Only 30% to 40% of acute subdural hematoma (SDH)

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1 Contralateral Acute Epidural Hematoma After Decompressive Surgery of Acute Subdural Hematoma: Clinical Features and Outcome Thung-Ming Su, MD, Tsung-Han Lee, MD, Wu-Fu Chen, MD, Tao-Chen Lee, MD, and Ching-Hsiao Cheng, MD Background: Delayed contralateral epidural hematoma (EDH) after decompressive surgery for acute subdural hematoma (SDH) is uncommon. If unrecognized, this delayed hematoma can cause devastating consequences. We present our experience with this group of patients and discuss the diagnosis and management of this dangerous condition. Methods: This study included 12 traumatic patients with acute SDH who developed delayed contralateral EDH after acute SDH evacuation. Clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs. Results: There were seven males and five females. Nine patients had severe head injury (Glasgow Coma Scale {GCS} score <8). Ten patients underwent acute SDH evacuation within 4 hours after the trauma. Intraoperative brain swelling during SDH evacuation was noted in 10 patients. A skull fracture at the site of the EDH on computed tomography (CT) was noted only in 10 patients. However, a skull fracture overlying the EDH was found during EDH evacuation in all patients. Only three patients with less severe head injury (GCS >8) had good recovery. Other patients with severe head injury (GCS <8) had poor outcome. Conclusions: Severe head injury, a skull fracture contralateral to the original hematoma, intraoperative brain protrusion, and a poor outcome are typical clinical findings in this disorder. In patients with acute SDH and a contralateral skull fracture, immediate postoperative CT scan is indicated to evaluate this rare but potentially lethal complication. According to the findings of the postoperative CT scan, the neurosurgeon can make an appropriate strategy of treatment promptly. Early detection and prompt treatment may improve the poor outcome in this group of patients. Key Words: Acute epidural hematoma, Acute subdural hematoma, Decompressive surgery. J Trauma. 2008;65: Only 30% to 40% of acute subdural hematoma (SDH) requiring surgery are isolated lesions. 1,2 The most frequently associated intracranial abnormalities are contusions and intracerebral hematomas. Associated epidural hematoma (EDH) is noted in 6% to 14% of patients. 2,3 However, development of contralateral EDH after decompressive surgery for acute SDH, where the brain is usually tense, is uncommon This delayed contralateral EDH may present with intraoperative brain swelling, postoperative neurologic deterioration, or intractably elevated intracranial pressure (ICP). 5 If unrecognized, this disorder can cause devastating consequences. In this report, we present our experience with 12 cases of delayed contralateral EDH after acute SDH evacuation. We describe the clinical features and outcome in our cases, and discuss the diagnosis and management of this dangerous condition. Submitted for publication March 22, Accepted for publication August 15, Copyright 2008 by Lippincott Williams & Wilkins From the Department of Neurosurgery, Chang Gung Memorial Hospital Kaohsiung Medical Center, Chang Gung University College of Medicine, Taiwan. Address for reprints: Ching-Hsiao Cheng, MD, Department of Neurosurgery, Chang Gung Memorial Hospital Kaohsiung Medical Center, 123, Ta Pei Road, Niao Sung Hsiang, Kaohsiung Hsien, Taiwan; ma4200@ adm.cgmh.org.tw. DOI: /TA.0b013e d9 PATIENTS AND METHODS Study Design From 1996 to 2006, 684 acute SDH evacuations were performed at Kaohsiung Chang Gung Memorial Hospital. Fourteen patients developed delayed contralateral EDH after acute SDH evacuation. Among these patients, two patients who did not have their contralateral hematoma operated upon were excluded from this study. In the remaining 12 patients, clinical and radiographic information was obtained through a retrospective review of the medical records and the radiographs. Clinical Data For each patient, the demographic data, mechanism of head injury, neurologic examination, clinical course, and operative findings were reviewed from the medical records. The findings of neurologic examination included the Glasgow Coma Scale (GCS) score and the pupillary size and reactivity. The measures undertaken to control the increased ICP such as mannitol infusion or hyperventilation were also documented. Time interval from the time of trauma to the time of hematoma decompression and postoperative computed tomography (CT) were reviewed. The decompression time was defined as 30 minutes after the start of surgery, which represents an estimated time of acute SDH evacuation. The reasons for postoperative CT examination were defined as intraoperative brain swelling, postoperative neurologic deterioration, and 1298 December 2008

