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Year : 2018  |  Volume : 13  |  Issue : 4  |  Page : 1213-1215

Extradural hematoma following decompressive craniectomy for acute subdural hematoma: Two case reports illustrating different mechanisms

Department of Neurosurgery, Sultan Qaboos University Hospital, Al khaud, Muscat, Oman

Date of Web Publication23-Oct-2018

Correspondence Address:
Dr. Mahesh Krishna Pillai
Department of Neurosurgery, PB 38, Sultan Qaboos University Hospital, Al khaud, Muscat
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajns.AJNS_87_17

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The occurrence of extradural hematoma (EDH) after decompressive craniectomy (DC) for traumatic brain injury is uncommon. We report two cases, one developing ipsilateral EDH and another developing contralateral simultaneous EDH and subdural hematoma after DC. The strategies to anticipate the occurrence of such concurrent hematomas (CH) are highlighted. We propose a subclassification of CH into “immediate” and “delayed,” based on their difference in clinical presentation, image findings, pathogenesis, and surgical management.

Keywords: Complication, concurrent hematoma, head injury, surgery

How to cite this article:
Pillai MK, Kariyattil R, Govindaraju V, Kochummen K, Kumar R. Extradural hematoma following decompressive craniectomy for acute subdural hematoma: Two case reports illustrating different mechanisms. Asian J Neurosurg 2018;13:1213-5

How to cite this URL:
Pillai MK, Kariyattil R, Govindaraju V, Kochummen K, Kumar R. Extradural hematoma following decompressive craniectomy for acute subdural hematoma: Two case reports illustrating different mechanisms. Asian J Neurosurg [serial online] 2018 [cited 2020 Oct 29];13:1213-5. Available from:

  Introduction Top

Traumatic brain injury (TBI) is the major cause of mortality and morbidity worldwide, with an estimated 10 million affected annually. TBI, according to the World Health Organization, will surpass many diseases as the major cause of death and disability by the year 2020. TBI resulting in acute subdural hematoma (SDH) carries the maximum mortality and morbidity. Majority of literature acknowledge decompressive craniectomy (DC), as a method of choice, to combat raised intracranial pressure, in TBI. The occurrence of extradural hematoma (EDH), following DC for SDH, is rare with about 50 reported cases.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] We report two cases of EDH, one developing ipsilateral and the other contralateral, following DC and evacuation of SDH. The differences in clinical presentation, pathogenesis, image findings, and outcomes are highlighted.

  Case Reports Top

Case 1

A 30-year-old male, presented after an hour following trauma, with a Glasgow Coma Scale (GCS) score of 6/15 and symmetric and reacting pupils. Computed tomography (CT) scan of the brain showed an acute SDH in the right fronto-temporo-parietal region with mass effect and midline shift [Figure 1]a. There were linear fractures of the ipsilateral parietal, temporal, and occipital bones with pneumocephalus, in the vicinity, of the right transverse sinus [Figure 1]b. He underwent emergency craniotomy and evacuation of the SDH. A lax duroplasty, was done and the bone flap not replaced, as the brain was tense. He remained neurologically stable on ventilator support, with symmetric and reacting pupils. A routine follow-up CT scan of the brain after 24 h showed an ipsilateral EDH straddling the transverse sinus, causing mass effect and herniation of the brain through the craniectomy defect [Figure 1]c. He underwent emergency craniotomy and evacuation of the hematoma. His extended glasgow outcome score (GOS-E) was 8 (upper good recovery), at 6 months.
Figure 1: (a) Right subdural hematoma (arrow). (b) Right postero-lateral view of skull (three-dimensional reconstruction) showing the linear fractures (arrows); P – parietal; T – temporal (squamous); O – occipital; M – mastoid bones. (c) Right extradural hematoma straddling the transverse sinus (arrow)

