Contralateral Epidural Hematoma Research Articles

Unusual neurosurgical emergency in Paget\u2019s disease of the skull: a case report and review of the literature

IntroductionPaget’s disease of bone is usually asymptomatic in most cases. The neurosurgeon should be familiar with the common presentation and complications. The rare presentation of this case of Paget’s disease of the skull raised our attention to report it.Case descriptionA Paget’s disease patient presented in the emergency department with a disturbed conscious level (GCS 8) without any history of trauma or seizures. CT showed severe hypertrophied left frontal, temporal, and parietal bones with midline shift. The patient underwent an emergency left decompressive craniectomy. Postoperative CT scan was done and showed frontoparietal epidural hematoma on the opposite side which was evacuated immediately. The patient started to improve and became fully conscious in few days with marked improvement of the motor power of her right side.Discussion and evaluationSevere skull involvement and impending brain herniation may occur in Paget’s disease of the skull which needs urgent decompressive surgery. Contralateral epidural hematoma after decompressive surgery may rarely occur and should be suspected in case of intraoperative brain swelling and postoperative failure of improvement. Neurosurgeons and radiologists should recognize the rare phenomenon of periosteal bone formation in the pagetic bone and its extension into surrounding tissues.ConclusionsIn our case, we faced an unusual life-threatening condition in a patient of Paget’s disease with severe skull involvement leading to rapid deterioration of consciousness and impending brain herniation. The neurosurgeon should be aware of this rare emergency condition.

Características do Hematoma Epidural Contralateral após Craniectomia Descompressiva para Tratamento de Trauma Cranioencefálico Grave. Revisão Sistemática

Introdução: A craniectomia descompressiva é considerada como o método cirúrgico mais utilizado no tratamento da hipertensão intracraniana refratária decorrente da injúria cerebral grave. Apesar de ser descrita como método resolutivo quando bem indicado, pode contar com severas complicações precoces, destacando-se dentre elas o hematoma epidural contralateral. Objetivos: Descrever os principais achados clínicos e tomográficos de pacientes que apresentaram hematoma epidural contralateral após a realização da craniectomia descompressiva para tratamento do trauma cranioencefálico grave. Metodologia: Trata-se de uma revisão sistemática de literatura, sem metanálise, realizada pelas bases de dados Pubmed e Scielo. Resultados: Foram encontrados sessenta e sete pacientes acometidos por hematoma epidural contralateral após a realização da craniectomia descompressiva. A suspeição para a formação do novo sangramento foi observada pela anormalidade pupilar (22,3%) e aumento da pressão intracraniana (18%) no pós-operatório, pelo inchaço cerebral no momento da primeira cirurgia (22,3%) ou revelado pela tomografia computadorizada de rotina (26,8%). Pelo menos 86,36% dos pacientes apresentaram fratura óssea contralateral ao hematoma inicial. Conclusão: O hematoma epidural contralateral tem uma incidência de 5,2%. A fratura óssea contralateral ao hematoma inicial se destaca como principal característica para o desenvolvimento de hematoma epidural contralateral. O edema cerebral intra-operatório inexplicável ou a presença de anormalidades pupilares no pós-operatório, se destacam como bom indicador do desenvolvimento do hematoma contralateral. Em contrapartida, a deterioração neurológica e a presença de coagulopatias não é uma característica confiável de hematoma epidural contralateral após craniectomia descompressiva.

A combination of acute and delayed contralateral epidural hematoma

Introduction. An acute bilateral extradural hematoma is an uncommon presentation of traumatic head injury; however, it leads to higher mortality rate than acute unilateral hematoma. A delayed epidural hematoma (DEDH) is a hematoma that is not present on initial computed tomography (CT) scan but is found on subsequent CT. While reviewing the literature, we could not find recently published papers considering supratentorial DEDH after primary operated contralateral EDH. Case report. A comatose 14-year-old male, with Glasgow Coma Scale score 4 and the right midriatic pupil on the side of the blunt trauma to the head, was admitted to ICU after he had survived a traffic accident. Initial brain CT scan showed an acute temporoparietal epidural hematoma on the right side of the cranium, with impressive midline shift and bilateral linear skull fracture. Surgery was performed and intracranial pressure (ICP) monitor was implanted, which showed the increased values of ICP. A control brain CT scan performed within 24 hours showed a new contralateral occipitoparietal epidural hematoma. Another operation was performed. Second, control CT brain scan showed favorable finding. The patient was transferred after 25 days to the rehabilitation center, with the disability rating score of 11 and after 3 months it was1. Conclusion. A contralateral DEDH is a lifethreatening neurosurgical emergency case which can occur during the first 24 hours after decompressive craniectomy. Control and ICP monitoring is recommended in these cases, especially after surgical decompression.