2 Contralateral Epidural Hematoma routine examination (no change of neurologic status). Postoperative neurologic deterioration might present as postoperative pupillary dilation contralateral to the SDH or neurologic deterioration in the postoperative period. Operative findings and details, including operative procedure, presence of intraoperative brain swelling during acute SDH evacuation, presence of a skull fracture overlying the EDH, the location and size of the EDH, and the bleeding source of the EDH, were reviewed. Functional outcome was evaluated 6 months after the injury by Glasgow Outcome Scale (GOS) score as follows: 1 death, 2 persistent vegetative state, 3 severe disability, 4 moderate disability, and 5 good recovery. 13 Radiographic Data The radiographic data, including the location and volume of EDH, presence of a skull fracture overlying the EDH, and associated brain injury was reviewed. The location of EDH was verified and recorded from both CT and operative findings, whereas the skull fracture was determined by either radiographic or operative confirmation. The volume of EDH was measured by the empirical formula of volume (0.5 height depth length) on the basis of distance measurements of the depth and the length on the CT slice having the largest area of clot. 14 Associated brain injury was defined as cases having the following significant brain injuries: severe subarachnoid hemorrhage or intraventricular hemorrhage, focal brain contusion of more than 2 cm in diameter, or multifocal brain contusion. RESULTS After reviewing the medical records and the radiographs, the clinical features and radiographic data about these 12 patients were summarized in Tables 1 and 2. There were seven males and five females. The cause of trauma was traffic crash in 10 patients, falling in 1 patient, and assault in 1 patient. All but one patient were younger than 60 years of Table 1 Clinical Features of 12 Cases With Postoperative Contralateral Epidural Hematoma Case Age/Sex Mechanism Admission GCS Preoperative GCS* Decompression Time (h) Brain Swelling Fracture at Surgery Postoperative CT (h) 1 39/M Traffic accident Positive PD (immediate) /M Traffic accident Positive ND (32) /F Traffic accident Positive ND (12) /F Traffic accident Positive ND (23) /M Traffic accident Positive ND (13) /M Traffic accident Positive RE (48) /M Assault Positive RE (48) /F Traffic accident Positive ND (16) /M Falling Positive RE (48) /M Traffic accident Positive PD (1) /F Traffic accident Positive RE (96) /F Traffic accident Positive PD (immediate) 1 * GCS before acute subdural hematoma evacuation Fracture at the site of epidural hematoma. GCS indicates Glasgow Coma Scale score;, not significant;, mild swelling;, moderate to severe swelling; CT, computed tomography; GOS, Glasgow Outcome Scale, 1 death, 2 persistent vegetative state, 3 severe disability, 4 moderate disability, 5 good recovery; M, male; F, female; PD, pupillary dilation contralateral to the subdural hematoma; ND, neurological deterioration; RE, routine examination. GOS Table 2 Radiographic Data of 12 Cases With Postoperative Contralateral Epidural Hematoma Case Fracture on CT* EDH Location EDH Volume (ml) Associated Brain Injury 1 Positive Frontotemporoparietal 100 Positive 2 Positive Temporoparietal Negative 3 Negative Temporal 50 Positive 4 Positive Temporal 50 Negative 5 Positive Temporoparietal Negative 6 Negative Temporal 50 Negative 7 Positive Frontal Positive 8 Positive Temporoparietal 100 Positive 9 Positive Parietooccipital Positive 10 Positive Temporoparietal Positive 11 Positive Frontal 50 Negative 12 Positive Frontotemporoparietal 100 Positive * Fracture at the site of epidural hematoma. CT indicates computed tomography; EDH, epidural hematoma. Volume 65 Number

age. Nine patients had severe head injury (GCS 8). Eleven patients accepted mannitol infusion to control the increased ICP before acute SDH evacuation.

