Remote site extradural haematoma

Share Embed


Descrição do Produto

Case Reports / Journal of Clinical Neuroscience 16 (2009) 1097–1098

1097

Remote site extradural haematoma Sachin A Borkar, Sumit Sinha *, B S Sharma Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India

a r t i c l e

i n f o

Article history: Received 21 June 2008 Accepted 12 August 2008

Keywords: Extradural haematoma Remote haemotoma Post-operative extradural haematoma

a b s t r a c t Postoperative extradural haematoma is a well described and serious complication of intracranial procedures that usually occurs at the site of the operation. Remote site extradural haematoma (that occurring distant to the site of the craniotomy) is relatively rare and may occasionally cause significant neurological morbidity or even death. We report this rare complication in an 18-year-old male who underwent craniotomy for excision of recurrent left temporal ganglioglioma. Ó 2008 Elsevier Ltd. All rights reserved.

1. Case report An 18-year-old male patient was referred to our outpatient services with multiple complex partial seizures for two years. He had been operated at a private hospital two years previously for a left temporal ganglioglioma. General physical and neurological examination of the patient was normal. A contrast-enhanced CT scan of the head revealed a large cystic mass with a mural nodule involving the left temporal lobe abutting the left ventricle. He subsequently underwent left temporal craniotomy and complete microsurgical excision of the left temporal ganglioglioma. Four hours after surgery, when the patient did not wake from anaesthesia, we repeated a CT scan of the head, which revealed a large extradural haematoma in the right frontal region (Fig. 1). Coagulation parameters of the patient were normal, both preoperatively and postoperatively. The patient had been operated in a supine position with the head on a horse-shoe headrest. A three-point fixator was not used during the procedure. There was also no history of trauma to the head when moving the patient. The patient was immediately returned to the operating theatre and the right frontal extradural haematoma was evacuated by a right frontal trephine craniotomy. He recovered uneventfully and was doing well at last follow-up six months after surgery. 2. Discussion Remote site intracranial haemorrhage is a rare complication of intracranial surgery.1,2 It has been reported following tumour excision2 and even following evacuation of chronic subdural haematoma.3 There are also isolated reports of infratentorial haematoma following supratentorial surgery.1,4 The pathophysiology of this entity is poorly understood although various hypotheses have been put forward. The loss of a substantial volume of cerebrospinal fluid (CSF) during surgery appears to be central to the pathophysiological development of remote site extradural haematoma.1 Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure with subsequent rupture of vessels.1

* Corresponding author. Tel.: +91 98 6839 8244; fax: +91 11 26589650. E-mail address: [email protected] (S. Sinha).

Fig. 1. Non-contrast axial CT scan of the head showing evidence of left temporal craniotomy with remote site hyperacute extradural haemorrhage in the right frontal region.

Thus, remote site extradural hemorrhage is a potentially fatal complication after supratentorial neurosurgical procedures, especially those involving the opening of CSF cisterns or the ventricular system. This condition, if detected early and treated promptly, carries an excellent prognosis. There is not a single preoperative or intraoperative factor that can reliably predict the occurrence of remote site hemorrhages, and the etiology remains unclear. The differential diagnosis of declining level of consciousness after supratentorial surgery must include remote site extradural haematoma and CT scan of the head is the diagnostic test of choice. Most important to minimize this hazardous complication is a high index of suspicion, a prompt diagnosis and emergency treatment in all cases.

1098

Case Reports / Journal of Clinical Neuroscience 16 (2009) 1098–1100

References 1. Landeiro JA, Flores MS, Lapenta MA, et al. Remote hemorrhage from the site of craniotomy. Arq Neuropsiquiatr 2004;62:832–4. 2. Kalfas IH, Little JR. Postoperative hemorrhage: a survey of 4992 intracranial procedures. Neurosurgery 1988;23:343–7.

