Contralateral Hematoma Research Articles

Abstract Number ‐ 99: Middle Meningeal Artery Embolization for Acute‐on‐Chronic Subdural Hematomas.

Introduction Chronic subdural hematomas (cSDH) are a challenge in management due to recurrent bleeds caused by focal inflammation and angiogenesis that produces frail vasculature. One intervention under investigation is endovascular embolization of the middle meningeal artery (MMA) for dura de‐vascularization. While there is increasing evidence for its utility, few investigations have been made into its role for acute‐on‐chronic SDHs and the timeline to intervention. Here, we identify 19 patients undergone MMA embolization to highlight preliminary trends in radiological and morbidity outcomes associated with time‐to‐intervention and hematoma size. Methods A retrospective cohort study of 19 patients undergone embolization of the anterior frontal and posterior parietal branches of the MMA for chronic or acute‐on‐chronic SDHs. Data retrieved is presented in Table 1 and includes: presenting symptoms; radiological features; surgical intervention(s); timeline to therapy and embolysate used; and procedural complications and outcomes. Results Preliminary findings suggests greater utility of MMA embolization for large‐sized subdural hematomas or when performed after 3–4 weeks of initial acute‐on‐chronic bleeds. We note 11 patients with complete or near‐complete resolution of the hematoma after several weeks without peri‐procedural complications or post‐surgical recurrence. In four of these cases (patients 7, 9, 18, and 19), there was resolution of the hematoma after only a brief interval of 2–14 days between radiographic evidence of the acute bleed and embolization. In these cases, the hematoma was noted to be considerably large in volume with a maximal width measuring between 18–30mm with resolution after 2–9 weeks post‐embolization. Conversely, we note poor outcomes in 4 cases (patients 6, 12, 13, and 15) when embolization was performed early (i.e. between 2–10 days) for smaller hematomas measuring between 5–12mm in maximal width. Conclusions MMA embolization functions to de‐vascularize capillary‐rich dura membranes to prevent re‐bleeds and allow for resorption of blood. However, the timeline for embolization of acute hematoma bleeds currently remains elusive. Here, we find preliminary evidence that suggests MMA embolization may be most appropriate for acute‐on‐chronic SDHs after a 3–4 week interval since time of radiographic evidence or for those with a large size hematoma when opting to treat sooner.These findings align with current understanding of the rapid angiogenetic formation of capillaries in the subacute phase (i.e. 0–3 weeks) with leaky vessels after the initial traumatic event. Occluding these vessels would prevent constant re‐bleeds and hematoma growth in the subacute phase. Theoretically, this would recede the hematoma, permit its resorption, and reduce angiogenesis. Moreover, in current literature there have been reports of contralateral hematoma formation in patients undergone surgical evacuation of an initial small acute hematoma. A similar pathogenic process may be implicit with an endovascular approach as well in which there is a natural tamponade effect of the larger coagulated chronic ematoma against frail vasculature causing acute bleeds.

Persistent Unilateral Labial Swelling After Straddle Injury and Contralateral Hematoma Evacuation

Background: Blunt trauma to the external female pelvis or “straddle injury” can usually be managed conservatively. Emergent surgery is indicated for unstable bleeding, need for thorough exam with penetrative trauma or expanding hematoma. Long-term complications after a straddle injury may include pain, scarring, recurrent hematoma or persistent edema.

Source of Bleeding and Per-Operative Findings in Extradural Hematoma (EDH): A Three-Year Experience in a Teaching Institute

Objective: The objective of this study was to analyze the main source of bleeding and operative findings in an extradural hematoma (EDH).
 Material and Methods: A descriptive study was conducted at the Neurosurgery Department of Hayatabad Medical Complex Peshawar from March 2017 to April 2020.The study included 550 patients that met the criteria of inclusion well. Demographic profile, location of Extra-Dural hematoma, the source of bleeding, presence or absence of skull fracture and per operative findings were documented in structured proforma.
 Results: 69% were male and 31% were female patients. The middle age group of 21 – 40 years mostly affected. Rupture or laceration of middle meningeal artery was the communal source of bleeding in 355 (64.5%) patients, followed by fracture bone in 285 (51.8%) of patients and dural venous sinus in 70 (12.7%) of patients. Preoperative findings in our study were linear skull fracture in 250 (45.4.0%), underlying contusion in 165 (30%), and contralateral hematoma in 70 (12.7%) of cases.
 Conclusion: Rupture or laceration of a Middle meningeal artery (MMA) was the most communal source of bleeding in extradural hematoma. Therefore, per-operative cauterization of this vessel is important to prevent the chances of re-bleed and re-do surgeries.

