Massive life-threatening bifrontal epidural hematoma following placement of an external ventricular drain.

Abstract

Dear Editor: External ventricular drainage is a life-saving neurosurgical procedure for CSF drainage in acute hydrocephalus. External ventricular drain (EVD) was first described by Dandy [2]. Most common EVD-related complications include infection and hemorrhage; however, literature on hemorrhagic complications of EVD remains sparse [4, 5]. Epidural hematoma is a rare complication and can occur at site of placement or at a distant site due to sudden decompression and dural stripping from the overlying bone. A 17-year-old male patient, a diagnosed case of thalamic glioma who received primary radiotherapy, presented to us with complaints of headache, repeated vomiting, and drowsiness. On examination, his GCS was E1VtM2. Non-contrast CT (NCCT) scan of the head showed right thalamic tumor with hydrocephalus (Fig. 1a). An EVD was inserted through right frontal twist drill craniostomy, at the Kocher’s point. CSF was under high pressure, and the EVD bag was kept at a level of patient’s tragus. The patient became conscious (GCS E4VtM6) after the placement of the EVD. After 4 h of EVD placement , pat ient again became unresponsive (GCS E1VtM1), and the EVD had drained 50 ml of CSF by then. NCCT scan of the head revealed massive bifrontal epidural hematoma (EDH) and the EVD tip was in the frontal horn of the right lateral ventricle (Fig. 1b). A bicoronal scalp incision, bilateral frontal bone flap was elevated and EDH was evacuated. The superior sagittal sinus and the bifrontal dura were found stripped from the bone. Multiple central and peripheral dural hitches were applied and the bone flap was placed back. The patient regained consciousness after surgery and his sensorium improved following surgery to E4VtM6 with CT head showing complete evacuation of EDH (Fig. 1c). Eight hours after EDH evacuation, the patient again became E1VtM1. NCCT scan showed dilatation of ventricles, so a right parietal EVD was inserted. The patient again regained consciousness (GCS E4VtM6). The EVD was converted to a ventriculo-peritoneal shunt as a definitive measure of CSF diversion after 48 h (Fig. 2a, b). The patient was doing good at 3 months follow-up with a functioning shunt. External ventricular drainage is one of the life-saving procedures in neurosurgery, although tapping ventricle still can cause hemorrhagic complications due to injury to cortical vein or the subependymal vasculature. The reported hemorrhagic complications of an EVD include a parenchymal bleed, intraventricular bleed, and subdural or epidural hematomas [1, 3]. Intra-parenchymal and subdural hematomas are mostly due to direct trauma, whereas an EDH occurs as a result of direct trauma to the dural vessel, venous lacunae, and diploe or may be due to the sudden decompression of the ventricles, * Kanwaljeet Garg gargneuro@hotmail.com