Clinical Features and Outcomes of Bilateral Decompression Surgery for Immediate Contralateral Hematoma after Craniectomy Following Acute Subdural Hematoma.

ObjectiveImmediate contralateral epidural hematoma (EDH) and traumatic intracerebral hematoma (T-ICH) after craniectomy for traumatic subdural hematoma (SDH) are rare but devastating post-operative complications. Their clinical features and outcomes are not well studied. In this report, we present the clinical features and outcomes of immediate contralateral acute hematoma cases requiring a second operation.MethodsThis study includes 10 cases of immediate contralateral EDH and T-ICH following bilateral craniectomy for the evacuation of traumatic SDH and contralateral hematoma between 2004 and 2015. Their medical records and radiographic findings were reviewed and analyzed retrospectively.ResultsTen of the 528 patients (1.89%) who underwent craniectomy for the evacuation of traumatic SDH developed post-operative EDH (n=5), T-ICH (n=5). The trauma was caused by a fall in 5 patients and by a traffic accident in 5 patients. The patients who suffered trauma due to pedestrian accidents died. Seven patients had a low admission Glasgow Coma Scale (GCS; GCS≤8) score in the preoperative state (average admission GCS, 7.7; average discharge GCS, 3.4; and average discharge Glasgow Outcome Scale, 2.0). Severe intra-operative brain swelling was noted in all patients, while skull fracture was observed in 8. Multiple associated injuries and medication for heart disease were characteristic of patients who died.ConclusionThe prognosis of delayed contralateral hematoma was very poor. Multiple associated injuries, past medical history and traffic accidents, especially pedestrians were seemed to be associated with higher mortality rates. Finally, contralateral skull fractures can indicate high risk of delayed contralateral acute intracranial hematoma.

Bilateral Acute Traumatic Epidural Hematoma Due to Coup and Contrecoup Head Injury: a Case Report and Review of the Literature

Background: Traumatic acute epidural hematoma following skull fracture may result from a direct head injury and develops unilaterally at the impact site. Contrecoup injury that occurs in head trauma has rarely been reported to result in a simultaneous contralateral epidural hematoma. When bilateral epidural hematoma does occur, the contralateral hematoma may be missed unless head computed tomographic images are requested. Case presentation: A 25-year-old man was involved in a road traffic accident and was struck on his right temporal region, rendering him unconscious. On admission to hospital, he had a swelling of the right temporal region of the scalp. An initial computed tomography scan demonstrated bilateral acute epidural hematoma of the middle cerebral fossa, with a linear fracture at the right temporoparietal region. Follow-up imaging showed the enlargement of the left-sided hematoma, and urgent hemai?¾toma evacuation of the left side was successful performed; the cause of bleeding was the left middle meningeal artery at the base of the left middle cerebral fossa. A small right-sided hematoma, believed to be due to rupture of the right posterior middle cerebral artery, was treated conservatively. The patient’s postoperative course was uneventful, and he was discharged from hospital 30 days following his initial admission, with no residual neurological deficit. Conclusions: Contrecoup epidural hematoma due to skull fracture and detachment of the dura mater from the base of the skull may be associated with rupture of the posterior middle cerebral artery causing a contralateral epidural hematoma. This case demonstrates an interesting mechanism to develop bilateral Epidural Hematoma (EDH).