Radiological prediction of contralateral extradural haematoma following evacuation of traumatic acute subdural haematoma

Objectives To identify radiological predictors of contralateral extradural haematoma (CEDH) in patients undergoing evacuation of acute subdural haematoma (ASDH). Design Retrospective case–control study. Subjects Patients requiring evacuation of traumatic ASDH via craniotomy/craniectomy with contralateral skull fracture were analysed in two groups: those who developed CEDH postoperatively and those who did not. Materials and Methods Retrospective analysis of severe traumatic brain injury admissions over 24 months (2017–2019) at a major trauma centre. Pre- and post-operative CT scans were reviewed by a Consultant Neuroradiologist for initial fracture haematoma (FH) and specific contralateral skull fracture features (CLFF) comprising: complex petrous fracture, suture diastasis and fractures involving foramen spinosum or middle meningeal groove (MMG). Results 35 patients had ASDH evacuation (age: 11–74); 7 with craniotomy, 28 with craniectomy. 9/35 developed CEDH of whom 7 underwent bilateral craniotomy/craniectomy. 8/9 with CEDH had FH, 6/26 of those without CEDH had FH. All patients with CEDH had CLFF. 6/9 had >1 CLFF. CLFF was identified in 9/26 patients without CEDH and only 3/26 non-CEDH had >1 CLFF. Analysis using univariate logistic regression identified statistically significant factors for the development of CEDH which were: younger age, FH on initial CT, increasing number of CLFF and MMG involvement alone. After multivariate analysis, only younger age and FH were significant. Conclusions FH and CLFF on CT enable prediction of CEDH in patients undergoing evacuation of traumatic ASDH. These features raise a high index of suspicion for this complication and may expedite investigation and management for CEDH.

Unilateral Bone Window Cerebral Falx Incision of Bilateral Frontal Lobes Cerebral Contusion and Laceration under Neuroendoscopy and Literature Review

Background: Bilateral frontal lobes cerebral contusion and laceration is one unique brain injury in neurosurgery department. It is characteristic of recessive attacking and develops quickly. The unilateral cerebral falx incision is a new minimally invasive surgery that can solve bilateral frontal lobes cerebral contusion and laceration in one surgery. However, it has some limitations in removal of contralateral frontal hematoma and hemostasis due to the limited field of view under the microscope. The unilateral bone window cerebral falx incision of bilateral frontal lobes cerebral contusion and laceration under a neuroendoscopy can acquire a good illumination and field of view. This is beneficial to complete removal of contralateral hematoma, effective hemostasis and retaining brain tissue functions to the maximum extent. Case Presentation: The patient, a 55-year-old man, was hospitalized for “consciousness disorder by 12 h because of car accident”. Physical Examination: Coma, GCS score of E1V2M5, bilateral pupil diameter of 2 mm, presence of light response, contusion of scalp at the left top, peripheral dysphoria and bilateral Bartter syndrome negative. The patient has a history of non-traumatic cerebral stroke 3 years ago. Head CT: Longitudinal fracture of frontal parietal occipital bone, bilateral frontal lobes contusion and laceration, subarachnoid hemorrhage. Diagnosis: Bilateral frontal lobes contusion and laceration, longitudinal fracture of frontal parietal occipital bone, subarachnoid hemorrhage and hematoma of scalp. In emergency treatment, unilateral bone window cerebral falx incision of bilateral frontal lobes cerebral contusion and laceration under a neuroendoscopy was performed. The surgery has achieved satisfying effect. Discussion: This case realized the goal of removing contralateral frontal hematoma through unilateral craniotomy under a neuroendoscopy. Due to the clear field of view, it retained extracerebral layer structures of contralateral olfactory nerve protection frontotemporal completely. Moreover, this surgical technique is conducive to intraoperative recognition of pericallosal arteries and lateral fractured blood vessels. It also involves protection, which conforms to the minimally invasive philosophy. The proposed surgical technology can eliminate contralateral frontal hematoma under a good field of view. However, it is suggested not to manage with the further operation on patients who have brain swelling and difficulties in exposure of cerebral falx. These patients need to determine causes of brain swelling and choose bilateral craniectomy if necessary. Conclusions: Unilateral bone window cerebral falx incision of bilateral frontal lobes cerebral contusion and laceration under a neuroendoscopy is a new application of minimally invasive philosophy in craniocerebral injury operation. It still needs further clinical verifications and experience accumulation.