3 age. Nine patients had severe head injury (GCS 8). Eleven patients accepted mannitol infusion to control the increased ICP before acute SDH evacuation. Only three patients accepted hyperventilation to control the increased ICP. Three patients deteriorated in neurologic status before acute SDH evacuation. The SDH was decompressed within 4 hours after the trauma in 10 patients. Two patients received immediate postoperative CT scan because they presented contralateral pupillary dilation immediately after acute SDH evacuation. One patient underwent postoperative CT scan 1 hour after acute SDH evacuation because his contralateral pupil dilated. In four patients, the postoperative CT scan was performed within 24 hours because their neurologic condition deteriorated. One patient received postoperative CT scan examination 32 hours later because of clinical deterioration. In four patients, the postoperative CT scan was performed late ( 48 hours) because their neurologic status did not change after acute SDH evacuation. Ten patients underwent second operation within 2 hours after the postoperative CT scan. Only two patients underwent second operation more than 2 hours after the postoperative CT scan. Intraoperative brain swelling and displacement during acute SDH evacuation was noted in 10 patients. Because of intraoperative brain swelling and displacement, these 10 patients underwent decompressive craniectomy to release mass effect. Craniotomy was performed in two patients because the brain was slack after SDH evacuation. No patient underwent ventriculostomy or ICP monitoring. During EDH operation, a skull fracture overlying the EDH was found in all patients. In six patients, the bleeding source was from the middle meningeal artery. In three cases, the bleeding source was from the middle meningeal vein. The bleeding source was unknown or undocumented in the operative record in three patients. After reviewing the radiographs, a skull fracture overlying the EDH was noted only in 10 patients. In two patients, the CT scan failed to demonstrate a fracture. The locations of EDH had an even distribution and depended on the site of the skull fracture and the volume of hematoma. Four patients had small EDH ( 50 ml) and eight patients had moderate to large hematoma ( 50 ml). Seven patients had significantly associated brain injuries. Only three patients with less severe head injury (GCS 8) had good recovery. Other patients with severe head injury (GCS 8) had poor outcome. In these patients, one presented with severe disability, four were in a persistent vegetative state, and four died. Illustrative Case Report A 39-year-old man suffered from a severe head injury during a motor vehicle crash. He was unconscious at the scene of the crash. On arrival at the emergency room, his blood pressure was 126/70 mm Hg and pulse rate was 72 bpm. On examination, he had labored breathing and a scalp hematoma over right frontoparietal area. He had an initial Fig. 1. The initial CT scan demonstrated a left subdural hematoma with marked shift of the midline structures (A) and a right parietal bone fracture (B). GCS score of 6. His pupils were equal and reactive to light. A CT scan demonstrated a left SDH with marked shift of the midline structures (Fig. 1, A) and a right parietal bone fracture (Fig. 1, B). An emergent left-sided craniectomy was performed to evacuate the SDH. Intraoperatively, the brain was markedly swollen and bulging even after removal of the SDH. After finishing the surgery, he was found to have right pupillary dilation. An immediate CT scan demonstrated a huge right EDH and a contusion hematoma over left frontal lobe (Fig. 2). A right-sided craniotomy was immediately performed to evacuate the hematoma, which the bleeding source was a tear in one branch of the middle meningeal artery at the level of the skull fracture. Postoperative CT scan was satisfactory. However, the patient remained severely disabled December 2008

Contralateral Epidural Hematoma Fig. 2. Immediate postoperative CT scan showed a large right epidural hematoma with marked mass effect and a contusion hematoma over left frontal lobe.

