Intraoperative Development of Contralateral Epidural Hematoma during Evacuation of Traumatic Extraaxial Hematoma

Abstract

Intraoperative development of an epidural hematoma contralateral to a craniotomy for acute traumatic extraaxial hematoma has been previously reported. This entity, however, has never been distinctly defined and differentiated from either the delayed or the bilateral acute epidural hematoma. We present 3 new cases of intraoperative contralateral acute epidural hematoma and review the 14 previously reported cases. The typical clinical presentation is a severe head injury with an acute extraaxial hematoma and severe ipsilateral brain displacement during craniotomy. If brain displacement is not noted at craniotomy, then the contralateral hematoma is manifested by immediate postoperative neurological deterioration or intractable elevated intracranial pressure. The presence of any of these signs makes an immediate postoperative CT scan or burr holes contralateral to the original craniotomy mandatory for early diagnosis. In addition to defining "intraoperative contralateral epidural hematoma," stricter definitions of the terms "delayed epidural hematoma" (no hematoma present on the initial CT scan but one present on a later scan) and "bilateral epidural hematomas" (present on the initial scan) are proposed.

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.…”

“…This scale measures social outcome, which has been defined as the net effect of all separate disabilities on functioning as a person, including dependency on others (9). The severity of disability is rated and classified into the following 5 levels: Good recovery (5): Patients resume normal life and live independently, but mild neurological or pathological defects might be present. Moderate disability (4):…”

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.…”