Development of a prognostic scoring system to predict risk of reoperation for contralateral hematoma growth after unilateral evacuation of bilateral chronic subdural hematoma

Bilateral chronic subdural hematoma (bCSDH) is frequently drained unilaterally when the contralateral CSDH is small and asymptomatic. However, reoperation rates for contralateral CSDH growth can be high. We aimed to develop a prognostic scoring system to guide the selection of suitable patients for unilateral drainage of bCSDH. Data were collected retrospectively across three tertiary hospitals from 2010 to 2017 on all consecutive bCSDH patients aged 21 or above. Predictors of reoperation were identified using multivariable logistic regression. A prognostic score was developed and internally validated. 240 bCSDH patients were analyzed. 98 (40.8%) underwent unilateral and 142 (59.2%) underwent bilateral evacuation. Clinical outcomes were comparable between the unilateral and bilateral evacuation groups. Within the unilateral evacuation group, 4 (4.1%) had a reoperation for contralateral CSDH growth. Reoperation for contralateral CSDH was predicted by preoperative use of anticoagulants (OR = 15.0, 95% CI: 1.49–169.15, p = 0.017). Complete resolution of contralateral CSDH was predicted by its preoperative maximum width, with a cut-off of 9 mm producing the highest sensitivity and specificity (OR = 4.17 for ≤9 mm, 95% CI: 1.54–11.11, p = 0.004). Using our prognostic score, reoperation rate for contralateral CSDH was 1.6%, 3.6%, 16.7%, and 50.0% in low-risk, moderate-risk, high-risk and very high-risk patients, respectively. With each increase of 1 in the prognostic score, patients were 4 times as likely to undergo reoperation for contralateral CSDH (OR = 3.98, 95% CI: 1.36–13.53, p = 0.013). Our proposed risk score may be used as an adjunct in clinical decision making for bCSDH patients undergoing unilateral evacuation.

Features of the Clinical Course and Prognosis of Severe Traumatic Brain Injury Outcomes

BACKGROUND. Traumatic brain injury (TBI) is one of the most important contemporary health issues. According to the World Health Organization, TBI is one of three leading causes of death in the world. Despite the development and widespread use of neuroimaging tools and instrumental research methods, clinical diagnosis of TBI is preferred. It is especially relevant at the prehospital stage when it is impossible to use instrumental diagnostic methods.THE AIM OF THE STUDY. To determine the clinical course features and prognosis of treatment outcomes in patients with various types of traumatic brain damage.MATERIAL AND METHODS. We studied the results of examination and treatment of 100 victims with a severe head injury hospitalized during the first days after receiving an injury and undergoing treatment at the N.V. Sklifosovsky Research Institute in 2008–2017. Depending on the type of brain injury patients were divided into 3 groups: Group 1 — isolated hematoma (n=20), Group 2 — hematomas and injuries of the brain (n=40), Group 3 — injuries of the brain (n=40). All patients underwent neurological examination, CT scan of the brain upon admission and over time within 12 days after trauma. In 30 victims, intracranial pressure (ICP) was monitored.RESULTS. We revealed features of the dynamics of individual neurological symptoms in patients with different types of brain damage. In patients with isolated hematomas, neurological status was represented mainly with clinic dislocation syndrome and contralateral hematoma hemiparesis, and clinical pattern significantly depended on intracranial hemorrhage. In patients with combination of hematomas and contusions, the neurological status and its dynamics were less dependent on the volume of the hematoma and were mainly determined by contusions of the midline structures of the brain. In patients with brain injuries, neurological status reliably correlated with injuries of midline structures.CONCLUSION. We revealed significant differences in neurological status, its changes over time and correlation with CT findings in patients with different types of traumatic brain injury.Authors declare lack of the conflicts of interests.