4 Contralateral Epidural Hematoma Fig. 2. Immediate postoperative CT scan showed a large right epidural hematoma with marked mass effect and a contusion hematoma over left frontal lobe. DISCUSSION Significant changes in posttraumatic intracranial hematomas and the appearance of new hematomas can occur without changes in the clinical status of the patient. 10 One of the major goals of neurosurgeons is early detection and treatment of new mass lesions that require surgery before clinical deterioration. Delayed development of contralateral EDH after acute SDH evacuation is a rare phenomenon However, it is a serious and potentially lethal disorder if unrecognized. In the reported cases, 4 12 no case was older than 60 years of age. In our report, only one case was older than 60 years of age. This may be explained by the fact of the increased adherence of the dura to the inner skull table in the elderly. Reviewing the reported cases, 4 10 development of contralateral EDH after acute SDH evacuation was typically manifested as intraoperative severe brain swelling, except in the reports of Thibodeau et al. 11 and Yague et al. 12 In our study, intraoperative brain swelling was noted in 10 cases. We think that the presence of intraoperative brain swelling depends on the severity of underlying brain injury and the developing speed of the contralateral EDH. However, intraoperative brain swelling is still a warning sign of delayed contralateral EDH formation in traumatic patients with acute SDH associated with a contralateral skull fracture. Besides, absence of intraoperative brain swelling does not exclude the possibility of delayed EDH formation in these patients. In most reports of delayed contralateral EDH after acute SDH evacuation, an overlying skull fracture was demonstrated at the site of the EDH. 4 10,12 In this report, CT scan failed to demonstrate a fracture at the site of the EDH in two cases, although a fracture was found during acute EDH evacuation. This may be explained by the fact that linear fracture of the cranial vault or skull base may be missed because of partial volume effects and pixel size. So absence of a skull fracture on CT scan does not completely exclude the possibility of this disorder. The mechanism of delayed postoperative EDH formation is unclear. It has been hypothesized that the initial impact causes contrecoup injury as well as coup injury with a skull fracture and bleeding from the dura mater or fracture site. However, mass effect from the contrecoup hematoma probably increases the ICP and produces a tamponade effect on the contralateral epidural bleeding source, delaying the formation of EDH. 2 Therefore, the measures, such as decompressive surgery and use of hyperosmolar agents undertaken to reduce the increased ICP, may release the tamponade effect and contribute to the formation of delayed contralateral EDH. 4,11 However, Piepmeier and Wagner 9 thought if this mechanism was operative, it would be anticipated that the complication of delayed EDH would be more frequently reported. In our opinion, when we face those patients with severe mass effect and brain stem compression, we should not be reluctant to use certain measures to reduce the increased ICP just because of the possible risk of delayed EDH formation. Someone may concern if decompressive craniectomy makes these patients more at risk for developing contralateral EDH when compared with craniotomy. In our opinion, decompressive craniectomy may release the tamponade effect and make these patients more at risk for developing contralateral EDH. However, in facing those patients with intraoperative brain swelling and displacement, decompressive craniectomy should be performed to release mass effect. In these patients, a CT scan should be performed immediately to evaluate the cause of the brain displacement and detect this potential complication. A high clinical suspicion or awareness of this entity is necessary to diagnose this dangerous disorder early. Complete reliance on neurologic monitoring, trust in an early CT scan, and a relative complacency after an apparently successful initial decompressive surgery may delay the diagnosis of this postoperative EDH and cause devastating consequence. In our study, neurologic status did not change in four patients before postoperative CT scan. Besides, the delayed EDH in these four patients was diagnosed late ( 48 hours). Accordingly, we recommend that postoperative CT scan should be performed immediately to evaluate this dangerous complication in those patients with acute SDH and a contralateral skull fracture, regardless of operative findings and neurologic status. Then the neurosurgeon can make an appropriate strategy of treatment according to the findings of the postoperative CT scan. Early diagnosis may reverse the poor outcome in this group of patients. In facing those cases with intraoperative brain swelling, immediate CT scan 4,5 or exploratory burr holes 7 over the fracture have been recommended to search for a contralateral EDH. We recommend a CT scan if it can be obtained immediately, because a CT scan has several advan- Volume 65 Number

