat Cordobés F, Lobato RD, Rivas JJ, Muñoz MJ, Chillón D, Portillo JM, Lamas E: Observations on 82 patients with extradural hematoma. Comparison of results before and after the advent of computerized tomography. J Neurosurg. 1981, 54 (2): 179-186. 10.3171/jns.1981.54.2.0179.CrossRefPubMed Cordobés F, Lobato RD, Rivas JJ, Muñoz MJ, Chillón D, Portillo JM, Lamas E: Observations on 82 patients with extradural hematoma. Comparison of results before and after the advent of computerized tomography. J Neurosurg. 1981, 54 (2): 179-186. 10.3171/jns.1981.54.2.0179.CrossRefPubMed
14.
Zurück zum Zitat Power D, Ali-Khan F, Drage M: Contralateral extradural haematoma after insertion of a programmable-valve ventriculoperitoneal shunt. J R Soc Med. 1999, 92 (7): 360-361.PubMedPubMedCentral Power D, Ali-Khan F, Drage M: Contralateral extradural haematoma after insertion of a programmable-valve ventriculoperitoneal shunt. J R Soc Med. 1999, 92 (7): 360-361.PubMedPubMedCentral
15.
Zurück zum Zitat Panourias IG, Skandalakis PN: Contralateral acute epidural haematoma following evacuation of a chronic subdural haematoma with burr-hole craniostomy and continuous closed system drainage: a rare complication. Clin Neurol Neurosurg. 2006, 108 (4): 396-399. 10.1016/j.clineuro.2004.12.014.CrossRefPubMed Panourias IG, Skandalakis PN: Contralateral acute epidural haematoma following evacuation of a chronic subdural haematoma with burr-hole craniostomy and continuous closed system drainage: a rare complication. Clin Neurol Neurosurg. 2006, 108 (4): 396-399. 10.1016/j.clineuro.2004.12.014.CrossRefPubMed
16.
Zurück zum Zitat Matsuno A, Katayama H, Wada H, Morikawa K, Tanaka K, Tanaka H, Murakami M, Fuke N, Nagashima T: Significance of consecutive bilateral surgeries for patients with acute subdural hematoma who develop contralateral acute epi- or subdural hematoma. Surg Neurol. 2003, 60 (1): 23-30. 10.1016/S0090-3019(03)00023-5.CrossRefPubMed Matsuno A, Katayama H, Wada H, Morikawa K, Tanaka K, Tanaka H, Murakami M, Fuke N, Nagashima T: Significance of consecutive bilateral surgeries for patients with acute subdural hematoma who develop contralateral acute epi- or subdural hematoma. Surg Neurol. 2003, 60 (1): 23-30. 10.1016/S0090-3019(03)00023-5.CrossRefPubMed
17.
Zurück zum Zitat Lesoin F, Viaud C, Pruvo J, Redford H, Jomin M: Traumatic and alternating delayed intracranial hematomas. Neuroradiology. 1984, 26: 515-516. 10.1007/BF00342691.CrossRefPubMed Lesoin F, Viaud C, Pruvo J, Redford H, Jomin M: Traumatic and alternating delayed intracranial hematomas. Neuroradiology. 1984, 26: 515-516. 10.1007/BF00342691.CrossRefPubMed
Metadaten
Titel
Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): a case report
verfasst von
Lucas Crociati Meguins
Gustavo Botelho Sampaio
Eduardo Cintra Abib
Rodrigo Antônio Rocha da Cruz Adry
Richam Faissal El Hossain Ellakkis
Filipe Webb Josephson Ribeiro
Ângelo Luiz Maset
Dionei Freitas de Morais
Publikationsdatum
01.12.2014
Verlag
BioMed Central
Erschienen in
Journal of Medical Case Reports / Ausgabe 1/2014
Elektronische ISSN: 1752-1947
DOI
https://doi.org/10.1186/1752-1947-8-153

Weitere Artikel der Ausgabe 1/2014

Journal of Medical Case Reports 1/2014 Zur Ausgabe