Multiple contralateral recurrence of bilateral chronic subdural hematoma: case report and literature review

We report a case of bilateral chronic subdural hematoma (CSDH) operated with a single burr-hole on the more symptomatic side (left) followed by a symptomatic expansion of the contralateral (right) hematoma 7 days after the surgery treated again with a burr-hole on the other side. A week later the patient presented again a bilateral CSDH that was re-operated on both side with a good outcome at 6 months follow-up. Relevant literature was reviewed, and we believe that the multiple recurrence of these hematomas in the opposite hemisphere resulted from the rapid drainage of the hematoma, which caused the rupture of weak bridging veins during drainage. Slow decompression is recommended to avoid rapid intracranial changes during drainage of a subdural hematoma.

Factors Predicting the Need for Surgery of the Opposite Side After Unilateral Evacuation of Bilateral Chronic Subdural Hematomas.

Patients with bilateral chronic subdural hematoma (bCSDH) undergo unilateral evacuation for the large or symptomatic side because the contralateral hematoma is either small or asymptomatic. However, the contralateral hematoma may subsequently grow and require evacuation. To characterize factors that predict contralateral hematoma growth and need for evacuation. A retrospective study on 128 surgically treated bCSDHs. Fifty-one and 77 were bilaterally and unilaterally evacuated, respectively. Glasgow Coma Scale was lower and midline shift was higher in those evacuated unilaterally compared to those evacuated bilaterally. Hematoma size was a significant determinant of decision for unilateral vs bilateral evacuation. The contralateral side needed evacuation at a later stage in 7 cases (9.1%). There was no significant difference in terms of reoperation rate between those evacuated unilaterally and bilaterally. Greater contralateral hematoma thickness on the first postoperative day computed tomography (CT) and more postoperative midline shift reversal had higher rates of operation in the opposite side. There was no difference between the daily pace of hematoma decrease in the operated and nonoperated sides (0.7% decrease per day vs 0.9% for the operated and nonoperated sides, respectively). Results of this study show that most bCSDHs evacuated unilaterally do not experience growth in the nonoperated side and unilateral evacuation results in hematoma resolution for both sides in most cases. Hematoma thickness on the opposite side on the first postoperative day CT and amount of midline shift reversal after surgery are the most important factors predicting the need for surgery on the opposite side.

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.

Risk Factors for Contralateral Hematoma Progression after Unilateral Evacuation of Bilateral Chronic Subdural Hematomas

To find risk factors for contralateral hematoma progression (CHP) in bilateral chronic subdural hematomas after initial unilateral evacuation. We retrospectively analyzed 53 patients with bilateral chronic subdural hematomas who underwent unilateral surgical evacuation in our department. Risk factors for CHP were identified by univariate analysis, a P value <0.05 were entered into multivariate logistic regression model and a predictive receiver operating characteristic curve model. The progression rate was 32.08%, the average progression interval was 2.32 months. The progression rate of the homogeneous hypodense group was significantly higher than that of the other density group (P= 0.017). The limited type of contralateral hematoma had a significantly lower progression rate than that of the widespread type (P= 0.001). Both pre- and postoperative volume of contralateral hematoma were significantly more in the CHP group compared with the contralateral hematoma without progression group (P= 0.031 and P= 0.001, respectively). Of the 4 risk factors, only postoperative volume of contralateral hematoma was an independent risk factor in multivariate logistic regression model (P= 0.033; 95% confidence interval, 1.005-1.124). The cut-off values of contralateral hematoma volume before and after operation were 29.27 cm3 and 37.84 cm3, respectively. Contralateral hematoma volume after operation is an independent risk predictor for CHP after unilateral evacuation. An additional surgery on contralateral hematoma or medical treatment should be taken into consideration if the volume is >37.84 cm3 in the first cranial computed tomography scan after surgery.

