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CASE REPORT
Year : 2017  |  Volume : 12  |  Issue : 2  |  Page : 259-262

Postoperative hematoma involving brainstem, peduncles, cerebellum, deep subcortical white matter, cerebral hemispheres following chronic subdural hematoma evacuation


1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
2 NRI Medical College, Mangalagiri, Andhra Pradesh, India
3 Guntur Medical College, Guntur, Andhra Pradesh, India

Date of Web Publication11-Apr-2017

Correspondence Address:
Dr. Mohana Rao Patibandla
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1793-5482.144163

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  Abstract 

Among the intracranial hematomas, chronic subdural hematomas (CSDH) are the most benign with a mortality rate of 0.5-4.0%. The elderly and alcoholics are commonly affected by CSDH. Even though high percentage of CSDH patients improves after the evacuation, there are some unexpected potential complications altering the postoperative course with neurological deterioration. Poor outcome in postoperative period is due to complications like failure of brain to re-expand, recurrence of hematoma and tension pneumocephalus. We present a case report with multiple intraparenchymal hemorrhages in various locations like brainstem, cerebral and cerebellar peduncles, right cerebellar hemisphere, right thalamus, right capsulo-ganglionic region, right corona radiata and cerebral hemispheres after CSDH evacuation. Awareness of this potential problem and the immediate use of imaging if the patient does not awake from anesthesia or if he develops new onset focal neurological deficits, are the most important concerns to the early diagnosis of this rare complication.

Keywords: Chronic SDH evacuation, intra-axial hemorrhage, intraparenchymal hemorrhage, postoperative hemorrhage


How to cite this article:
Patibandla MR, Thotakura AK, Shukla D, Purohit AK, Addagada GC, Nukavarapu M. Postoperative hematoma involving brainstem, peduncles, cerebellum, deep subcortical white matter, cerebral hemispheres following chronic subdural hematoma evacuation. Asian J Neurosurg 2017;12:259-62

How to cite this URL:
Patibandla MR, Thotakura AK, Shukla D, Purohit AK, Addagada GC, Nukavarapu M. Postoperative hematoma involving brainstem, peduncles, cerebellum, deep subcortical white matter, cerebral hemispheres following chronic subdural hematoma evacuation. Asian J Neurosurg [serial online] 2017 [cited 2021 Jul 30];12:259-62. Available from: https://www.asianjns.org/text.asp?2017/12/2/259/144163


  Introduction Top


Among the intracranial hematomas, chronic subdural hematomas (CSDH) are the most benign with a mortality rate of 0.5-4.0%.[1],[2],[3] The elderly and alcoholics are commonly affected by CSDH. Even though high percentage of CSDH patients improves after the evacuation, there are some unexpected potential complications altering the postoperative course with neurological deterioration. Spontaneous intracerebral hematoma (ICH) following evacuation of the CSDH is rare, but potentially lethal complication with a reported incidence of 0.7-4.0%.[2],[3],[4],[5] Review of literature showed 28 cases. We present a case report with multiple hemorrhages in brainstem, cerebral and cerebellar peduncles, right cerebellar hemisphere, right thalamus, right capsulo-ganglionic region, right corona radiata and cerebral hemispheres after CSDH evacuation. This case is unique in that it involved almost all the territories of the brain.


  Case Report Top


A 48-year-old man known hypertensive with blood pressure under control was admitted to our institution 6 weeks after minor head trauma caused by fall. He had complained of progressive frontal headache and became confused. There was no history of vomiting, weakness, sensory complaints and bowel or bladder disturbances. Glasgow Coma Scale (GCS) of the patient was E4M6V4 (14/15). A computerized tomography (CT) scan showed bilateral fronto-temporo-parietal large, mixed dense, CSDHs with multiple septations. There was ventricular compression on left side with shift of the midline structures to right [Figure 1]. The subdural collections were treated through left fronto-temporo-parietal craniotomy, excision of membranes with evacuation of subdural hematoma on left side and evacuation of the subdural hematoma with burr holes on right side followed by closed-system drainage. During the surgery he had transient increases in arterial pressure up to 180/100 mmHg with fluctuations. In the immediate post operative period, patient could not be extubated with GCS of E1M2VT. Patient had spontaneous respirations with stable blood pressure but showed right-sided pupil dilatation without reaction to light. Immediately patient shifted to magnetic resonance imaging (MRI) which showed multiple large mixed intensity areas involving brainstem, cerebral and cerebellar peduncle, right cerebellar hemisphere, right thalamus, right capsulo-ganglionic region, right corona radiata and adjacent frontal lobe causing effacement of 3rd and 4th ventricles [Figure 2] with blooming of all these areas in gradient images [Figure 3] suggestive of intraparenchymal hemorrhages. MRI also showed right frontal pneumocephalus. Patient was evaluated for coagulation disorders, which were negative. The patient was further managed conservatively. On postoperative day 3 imaging was repeated which showed no increase in hematoma and decrease of pneumocephalus. After a complicated postoperative course he expired on postoperative day 7.
Figure 1: Preoperative computerized tomogram showing bilateral fronto-temporo-parietal subdural hematomas with multiple septations