Serial Attacks

A 40-year-old man suffered severe brain injury and received left side subdural hematoma evacuation with decompressive craniectomy. Intraoperative brain swelling had occurred during the surgery. Postoperative computed tomography (CT) scan was done immediately and showed a contralateral epidural hematoma resulting in herniation. Secondary hematoma evacuation was performed and found a linear fracture near a bleeding meningeal artery. 2 days later CT scan showed cerebral infarction mainly in right posterior cerebral artery distribution. Early diagnosis by postoperative CT scan or other potential ways such as intraoperative sonography is important to prompt treatments and interrupt the pathophysiological chain of the serial attacks.

Risk Factors for the Development of Contralateral Epidural Hematoma Following Decompressive Craniectomy in Patients with Calvarial Skull Fracture Contralateral to the Craniectomy Site

To investigate the frequency and risk factors of contralateral epidural hematoma (CEDH) following decompressive craniectomy (DC) in patients with calvarial skull fracture contralateral to the craniectomy site. After reviewing the medical records and radiographs over a 5-year period, 72 patients with calvarial fracture contralateral to the craniectomy site were enrolled to determine the risk factors for the development of CEDH following DC. Among 13 patients with CEDH following DC, all but 1 patient were younger than 60 years of age. In 10 patients (77%) with CEDH, the contralateral calvarial fracture involved more than 1 bone plate. Comparatively, contralateral calvarial fracture involving more than 1 bone plate was noted in 21 patients (35.6%) without CEDH. After multiple logistic regression analysis, only age (P= 0.008, odds ratio [OR]= 0.916, 95% confidence interval [CI]= 0.858-0.987) and number of fracture-involved bone plate (P= 0.006, OR= 10.971, 95% CI= 2.02-59.70) remained independently associated with CEDH development following DC, and CEDH development rate increased by 8.4% with every 1-year decrease in age. Age and number of fracture-involved bone plate are significant risk factors for CEDH development following DC. Involvement of 2 or more bone plates of contralateral calvarial skull fracture in young adult may prompt an immediate postoperative computed tomography scan to detect the occurrence of CEDH, irrespective of the operative findings and neurologic status. This may prevent devastating neurologic consequences of CEDH and improve therapeutic outcome.

Intracranial pressure monitoring alone: Not an absolutely reliable tool after decompressive craniectomy for traumatic acute subdural hematoma

Introduction: The monitoring of intracranial pressure (ICP) in traumatic brain injury (TBI) is important for postoperative care. In our clinical practice, we have found that neurological deterioration because of contralateral epidural hematoma (EDH) occurs despite normal ICP in patients who have undergone decompressive craniectomy (DC). This study was performed to elucidate the dilemmas associated with ICP monitoring after DC and the possible complementary role of intraoperative and immediate postoperative imaging studies. Methods: Patients who had received DC due to TBI during a 7-year period were retrospectively identified from our database and evaluated. Logistic regression analyses were used to evaluate the associations between patients. Results: Twenty patients had contralateral skull fractures. Five patients (5 of 10, 50%) who developed EDH on the ipsilateral side of the skull fracture underwent operations for EDH evacuation due to the deterioration of their clinical condition. The ICP was significantly lower (P = 0.016) in these patients compared with patients who did not undergo secondary surgery due to EDH. Conclusions: ICP monitoring alone cannot absolutely ensure early detection of contralateral space-occupying lesion after DC due to improvement in cerebral compliance. Imaging studies using brain computed tomography is beneficial for early detection of delayed EDH after DC in a high-risk skull fracture with contralateral acute subdural hematoma patients.

Delayed contralateral epidural hematoma after decompressive craniectomy for a traumatic acute subdural hematoma

Summary After falling from a height, a 29-year-old male patient developed a traumatic left subdural hematoma (SDH) with brain swelling and a midline shift to the right side, as well as a small epidural hematoma (EDH) (thickness: 35 mmHg) 48 hours after surgery, a left, extended decompressive craniectomy was performed in combination with therapeutic hypothermia for 6 days, including rewarming for 3 days. The patient remained stable for several days. However, the patient developed sudden right pupil dilatation with an uncal herniation on Day 14. Computed tomography revealed a considerable enlargement of the contralateral EDH. An emergency craniectomy was performed for EDH evacuation. In this paper, we describe this rare case, in which the delayed expansion of the contralateral EDH occurred 14 days after the initial surgery, and discuss its clinical management and radiologic findings, in addition to reviewing the literature and presenting the possible mechanism of this complication.