3. Dinc C, Iplikcioglu AC, Bikmaz K, et al. Intracerebral haemorrhage occurring at remote site following evacuation of chronic subdural haematoma. Acta Neurochir (Wien) 2008;150:497–9. 4. Tondon A, Mahapatra AK. Supratentorial intracerebral hemorrhage following infratentorial surgery. J Clin Neurosci 2004;11:762–5.

doi:10.1016/j.jocn.2008.08.007

Blister-like aneurysm of the anterior communicating artery T.C. Morris *, B.P. Brophy Department of Neurosurgery, Royal Adelaide Hospital, North Terrace Adelaide, South Australia 5000, Australia

a r t i c l e

i n f o

Article history: Received 29 August 2008 Accepted 7 October 2008

a b s t r a c t We report a recent experience with a blister-like aneurysm of the anterior communicating artery and suggest that this entity may be responsible for so-called non-aneurysmal haemorrhage when the distribution of blood is atypical. Ó 2009 Elsevier Ltd. All rights reserved.

Keywords: Subarachnoid haemorrhage Blister-like aneurysm Anterior communicating artery Angiogram-negative Non-perimesencephalic

1. Introduction Blister-like aneurysms of the internal carotid artery are well recognised and constitute up to 7% of internal carotid aneurysms.1,2 Blister-like aneurysms of the anterior communicating artery are less common and have been characterised only recently.3 2. Case report A 52-year-old male presented to a country hospital on 20 October 2007 with an abrupt onset of a coital headache. He was transferred to the Royal Adelaide Hospital and admitted on the 22 October 2007. A CT scan on admission revealed a subarachnoid haemorrhage with a pattern consistent with the rupture of an anterior communicating artery (AcomA) aneurysm (Fig. 1). A CT cerebral angiogram, including a three-dimensional reconstruction, performed on the same day, was negative for aneurysm. A digital subtraction four-vessel cerebral angiogram was performed on the following day, which again did not demonstrate any aneurysm, but we noted some minor irregularity of the AcomA close to the left A1/A2 junction (Fig. 2). A stereoangiogram was also performed. A repeat angiogram was performed 1 week after admission, and on this occasion was highly suggestive of an aneurysm on the AcomA (Fig. 3). A fluid-attenuated inversion recovery MRI gave further weight to this diagnosis (Fig. 4). The aneurysm had a broad base and was not considered suitable for radiological neurointerventional management. We decided to explore the AcomA but also decided to repeat the angiogram on 2 November 2007 prior to the planned operation. This repeat angiogram showed progression of the abnormality and some focal vasospasm (Fig. 5). * Corresponding author. Tel.: +61 8 8222 4000. E-mail address: [email protected] (T.C. Morris).

At surgery the abnormality was found projecting from the anterior aspect of the AcomA on the left side. An encircling clip around the right A2 was used to refashion the AcomA and obliterate the abnormality. At surgery the abnormality was extremely fragile and thin walled and it was consistent with a diagnosis of a blister-like aneurysm. The postoperative angiogram performed on 9 November 2007 (Fig. 6) showed a secured AcomA aneurysm, and this finding was stable at repeat angiography 2 months later. The patient’s postoperative course was complicated by a persistent low density collection over the right hemisphere and chronic headache. This was treated with placement of a ventriculoperitoneal shunt, with complete resolution of his symptoms.

3. Discussion Our patient was initially reported as having a negative angiogram (digital subtraction angiogram and CT angiogram). In retrospect the minor abnormality on the AcomA (Fig. 2) was significant but whether this alone would be enough for most surgeons to recommend exploration is doubtful. In this regard the fluid-attenuated inversion recovery MRI performed 1 week after admission gave further support for the origin of the haemorrhage from the AcomA (Fig. 4). Surgeons have explored cases of atypical subarachnoid haemorrhage with negative angiograms and have reported a high incidence of positive findings.12–14 The abnormality we describe evolved over 1 week as has been reported for blister-like aneurysms of the internal carotid artery.2,4–7 At surgery a blister-like aneurysm was confirmed. Traditionally angiography is delayed for 2 weeks in suspicious cases of subarachnoid haemorrhage with atypical haemorrhage patterns but the rapid evolution of this aneurysm suggests that angiography should be performed earlier.

Lihat lebih banyak...

Comentários

Copyright © 2017 DADOSPDF Inc.