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Figure 2: Immediate postoperative MRI showing multiple mixed intensity lesions with edema and pneumocephalus with ventricular compression

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Figure 3: Postoperative MRI gradient images showing blooming of the lesions in Figure 2 suggestive of hemorrhages

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  Discussion Top


Review of literature showed spontaneous ICHs complicating surgical evacuation of CSDHs. Following the evacuation of subdural hematoma intra-axial hemorrhages were noted in the following sites: Brainstem,[6] cerebellum,[7] cerebral hemispheres [8] ventricles.[9] Symptoms of the ICH appeared in immediate postoperative period [4],[10],[11],[12],[13] or several days after the event.[2],[4],[5],[11],[14] In all the cases the hematoma developed in the ipsilateral hemisphere, but in our case the hematomas were multiple and appeared bilaterally with large part on the contralateral side. This complication usually lead to the poor outcome in these patients [4],[5],[10],[11],[12] with a fatal outcome reported in one-third of the patients, with another third severely disabled.[4],[5],[11],[14],[15]

The theory of rapid perioperative parenchymal shift causing direct vascular damage fit well with the phenomenon of ICH formation in our patient, who had previous bilateral subdural collections with shift of the midline structures. The pathogenic mechanism that seems most likely to be responsible for these hemorrhages may involve a sudden increase in cerebral blood flow combined with defective vascular autoregulation. Labile hypertension and wide swings in blood pressure during operation, as in our patient, may be contributory. Preoperative cerebral blood flow in patients with CSDH is known to be uniformly decreased over the compressed brain. Surgical decompression allows cerebral blood flow to return to normal values.[16] We hope that sudden restoration of normal perfusion pressure in areas of defective cerebral vascular autoregulation due to subcortical swelling underlying surface compression,[17] focal impedance of the venous drainage, or ischemic loss of CO2 reactivity [18] might in turn lead to the vascular damage that resulted in intraparenchymal hemorrhage.

Those previous theories are supported by recent Single positron emission computed tomogram (SPECT) studies, which showed there is ipsilateral cortical and subcortical hyperemia especially in the elderly age group.[19] Ogasawara et al., showed postoperatively, there is a progressive normalization of the blood flow to these areas.[19] Physiological aging of the vessels with increased fragility may not able to sustain the rapid alterations in the blood pressures in the immediate postoperative period. Seizures are an important factor in these patients. Grunwald et al.[20] revealed an actually increased uptake in the epileptic focus following a Tc99 ECD SPECT scan.

Poor prognosis of the patient in the postoperative period is due to complications like failure of brain to re-expand, recurrence of hematoma and tension pneumocephalus. Previous reports showed the occurrence of postoperative hematoma in one of the location of the previously mentioned sites. The unique feature in this case report is occurrence of the hematoma in all the above-mentioned locations. This may be due to the large amount of SDH, long duration of symptoms along with massive midline shift before evacuation, in turn those further leads to changes in the perfusion of the brain. In this regard we stress the need for slow decompression of CSDHs, possibly with controlled re-expansion, careful control of the blood pressure lability with a gradual emergence from anesthesia.