Technique of Stepwise Intracranial Decompression Combined with External Ventricular Drainage Catheters Improves the Prognosis of Acute Post-Traumatic Cerebral Hemispheric Brain Swelling Patients.

Acute post-traumatic cerebral hemispheric brain swelling (ACHS) is a serious disorder that occurs after traumatic brain injury, and it often requires immediate treatment. The aim of our clinical study was to assess the effects of stepwise intracranial decompression combined with external ventricular drainage (EVD) catheters on the prognosis of ACHS patients. A retrospective study was performed on 172 cases of severe craniocerebral trauma patients with ACHS. The patients were divided into two groups: unilateral stepwise standard large trauma craniectomy (S-SLTC) combined with EVD catheter implants (n = 86) and unilateral routine frontal temporal parietal SLTC (control group, n = 86). No significant differences in age, sex, or pre-operative Glasgow Coma Scale score were observed between groups (P < 0.05). There were no significant differences in the ipsilateral subdural effusion incidence rates between the S-SLTC + EVD treatment group and the routine SLTC group. However, the incidence rates of intraoperative acute encephalocele and contralateral epidural and subdural hematoma in the S-SLTC + EVD group were significantly lower than those in the SLTC group (17.4 and 3.5 vs. 37.2 and 23.3%, respectively). The mean intracranial pressure (ICP) values of patients in the S-SLTC + EVD group were also lower than those in the SLTC group at days 1 through 7 (P < 0.05). A positive neurological outcome [Glasgow Outcome Scale (GOS) score 4-5, 50.0%] and decreased mortality (15.1%) was observed in the S-SLTC + EVD group compared to the neurological outcome (GOS score 4-5, 33.8%; 36.0%) in the SLTC group (P < 0.05). Our data suggest that S-SLTC + EVD is more effective for controlling ICP, improving neurological outcome, and decreasing mortality rate compared with routine SLTC.

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

Expanding contralateral epidural hematoma causing acute intraoperative brain swelling

Contralateral delayed epidural hematoma following intracerebral hematoma surgery

Background:Delayed epidural hematoma (EDH) is an uncommon finding in patients after intracranial hematomas evacuation. It occurs in 6.7-7.4% of cases. A total of 29 reports were found in literature. Between them were no cases of delayed contralateral EDH after intracerebral hematoma evacuation.Case Description:This paper represents a clinical case of a 28-year-old male patient with opened penetrating head injury, who underwent left frontal lobe intracerebral hematoma evacuation and one day later a contralateral EDH was found and successfully surgically treated.Conclusion:Contralateral EDH is a life-threatening neurosurgical emergency case, which can occur during first 24 hours after decompressive craniectomy. Control CT scans must be performed next day after the operation to verify and treat contralateral EDH timely.

Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: a case report

Head injury is one of the leading causes of death and disability in traumatic accidents. Post-operative contralateral epidural hematomas after surgery for acute subdural hematoma seem to be rare. In this case, expansion and spontaneous resolution of a fractural epidural hematoma contralateral to the side of acute subdural hematoma is presented. The importance of immediate post-operative computed tomography is also highlighted to detect delayed traumatic mass lesions.

Contralateral Acute Epidural Hematoma After Decompressive Surgery of Acute Subdural Hematoma: Clinical Features and Outcome

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. 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. There were seven males and five females. Nine patients had severe head injury (Glasgow Coma Scale {GCS} score < or = 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 < or = 8) had poor outcome. 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.

Intraoperative development of contralateral extradural hematoma during evacuation of traumatic acute subdural hematoma: A rare cause of malignant brain bulge during surgery

AbstractIntraoperative development of epidural hematoma (EDH) is an unusual happening. We report a 36-year-old female who developed severe brain bulge while she was being operated for a traumatic left fronto-temporal acute subdural hematoma. Immediate post-operative CT scan revealed a massive contralateral EDH, which was subsequently evacuated. When a craniotomy is performed for a traumatic hematoma, intraoperative severe brain swelling should alert the surgeon about possibility of contralateral EDH formation especially if there is contralateral skull fracture.

