Temporal muscle haematoma as a cause of suboptimal haemicraniectomy: case report

Abstract

-Objective: To call attention to an unusual complication of decompressive haemicraniectomy in the treatment of malignant haemispheric infarction. Method: We describe a case in which partial decompression occurred despite large craniectomy. Complete decompression followed resection of the temporal muscle. Pertinent literature is briefly reviewed. Case description: A 55-year old woman developed massive right middle cerebral artery infarction evolving to cerebral haerniation in 40 hours. Decompressive haemicraniectomy without cortical excision was unable to revert coma and decerebrate posturing because of a massive temporal muscle haemorrhage with persistent contralateral deviation of midline structures. Muscle resection was followed by adequate external haerniation of the affected haemisphere and fast recovery. Cranioplasty was succesfully performed 22 days later, following gradual regression of cerebral oedema. Conclusion: There is an increasing perception of the need to operate patients with massive middle cerebral or internal carotid artery territory infarctions before the development of coma and cerebral haerniation. The most common factor leading to inadequate surgical decompression is small size craniectomy. The case reported calls attention to temporal muscle bleeding as an additional complication of craniectomy.KEY WORDS: ischaemic stroke, acute cerebral infarct, craniectomy. Hematoma de músculo temporal como causa de inadequada descompressão após hemicraniectomia descompressiva: relato de casoRESUMO -Objetivo: Alertar para o risco de descompressão cirúrgica subótima após hemicraniectomia descompressiva. Método: Revisão da literatura pertinente após descrição de caso clínico exemplificador. Resultados -Descrição do caso: Mulher de 55 anos, com instalação rápida de infarto cerebral no território da artéria cerebral média à direita. Evolução em 40 horas para coma e síndrome de herniação uncal. Tratada com salina hipertônica, hiperventilação e hemicraniectomia descompressiva (sem excisão de tecido cerebral), mantendo, porém, coma e decerebração persistentes. Exame de controle demonstrando volumoso hematoma de músculo temporal, levando a persistente desvio contralateral do segmento anterior do hemisfério afetado. Reoperação após 72 horas (exérese de músculo temporal), com rápida recuperação do nível de consciência e extubação. Controles neurorradiológicos mostrando adequada herniação externa do hemisfério, seguida de lenta regressão do edema cerebral, permitindo cranioplastia após 22 dias da primeira cirurgia. Conclusão: Progressivamente torna-se clara a importância potencial da cirurgia descompressiva. Estudos recentes sugerem maior benefício em casos de cirurgia precoce (de preferência antes da instalação de herniação cerebral) e de grandes craniectomias com descompressão completa para a evolução favorável de pacientes com infarto cerebral maciço. Hematoma de músculo temporal pode constituir causa não rara de descompressão incompleta. PALAVRAS-CHAVE: acidente vascular cerebral agudo, craniectomia de...

Massive Temporalis Muscle Swelling after Decompressive Craniectomy: Case Report

“…2 The most common complication of temporalis muscle is atrophy and also various studies have shown the atrophy of muscle after craniofacial surgeries with extensive dissection or electrocautery of the muscle causing cosmetic deformity. 3,4 However, we routinely use electrocautery while dissecting the temporalis muscle from the calvarium to minimize bleeding.…”

Addition of Resection of Temporal Muscle and Fascia in Decompressive Craniectomy in the Treatment of Traumatic Brain Injury

“…Significant effort is made not to damage this muscle to avoid temporomandibular disorder, which could results in pain, masticatory dysfunction, and cosmetic deformity 1319). However, bleeding, contused, swollen muscle, and associated hematoma can cause suboptimal decompression,18) especially in patients with craniofacial injury and temporal base contusion.…”

Contralateral Subdural Effusion Secondary to Decompressive Craniectomy Performed in Patients with Severe Traumatic Brain Injury: Incidence, Clinical Presentations, Treatment and Outcome

“…Generally, decompressive craniectomy is a technically simple procedure with few surgical complications [4,[9][10][11] . Tabaddor and LaMor- In this 69-year-old patient, a right subdural effusion contralateral to the cranial defect was discovered a week after decompressive craniectomy.…”

“…gese [9] reported harmful effects of large craniectomy on brain functions, suggesting early cranioplasty; Andre et al [10] reported a temporal muscle hematoma. Wagner et al [11] reported an unexpectedly high occurrence of direct craniectomy-related parenchymal bleeding (41.6%) and ischemic lesions (28.4%).…”