  Conclusions Top


Awareness of this potential problem and the immediate use of imaging if the patient does not awake from anesthesia or if the patient develops new onset focal neurological deficits are the most important concerns to the early diagnosis of this rare complication. Slow decompression of CSDHs, possibly with controlled re-expansion is advised and careful control of the blood pressure lability with a gradual emergence from anesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sambasivan M. An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol 1997;47:418-22.  Back to cited text no. 1
    
2.
Kotwica Z, Brzeziński J. Chronic subdural haematoma treated by burr holes and closed system drainage: Personal experience in 131 patients. Br J Neurosurg 1991;5:461-5.  Back to cited text no. 2
    
3.
Richter HP, Klein HJ, Schäfer M. Chronic subdural haematomas treated by enlarged burr-hole craniotomy and closed system drainage. Retrospective study of 120 patients. Acta Neurochir (Wien) 1984;71:179-88.  Back to cited text no. 3
    
4.
Ramamurthi B, Ganapathi K, Ramamurthi R. Intracerebral hematoma following evacuation of chronic subdural hematoma. Neurosurg Rev 1989;12 Suppl 1:225-7.  Back to cited text no. 4
    
5.
d'Avella D, De Blasi F, Rotilio A, Pensabene V, Pandolfo N. Intracerebral hematoma following evacuation of chronic subdural hematomas. Report of two cases. J Neurosurg 1986;65:710-2.  Back to cited text no. 5
    
6.
McKissock W, Richardson A, Bloom WH. Subdural haematoma. A review of 389 cases. Lancet 1960;1:1365-9.  Back to cited text no. 6
    
7.
Chang SH, Yang SH, Son BC, Lee SW. Cerebellar hemorrhage after burr hole drainage of supratentorial chronic subdural hematoma. J Korean Neurosurg Soc 2009;46:592-5.  Back to cited text no. 7
    
8.
Brisman MH, Bederson JB, Sen CN, Germano IM, Moore F, Post KD. Intracerebral hemorrhage occurring remote from the craniotomy site. Neurosurgery 1996;39:1114-21.  Back to cited text no. 8
    
9.
Muneza S, Rasoloherimampiononiaina MR, Nduwamariya MJ. Postoperative intracerebral and intraventricular hemorrhages following removal of a chronic subdural hematoma. J Clin Neurosci 2009;16:1346-8.  Back to cited text no. 9
    
10.
Kotwica Z, Brzeziński J. Intracerebral hematoma as the complication of the surgical removal of chronic subdural hematoma. Case report. Neurol Psychiatr (Bucur) 1989;27:167-9.  Back to cited text no. 10
    
11.
Modesti LM, Hodge CJ, Barnwell ML. Intracerebral hematoma after evacuation of chronic extracerebral fluid collections. Neurosurgery 1982;10:689-93.  Back to cited text no. 11
    
12.
Hayashi T, Kobayashi H, Sekino H. Intracerebral hematoma after evacuation of chronic subdural fluid collection. Report of three cases. Neurol Med Chir (Tokyo) 1987;27:1087-92.  Back to cited text no. 12
    
13.
Missori P, Salvati M, Polli FM, Conserva V, Delfini R. Intraparenchymal haemorrhage after evacuation of chronic subdural haematoma. Report of three cases and review of the literature. Br J Neurosurg 2002;16:63-6.  Back to cited text no. 13
    
14.
Ovül I, Oner K. Intracerebral hematoma after evacuation of chronic subdural hematoma. Neurochirurgia (Stuttg) 1988;31:160-1.  Back to cited text no. 14
    
15.
Nakahara N, Masuzawa T, Kuno K, Sato F. Intracerebral hemorrhage immediately following surgical treatment of chronic subdural hematoma. Report of two cases. Neurol Med Chir (Tokyo) 1984;24:27-9.  Back to cited text no. 15
    
16.
Brodersen P, Gjerris F. Regional cerebral blood flow in patients with chronic subdural hematomas. Acta Neurol Scand 1975;51:233-9.  Back to cited text no. 16
    
17.
Cook AW, Browder EJ, Carter WB. Cerebral swelling and ventricular alterations following evacuation of intracranial extracerebral hematoma. J Neurosurg 1962;19:419-23.  Back to cited text no. 17
    
18.
Spetzler RF, Wilson CB, Weinstein P, Mehdorn M, Townsend J, Telles D. Normal perfusion pressure breakthrough theory. Clin Neurosurg 1978;25:651-72.  Back to cited text no. 18
    
19.
Ogasawara K, Koshu K, Yoshimoto T, Ogawa A. Transient hyperemia immediately after rapid decompression of chronic subdural hematoma. Neurosurgery 1999;45:484-8; discussion 488-9.  Back to cited text no. 19
    
20.
Grünwald F, Menzel C, Pavics L, Bauer J, Hufnagel A, Reichmann K, et al. Ictal and interictal brain SPECT imaging in epilepsy using technetium-99 m-ECD. J Nucl Med 1994;35:1896-901.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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