Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 6 (2016) 23–25
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Contralateral development of acute subdural hematoma (SDH) immediately following a burr-hole craniostomy for chronic SDH Jae Sung Park a,⁎, Shin Kyung Kim b, Myeong Sang Yu c a b c
Department of Neurosurgery, Konkuk University School of Medicine, Chungju, Chungcheongbuk-do, Republic of Korea Department of Rehabilitation Medicine, Konkuk University School of Medicine, Chungju, Chungcheongbuk-do, Republic of Korea Department of Otolaryngology, Konkuk University School of Medicine, Chungju, Chungcheongbuk-do, Republic of Korea
a r t i c l e
i n f o
Article history: Received 3 February 2016 Revised 18 April 2016 Accepted 22 May 2016 Available online xxxx Keywords: Hematoma Subdural Trephining Postoperative complications
a b s t r a c t Background: Burr-hole trephination is a widely used surgical technique for chronic subdural hematoma (CSDH). Although various postoperative complications following burr-hole craniostomy have been discussed, no contralateral acute SDH (ASDH) immediately after the initial surgery without concurrent hemorrhages has been reported so far; we experienced this very rare complication in a previously healthy 84 year old male. Details of this very rare case are presented in this report. Materials and methods: 87 patients with chronic SDH underwent a burr hole trephination, that is, craniostomy between July 2012 and June 2014; there were 47 male and 40 female patients. 24 of 87 patients harbored bilateral SDHs. 67 of 111 lesions were drained with two catheters and the remaining 44 employed a single catheter. Results: Unsatisfactory results following the craniastomy included recurrence, insufﬁcient drain, aggravated acute SDH and contralateral development of incracranial hemorrhage. Contralateral intracranial hemorrhage occurred to three patients. One died and the other two were discharged without any sequelae. One of the three contralateral hemorrhages was a mere ASDH which was complicated to a previously healthy 84 year old male within less than an hour after the initial surgery. The patient was discharged without sequelae. Conclusion: This report represents a contralateral ASDH that occurred less than an hour after a burr-hole trephination for CSDH. Several hypotheses concerning the etiology of this rare complication, albeit inconclusive, are worth contemplation. Excessive drain of CSDH must be refrained from in order not to encounter any unexpected complications. © 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Chronic subdural hematoma (CSDH) is a very common entity of intracranial hemorrhages especially among the elderly . Burr-hole cranistomy with closed-system drainage is widely utilized for CSDH, although no surgical technique of choice has reached the universal consensus. Various postoperative complications following burr-hole craniostomy have been discussed, including seizure, subdural empyema, intracerebral hemorrhage, etc. [2–3]. A total of four cases of contralateral development of acute SDH (ASDH) following a craniostomy for CSDH have been reported so far, but none of them occurred immediately after the surgery without a concurrent hemorrhage. Hereby, we report the ﬁrst case described in the literature where a mere ASDH developed in the contralateral hemisphere immediately after the burrhole trephination for CSDH.
An 84 year old male presented with moderate pancephalic headache that had lasted for three days. He had slipped and fallen hitting his head to the ground about one month before the visit. He had previously been healthy and his routine coagulation tests were normal. The initial brain computed tomography (CT) delineated CSDH in the right frontotemporo-parietal region with the maximal thickness of 15 mm as well as minimal (6 mm) subdural hygroma in the left fronto-temporal region (Fig. 1A). A standard burr-hole trephination was performed under general anesthesia. Upon the opening of the dura, dark yellowish yet clear ﬂuid was drained and a 12-French catheter was subdurally inserted. A total of 30 cm3 of clear ﬂuid was drained until an immediate postoperative CT was taken, which was less than an hour after the surgery. The postoperative CT showed not only almost the same amount of CSDH on the right side, but also a new collection of acute hemorrhage in the left subdural space (Fig. 1B). The maximal thickness of the ASDH (11 mm) was greater than the previously measured subdural hygroma (6 mm), and yet no midline shift was seen. Neither deterioration of consciousness nor focal neurologic deﬁcit was observed. Another CT on the
⁎ Corresponding author at: Neurosurgery Department, Konkuk University Chungju Hospital, 82, Gugwon-daero, Chungju-si, Chungcheongbuk-do 380-704, Republic of Korea. E-mail address: [email protected]
http://dx.doi.org/10.1016/j.inat.2016.05.005 2214-7519/© 2016 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.S. Park et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 6 (2016) 23–25
Fig. 1. A: preoperative brain CT. CSDH on the right and minimal hygroma on the left. B: immediate postoperative brain CT. CSDH with the unchanged volume and a new ASDH on the left with the greater volume than that of the previous hygroma. Arrow: inserted subdural catheter. C: Brain CT on the second postoperative day. CSDH was nearly drained and ASDH was substantially absorbed. CSDH: chronic subdural hematoma, ASDH: acute subdural hematoma.
