Acute Brain Swelling during Evacuation of Subdural Hematoma Caused by Delayed Contralateral Extradural Hematoma: Report of Two Cases

Abstract

Two patients experienced severe brain swelling during the evacuation of acute subdural hematomas. Postoperative computed tomographic (CT) scans revealed delayed extradural hematomas on the sides opposite the subdural hematomas. Extradural bleeding occurred in the area of the fractured skull. One patient improved neurologically after evacuation of the extradural hematoma, and the other was not operated because he was moribund. Drilling exploratory burr holes in the fractured area may have been a better strategy than awaiting a postoperative CT scan. The reduction of intracranial pressure after the removal of subdural hematoma was postulated to be the most important factor contributing to the formation of the extradural hematoma.

Controlled decompression for the treatment of severe head injury: a preliminary study

“…In a study performed by Fukamachi et al, 13 of 15 patients who underwent CT within 6 hours of traumatic head injury had extradural hematomas that were not detected until repeat CT examination (6). Based on clinical practice, we believe that rapid decompressionassociated formation of delayed hematoma and diffuse brain swelling are also important causes of intraoperative acute encephalocele (5,6,10). When an intracranial space-occupying hematoma is removed rapidly, we suggest that blood vessels that are not bleeding may rupture and bleed due to the filling pressure effect, thereby resulting in a brain tissue shift.…”

Intraoperative development of extensive supratentorial extradural haematoma during evacuation of occipital–suboccipital extradural haematoma

“…5 It is typically heralded by severe brain displacement during craniotomy, which is manifested by tense dura mater, or if the dura mater has been opened, brain protrusion from the wound. 7, 8 We present a unique case of bilateral supratentorial extensive AEDH following decompressive suboccipital craniectomy for evacuation of AEDH, in which a variety of aetiologies might have contributed to the newly formed AEDH.…”

Calvarial Fracture Patterns on CT Imaging Predict Risk of a Delayed Epidural Hematoma following Decompressive Craniectomy for Traumatic Brain Injury

“…10,15 A frequent radiographic abnormality found in association with a DEDH is the presence of a calvarial skull fracture, contralateral to the craniectomy (Figs 1-3). [8][9][10][11][12][13]16 In the case series of Su et al, 8 contralateral calvarial fractures were present on the preoperative CT in 10 of 12 patients who developed a DEDH. 8 In the remaining 2 patients, a radiographically occult fracture was identified intraoperatively during DEDH evacuation.…”

“…[5][6][7] One potential devastating complication following DC is the development of an epidural hematoma remote to the craniectomy. 6,[8][9][10][11][12][13] This hematoma has been termed a delayed epidural hematoma (DEDH), as it is often first detected on the postoperative CT imaging studies. However, the hematoma may evolve during the decompression and present intraoperatively with external cerebral herniation through the craniectomy defect.…”

“…However, the hematoma may evolve during the decompression and present intraoperatively with external cerebral herniation through the craniectomy defect. 8,11,12 Although initially considered rare, the DEDH has become more common in the last decade with the resurgence of DC as a means to control raised ICP following traumatic brain injury (TBI). Clinical findings associated with DEDH include intraoperative brain swelling, 8 pupillary abnormalities, 14 increased ICP measurements, and acute neurologic deterioration.…”