Bilateral asynchronous acute epidural hematoma : a case report.

BackgroundBilateral extradural hematomas have only rarely been reported in the literature. Even rarer are cases where the hematomas develop sequentially, one after removal of the other. Among 187 cases of operated epidural hematomas during past 4 years in our hospital, we found one case of sequentially developed bilateral epidural hematoma.Case PresentationAn 18-year-old conscious male worker was admitted to our hospital after a fall. After deterioration of his consciousness, an emergency brain CT scan showed a right temporoparietal epidural hematoma. The hematoma was evacuated, but the patient did not improve afterwards. Another CT scan showed contralateral epidural hematoma and the patient was reoperated. Postoperatively, the patient recovered completely.ConclusionsThis case underlines the need for monitoring after an operation for an epidural hematoma and the need for repeat brain CT scans if the patient does not recover quickly after removal of the hematoma, especially if the first CT scan has been done less than 6 hours after the trauma. Intraoperative brain swelling can be considered as a clue for the development of contralateral hematoma.

O-5-69 - Rapid diagnosis and treatment of contralateral epidural hematoma following decompressive craniotomy

O-5-69 - Rapid diagnosis and treatment of contralateral epidural hematoma following decompressive craniotomy

穿頭血腫除去術が奏効した急性硬膜下血腫の１例 頭蓋内圧の評価に対するＴＣＤの有用性について

We describe a case of acute subdural hematoma, successfully treated by burr-hole opening and subdural tapping. The patient was a 55-year-old man who fell from the third floor of his house and suffered a head injury. On admission, he was semicomatose, and a computed tomography (CT) scan showed a right acute subdural hematoma and brain contusion. During preparation for the craniotomy, the patient's neurological state deteriorated. Transcranial Doppler (TCD) examination showed a decrease in mean flow velocity (MFV) in the right middle cerebral artery (MCA) and an increase in the pulsatility index (PI), which means an increase in intracranial pressure and a decrease in cerebral perfusion pressure. The patient was therefore subjected to burr-hole opening and subdural tapping in the right parietal region on the spot, and about 100ml of semiliquid subdural hematoma was drained off. At this time, the both MFV and PI according to TCD had improved. A craniotomy was then performed, and the subdural hematoma was totally evacuated. A postoperative CT scan revealed a contralateral epidural hematoma. Therefore a second craniotomy was performed, and the epidural hematoma was totally evacuated. After surgery, the patient's neurological condition improved to a confused state. Our experience in this case suggests that assessment of intracranial pressure by TCD and subdural tapping in the emergency room prior to craniotomy in the operating room, are beneficial in emergency cases of acute subdural hematoma.

Intraoperative development of contralateral epidural hematoma during evacuation of traumatic extraaxial hematoma

Intraoperative development of contralateral epidural hematoma during evacuation of traumatic extraaxial hematoma

Contralateral Epidural Hematoma after Aneurysmal Clipping

Cerebral angiograms of a 48-year-old woman with subarachnoid hemorrhage revealed an aneurysm on the anterior communicating artery. The aneurysm was clipped 38 days after onset via the pterional approach, with the patient in the supine position. During surgery, 900 ml of mannitol was administered and her blood pressure and body temperature were normal. However, 1 hour postoperatively, disturbance of consciousness and right hemiparesis were noted. Computed tomographic scans obtained 30 minutes later showed a large epidural hematoma in the left frontoparietal region, contralateral to the craniotomy site. Emergency evacuation of the hematoma was performed. The patient's postoperative course was uneventful and she had fully recovered at the time of discharge. Postoperative epidural hematomas distant to the operative site are often seen after ventricular drainage, shunting, and suboccipital craniectomy and are attributed to intensive internal decompression. However, a review of the literature yielded only four other cases of contralateral epidural hematoma following aneurysmal clipping. Among the five reported cases (the authors' case included), surgery was performed within 16 to 47 days of the onset of subarachnoid hemorrhage. The interval between surgery and detection of the hematoma ranged from 1.5 to 4 hours in four cases. In three cases the hematoma was in the contralateral frontal region.