Delayed posterior fossa epidural hematoma originating from occipital artery after infratentorial craniotomy.

Abstract

Sir, The incidence of postoperative epidural hematoma (EDH) is less than 2 % and most EDHs occur in the supratentorial compartment and produce clinical symptoms within the first 3 days after operation [1, 2]. Different types of EDH respond to different bleeding causes. For regional hematoma which occurred just in the operative area, incomplete hemostasis, hypertension and coagulopathy are regarded as the most important risk factors [1]. Delayed posterior fossa epidural hematoma (PFEDH) is usually associated with occipital trauma as a result of oozing from the fracture edges or a lacerated venous sinus [3, 4]. PFEDH originating from occipital artery (OA) with a long delay after suboccipital craniotomy has not been reported in the English literature. A 51-year-old normotensive male was diagnosed of multiple mass lesions in the bilateral cerebellar hemispheres, vermis and left cerebellopontine angle region with hydrocephalus (Fig. 1a). Decompressive resection of left cerebellar lesion was performed via suboccipital retrosigmoid approach. The surgical procedure was uneventful. Postoperative CT at 1 day and magnetic resonance imaging (MRI) at 3 days showed no bleeding in the surgical region (Fig. 1b, c). Pathological diagnosis of specimen was anaplastic glioma. On the fifth postoperative day, the patient underwent ventricular external drainage as hydrocephalus worsened. Later, he experienced intracranial infection. On the tenth day, sudden incision pain followed by huge hemorrhage from wound occurred without any warning and the patient fell into coma within minutes. Urgent CT revealed a large fresh epidural hematoma of the surgical area (Fig. 1d). The timely hematoma evacuation was performed and an active source of bleeding was identified from the proximate broken end of the occipital artery (Fig. 1e). Despite the total hematoma removal (Fig. 1f), the patient died of intracranial infection and pneumonia. PFEDH after suboccipital craniotomy occurs uncommonly, representing approximately 1 % of all infratentorial craniotomies usually within three postoperative days [5]. Delayed PFEDHs are rarely reported with most of them caused by trauma [3, 4]. To our knowledge, no delayed PFEDH of occipital artery (OA) origin after craniotomy was published. In this case, OA was cut off together with suboccipital muscles by monopolar electrocoaglulation during craniotomy. Although the hemostasis of the broken ends of OA was enhanced by an additional bipolar electrocautery, the risk of rebleeding is possible because the end may contract by its own elasticity into muscle leading to incomplete or C. Tao H. Feng C. You (&) Department of Neurosurgery, West China Hospital, Sichuan University, 37 Guoxue Alley, Chengdu 610041, Sichuan, China e-mail: tcywjj106@163.com