Abstract
A 47-year-old man (body weight 102 kg, isolated head injury,Glasgow Coma Scale Score GCS 13) was admitted as anemergency 2 h after a road accident. Within the followingminutes, his neurological state deteriorated and the signs ofhigh intracranial pressure and resultant brain injury wereobserved (GCS 5). The clinical picture indicated a subtentor-ial herniation, and the man was immediately transferred tothe operating theatre. No imaging was performed preopera-tively. A left-sided craniotomy was carried out at the site ofvisible and palpable fracture of the parietal and squamoustemporal bones. Extradural and subdural haematomas werefound over almost the entire left hemisphere as well as asmall dural wound in the parietal area. During evacuation ofthehaematoma,massivebleedingoccurredatthebaseoftheskull. The craniotomy was extended to 2 cm above theexternal auditory meatus and a number of bone fragmentswere removed. The source of bleeding (10 ml/kg bodyweight/min) was found to be a breach (6 mm 5 mm) inthe sigmoid sinus wall, caused by one of the bony fragmentsremoved from the primary fracture site. The only possiblemethod of decreasing the bleeding was to pack with a fibrinsponge fixed with a strap of gauze. Partial haemostasis wasachieved and blood loss decreased to 3—4 ml/kg bodyweight/min. The dural defect in the roof of the left sigmoidsinus was covered with a piece of temporalis muscle fixedwith a strap of gauze (Fig. 1), and 9.6 mg rFVIIa was infusedintravenously(94 mg/kgbodyweight).Atthisstagebloodlosswas below 1 ml/kg body weight/min and progressivelydecreasing, so the haemostatic effect was deemed accep-table. After 15 min blood loss had ceased. A second 9.6 mgdose of rFVIIa was administered 60 min after the first dose.During surgery the patient received 19 units red cell con-centrate, 12 units fresh frozen plasma and 12 l crystalloid.International normalised ratio (INR) values of 1.2, 1.6 and1.2 from three consecutive preoperative coagulationscreens, performed during the sustained haemorrhage andafter the administration of the first dose of rFVIIa, werenormal or slightly raised (normal range 0.8—1.1). This equa-ted to normal or slightly prolonged prothrombin times of 12,18,and11 s(normalrange12—16 s).D-dimersincreasedfrom
Published Version
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