second postoperative day revealed near complete evacuation of CSDH on the right side as well as substantial resorption of ASDH on the left side (Fig. 1C). The patient was discharged without sequelae. 3. Discussion Contralateral development of intracranial hemorrhages after surgical evacuation of initial hematoma is rare but not unprecedented [4–5]. By 2013, nine contralateral ASDH cases after initial craniotomy or craniectomy for ASDH had been reported; three of them were dead and the remaining six suffered moderate to severe disability . Moon et al. reported a contralateral ASDH after removal of calciﬁed CSDH in 2007, in which a craniotomy instead of burr-hole craniostomy preceded the complication . Four cases of contralateral ASDH following a burrhole craniostomy have been reported so far; one case where development of bilateral ASDH was detected on the date of the initial surgery , one with contralateral ASDH concurrent with intracerebral hemorrhage , and two cases of mere contralateral ASDH that occurred one and three days after the surgery, respectively [10–11]. Our present case is the ﬁrst one described in the literature where a mere ASDH contralaterally developed on the same day of the initial burr-hole craniostomy for CSDH. Pathophysiology of this complication lacks sufﬁcient investigation mainly due to the scarcity of cases. Several assumptions, however, could be borrowed from other adjacent entities. 3.1. Altered Cerebral Blood Flow (CBF) and fragile vessels According to researches concerning CBF in CSDH patients, reduction of CBF was observed not only in the adjacent cortex, but also in the deeper structures including thalamus or even the contralateral hemisphere [12–13]. Several authors who reported postoperative intracerebral hematomas occurring remote from the initial craniotomy or craniostomy attributed their complication to possible sudden increase in CBF following the initial surgery [9,14–15]. Long term decrease of CBF might have contributed to fragile vessels, which may lead to intracerebral hemorrhage when CBF is restored during or after the evacuation. The thickness of bridging vein in subdural space remarkably vary and it can be as thin as 10μm, whereas that of vessels in subarachnoid space is fairly constant (50-200μm) . One can assume that sudden increase of CBF in these fragile and thin bridging veins may be the cause of our present complication. 3.2. Systemic hyperactive ﬁbrinolysis in CSDH patients Kawakami et al. reported increased ﬁbrinolytic activity in 19 patients, either from their chronic subdural hematoma or from venous blood . Another study by Yamashita et al. investigated coagulation and ﬁbrinolysis in 88 elderly patients (N65) who had experienced minor head injury, using 7 parameters including ﬁbrinopeptide A, ﬁbrinopeptide Bβ in systemic blood and Aα plasmin inhibitor, plasmin-aα2 plasmin inhibitor complex, ﬁbrinogen, D-dimer, antithrombin-III in
hematoma contents . 61 of 88 patients were with CSDH and the remaining 27 were not. As anticipated, ﬁbrinolysis in hematoma contents was increased and the majority of patients showed hyperﬁbrinolytic activity in their venous blood as well whether or not they had subdural hematoma. Although our present patient yielded normal results in his routine coagulation test, it is probable that his ﬁbrinolysis had been hyper-activated prior to the surgery, which might have affected the development of a new hematoma. 3.3. Spinal Cerebrospinal Fluid (CSF) leak induced CSDH CSDH has been addressed to as a rare complication of lumbar puncture, spontaneous intracranial hypotension, neurosurgical shunting procedures, spinal anesthesia, etc., which are related to CSF outﬂow [19–20]. In these studies, spinal outﬂow of CSF was suspected to cause sagging of brain that can lead to a tear of congested bridging veins . According to another research concerning CSF leak and CSDH, seven (25.9%) of 27 patients with CSDH possessed CSF ﬁstula proven by CT/MRI or myelography, while one and four patients had previous medication history of warfarin and aspirin, respectively . Based on the premise that CSF outﬂow can be a predisposition to SDH, drain of yellowish yet clear ﬂuid in our case during the ﬁrst postoperative hour may account for the development of contralateral ASDH. It is probable that the clear ﬂuid was not solely chronic hematoma, but a mixture of it with CSF that had entered into subdural space through torn arachnoid layer. Despite relatively small amount (30 cm3) of CSF mixed ﬂuid drained, it may be sufﬁcient to disrupt the homeostasis in CSF containing structures. 4. Conclusion Burr hole craniostomy for CSDH, albeit a simple procedure, can be associated with various postoperative complications. Pathophysiology of each complication has not been fully elucidated, whereupon, excessive or too fast drain of CSDH must be avoided in order not to encounter any unexpected complications. References  K. Tsutsumi, K. Maeda, A. Iijima, M. Usui, Y. Okada, T. Kirino, The relationship of preoperative magnetic resonance imaging ﬁndings and closed system drainage in the recurrence of chronic subdural hematoma, J. Neurosurg. 87 (1997) 870–875.  D. d'Avella, F. De Blasi, A. Rotilio, V. Pensabene, N. Pandolfo, Intracerebral hematoma following evacuation of chronic subdural hematomas. Report of two cases, J. Neurosurg 65 (1986) 710–712.  A. Weisse, B. J., Chronic subdural haematomas. Results of a closed drainage method in adults, Acta Neurochir. 127 (1994) 37–40.  A. Rapana, E. Lamaida, V. Pizza, Multiple postoperative intracerebral haematomas remote from the site of craniotomy, Br. J. Neurosurg. 12 (1998) 364–368.  M.H. Brisman, J.B. Bederson, C.N. Sen, I.M. Germano, F. Moore, K.D. Post, Intracerebral hemorrhage occurring remote from the craniotomy site, Neurosurgery 39 (1996) 1114–1121 (discussion 21-2).  J. Fridley, J. Thomas, R. Kitagawa, J. Chern, I. Omeis, Immediate development of a contralateral acute subdural hematoma following acute subdural hematoma evacuation, J. Clin. Neurosci. 18 (2011) 422–423.
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