A case of severe head injury with repeated contralateral hematomas in a young patient — Study of surgical strategy

A case of severe head injury with repeated contralateral hematomas in a young patient — Study of surgical strategy

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.

Contralateral progression after unilateral evacuation of bilateral chronic subdural hematomas: the volume relation ratio as prognostic factor?

Unilateral evacuation of bilateral chronic subdural hematomas (bcSDHs) is associated with higher retreatment rates than an initial bilateral intervention. One reason for that is a possible progression in the size of the contralateral side after unilateral treatment. Thus, the authors focused their study on finding predictors of the need for contralateral retreatment. All patients who had undergone unilateral or bilateral evacuation of bcSDHs in the Department of Neurosurgery at the University Hospital of St. Poelten during a 5-year period (7/2012 to 6/2017) were retrospectively identified. The preoperative hematoma volume was calculated using the XYZ/2 method. Of a total of 103 patients with bcSDHs, 61 patients underwent bilateral evacuation and 42 patients underwent unilateral evacuation. The retreatment rate after bilateral evacuation was significantly lower than that after unilateral evacuation (14.8% vs 31%, respectively; p = 0.049). Contralateral retreatment after unilateral evacuation was necessary in 9 patients (21.4%). The preoperative contralateral hematoma volume was significantly higher in those patients who needed contralateral retreatment after initial unilateral evacuation (68.4 cm3 vs 27.4 cm3, respectively; p < 0.001). Furthermore, the so-called volume relation ratio created by dividing the smaller by the larger hematoma volume was significantly higher when contralateral retreatment became necessary (0.56 vs 0.21, respectively; p < 0.001). Patients needing evacuation of bcSDHs should be considered for primary bilateral evacuation if the hematoma volume on the smaller side is greater than 40 cm3 and the subsequent volume relation ratio is greater than 0.4.

Ipsilateral facial nerve injury with contralateral labyrinthine concussion and subdural hematoma in a case of longitudinal temporal bone fracture

Head trauma can lead to hearing loss. Both sensorineural and conductive hearing loss has been reported in cases of head injury. We report a case of labyrinthine concussion and subdural hematoma in the opposite ear of a patient who had head trauma after involved in motor vehicle accident. A complete hearing assessment for head trauma patients should be advised as it can avoid misdiagnosis and negligence in management.Bangladesh Journal of Medical Science Vol.16(4) 2017 p.594-596

Risk factors for second operation on remote site of severe traumatic brain injury patients after craniotomy

Objective To explore the risk factors for second operation on remote site of severe traumatic brain injury patients after craniotomy. Methods The clinical data of 180 patients with severe traumatic brain injury were analyzed retrospectively who underwent craniotomy from February 2010 to October 2014 at Department of Neurosurgery, the 101 Hospital of PLA, Craniocerebal Injury Cure Center of PLA. Among them, 39(21.7%) patients received a second operation on the remote side. The correlation between multiple factors and second operation on remote site was analyzed, which included sex, trauma site (frontal-temporal, parietal, occipital or multiple), relationship of trauma site to hematoma location (ipsilateral, contralateral or bilateral), fracture on remote site, preoperative pupils (normal, unilateral large or bilateral large), ambient cistern (clear or unclear), midline shift (no, ≤5 mm, >5-10 mm or ≥10 mm), preoperative hypoxia, combined injuries, placement of ventricle drainage and decompressive craniotomy. Results It was suggested by multiple logistic regression that the trauma site in frontal-temporal areas with ipsilateral hematoma was the protective factor for re-operation on remote site (OR=0.222, 95% CI: 0.073-0.674, P=0.008), while the occipital trauma with contralateral hematoma (OR=4.647, 95% CI: 1.078-20.033, P=0.039), skull fracture on remote site (OR=3.133, 95% CI: 1.247-7.867, P=0.015) and decompressive craniotomy (OR=5.684, 95% CI: 1.759-18.370, P=0.004) were risk factors associated with second operation on remote site in severe traumatic brain injury patients after craniotomy. Conclusion Trauma in the occipital region with contralateral hematoma, skull fracture in distal area and decompressive craniotomy might be related to a larger chance of re-operation on remote site of severe traumatic brain injury patients after craniotomy. Sufficient attention to the patient's conditions are suggested and caution should be warranted. Key words: Craniocerebral trauma; Decompressive craniectomy; Reoperation; Risk factors; Remote site