5 tages over burr holes. The CT scan can delineate the location and size of the contralateral EDH and allow for surgical plan. Furthermore, a CT scan will diagnose other lesions, such as an intracerebral hematoma or cerebral edema, which may be the cause of the brain displacement. A careful review of reported cases of this disorder suggests that the outcome is better in those patients in whom the EDH was responsible for the worsening neurologic status rather than the underlying brain injury, and in whom the recognition and treatment of the first and the contralateral hematoma was promptly undertaken. Patients with severe and diffuse parenchymal injury as evidenced by poor neurologic status from the instant of trauma did poorly. Our report is compatible with this finding. In this study, those patients with severe head injury (GCS 8) had poor outcome. However, we think that EDH evacuation still has its potential value in improving the prognosis in these patients with severe head injury, unless they have expressed the signs of brain stem failure. So we should evacuate the EDH promptly if it causes significant mass effect and give these patients the chance to improve. In conclusion, delayed contralateral EDH after acute SDH evacuation is a rare but dangerous complication. Severe head injury, a skull fracture contralateral to the original hematoma and intraoperative brain protrusion are typical clinical findings. A high clinical suspicion or awareness of this entity is necessary to diagnose this dangerous disorder early. In patients with acute SDH and a contralateral skull fracture, immediate postoperative CT scan is indicated to evaluate this rare but potentially lethal complication. According to the findings of the postoperative CT scan, the neurosurgeon can make an appropriate strategy of treatment promptly. Early detection and prompt treatment may improve the outcome in this group of patients. REFERENCES 1. 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: Servadei F, Nasi MT, Giuliani G, et al. CT prognostic factors in acute subdural haematomas: the value of the worst CT scan. Br J Neurosurg. 2000;14: Cordobes F, Lobato RD, Rivas JJ, et al. Observations on 82 patients with extradural hematoma. Comparison of results before and after the advent of computerized tomography. J Neurosurg. 1981;54: Borovich B, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg. 1985;63: Feuerman T, Wackym PA, Gade GF, Lanman T, Becker D. Intraoperative development of contralateral epidural hematoma during evacuation of traumatic extraaxial hematoma. Neurosurgery. 1988;23: Matsuno A, Katayama H, Wada H, et al. Significance of consecutive bilateral surgeries for patients with acute subdural hematoma who develop contralateral acute epi- or subdural hematoma. Surg Neurol. 2003;60: Meguro K, Kobayashi E, Maki Y. Acute brain swelling during evacuation of subdural hematoma caused by delayed contralateral extradural hematoma: report of two cases. Neurosurgery. 1987; 20: 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: Piepmeier JM, Wagner FC Jr. Delayed post-traumatic extracerebral hematomas. J Trauma. 1982;22: Servadei F, Nanni A, Nasi MT, et al. Evolving brain lesions in the first 12 hours after head injury: analysis of 37 comatose patients. Neurosurgery. 1995;37: Thibodeau M, Melanson D, Ethier R. Acute epidural hematoma following decompressive surgery of a subdural hematoma. Can Assoc Radiol J. 1987;38: Yague LG, Rodriguez-Sanchez J, Polaina M, Porras LF, Lorenzana L, Cabezudo JM. Contralateral extradural hematoma following craniotomy for traumatic intracranial lesion. Case report. J Neurosurg Sci. 1991;35: Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet. 1975;1: Peterson OF, Espersen JO. Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology. 1984; 26: December 2008

Intraoperative contralateral extradural hematoma during evacuation of traumatic acute extradural hematoma: A case report with review of literature

Intraoperative contralateral extradural hematoma during evacuation of traumatic acute extradural hematoma: A case report with review of literature Anand Sharma 1, Arti Sharma 2, Yashbir Dewan 1 1 Artemis