Postoperative Contralateral Hematoma in Patient with Acute Traumatic Brain Injury.

ObjectiveHead injury is a leading cause of death and disability in subjects who suffer a traumatic accident. Contralateral hematomas after surgery for traumatic brain injury are rare. However, an unrecognized, these hematomas can cause devastating results. We presented our experience of these patients and discussed diagnosis and management.MethodsThis study included 12 traumatic patients with acute traumatic brain injury who developed delayed contralateral hematoma after evacuation of an acute hematoma. Clinical and radiographic data was obtained through review of medical records and radiographs retrospectively.ResultsTen males and two females were included in the study. Ten (83.3%) patients had severe head injury (Glasgow Coma Scale [GCS] score <8). Intraoperative brain swelling during removal of the traumatic subdural hematoma was noted in 10 (83.3%) patients. A skull fracture on the side contralateral to the acute hematoma was noted on computed tomography (CT) scans of nine (75%) patients. Three (33.3%) patients with severe head injury (GCS <8) died. Only (10%) one patient with a severe head injury had less severe disability.ConclusionA postoperative CT scan is essential in patients with acute traumatic brain injury and a contralateral skull fracture or a low GCS score. Our results indicated that it is very important to evaluate this rare but potentially devastating complication.

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.

Optimal perioperative management of antithrombotic agents in patients with chronic subdural hematoma

ObjectiveThe use of antithrombotic agents such as anticoagulants and antiplatelet agents is widespread, and the opportunities to treat patients with chronic subdural hematoma (CSDH) under antithrombotic therapy are growing. However, whether antithrombotic therapy contributes to postoperative complications and recurrences of CSDH and how these agents should be managed in the surgical treatment of CSDH remains unclear. MethodsWe retrospectively analyzed 150 consecutive patients with CSDH who underwent neurosurgical interventions at Kyushu Rosai Hospital from 2011 to 2015 and followed them for more than 3 months. ResultsOf the 150 study patients, 44 received antithrombotic therapy. All anticoagulants and 76% of the antiplatelet agents were discontinued before surgical treatment of CSDH and resumed within 1 week except in 4 patients whose treatment was terminated and 7 patients who developed postoperative complications or underwent reoperations before resumption of these agents. Postoperative hemorrhagic complications associated with surgical treatment of CSDH occurred in 8 patients (5.3%), and there was no significant difference in the incidence of these complications between patients with and without antithrombotic therapy (6.8% vs. 4.7%, respectively; p=0.90). Postoperative thromboembolic complications occurred in 5 patients (5.4%), including 4 patients with antithrombotic therapy; these complications developed before resumption of antithrombotic agents in 2 patients. There was a significant difference in the incidence of postoperative thromboembolic complications between patients with and without antithrombotic therapy (9.1% vs. 0.9%, respectively; p=0.04). There were no significant differences in the incidence of radiographic deterioration or reoperation of ipsilateral or contralateral hematomas between patients with and without antithrombotic therapy after surgical treatment of unilateral CSDH. ConclusionA history of antithrombotic therapy was significantly correlated with the incidence of postoperative thromboembolic complications in patients with CSDH. Antithrombotic agents should be resumed as soon as possible when no hemorrhagic complication is confirmed after neurosurgical intervention for CSDH.

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).