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Case 2

A 30-year-old male, was admitted 1.5 hrs following trauma, with a GCS score of 7/15 and asymmetric but reacting pupils. A CT scan of the brain showed an acute SDH in the right fronto-temporo-parietal region with mass effect and midline shift [Figure 2]a. There was also a thin EDH and a speck of extradural air in the contralateral temporal region, underlying an undisplaced fracture of the parietal bone, and diastasis of the squamosal suture [Figure 2]a and [Figure 2]b. He underwent emergency surgical evacuation of the SDH. A lax duroplasty, was performed, and the bone flap was not replaced, as the brain was tense. He remained under ventilator support, with the pupils equal and reacting to light. An hour later, his left pupil became dilated and nonreacting. A CT scan of the brain showed a large contralateral EDH and a thin SDH with midline shift, subfalcine, and uncal herniation [Figure 3]a. The EDH showed mixed densities and “swirl sign” suggesting active hemorrhage. He underwent an emergency craniotomy, evacuation of the left EDH, and bipolar coagulation of the actively bleeding posterior branch of the middle meningeal artery (MMA). The dura was not opened, as the SDH was thin and the dura was lax after the evacuation of the EDH. Postoperatively, the pupils were again equal and reacting to light. A follow-up CT scan of the brain showed no residual EDH and a thin acute SDH [Figure 3]b. His GOS-E was 7 (lower good recovery), at 6 months.
Figure 2: (a) Right subdural hematoma (arrow) causing mass effect and midline shift. (b) Right subdural hematoma (large arrow) and left thin extradural hematoma with speck of air (small arrow). (c) Three-dimensional reconstruction showing linear fracture of left parietal bone and diastasis of squamosal suture (arrow)

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Figure 3: (a) Left subdural hematoma (upper arrow) and extradural hematoma (lower arrow) – Note the mixed densities in the extradural hematoma and “swirl sign” which are indicates active hemorrhage. (b) Postoperative computed tomography scan with no residual extradural hematoma - Note the more evident thin subdural hematoma (arrow)

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  Discussion Top

The incidence of contralateral EDH, secondary to DC for TBI, ranges from 1.3% to 10%.[2],[12] Skull fractures, rupture of blood vessels, surgical decompression, coagulopathy, aggressive anti-edema measures, intracranial hypotension, cerebrospinal fluid fistula, and defective autoregulation are the various factors implicated.[10] The absence of contusional hemorrhage and presence of remote skull fracture are independent risk factors for the development of EDH.[1] Linear fracture in line with the axial CT scan images may be undetected [Figure 2]c, but indirect evidence like pneumocephalus, thin EDH or SDH are useful pointers [Figure 2]b. Clinical indicators of a remote hematoma are progressive intra-operative brain swelling (76%) and new-onset asymmetry of pupils in the postoperative period.[2]

In the first case, the cause of ipsilateral EDH was bleeding from the right transverse sinus, due to the loss of tamponade effect after DC, as evidenced by the fracture crossing the sinus. In the second case, the cause of contralateral EDH was arterial hemorrhage secondary to loss of tamponade effect after DC. The common factor in both situations was the presence of a skull fracture which is present in 81% of contralateral EDH.[2]

Concurrent EDH may be, considered to be, immediate or delayed, based on the speed of deterioration, image findings, and pathogenesis. The management and the neurological outcome differ in each situation. Immediate concurrent EDH presents within the first 6 h after DC. Here, the source of bleed is arterial and may be associated with intra-operative external cerebral herniation and rapid onset neurological signs like the asymmetry of pupils. This is likely to carry a less favorable prognosis due to secondary insult as illustrated by the second case. Immediate postoperative CT scan, in a patient with unusually tense brain during the closure, may reveal the EDH. On the other hand, delayed concurrent EDH may occur any time after 6 h, following DC. Here, the source of bleed is usually venous, due to the loss of tamponade, and may not be associated with any new neurological signs. Here, the diagnosis is evident only on a routine postoperative CT scan after 24–48 h. This type probably carries a more favorable prognosis, as illustrated by the first case. Another unique feature demonstrated in Case 2, was the simultaneous presence of a contralateral acute SDH and EDH, after SDH evacuation.

Early complications of DC are the development of remote hematoma, contusion expansion, seizures, pseudomeningocoele, external cerebral herniation, interhemispheric/contralateral subdural effusion and infection. Late complications are hydrocephalus and syndrome of the trephine. There are published literature citing the importance of guarded durotomy as an effective measure to reduce the incidence of immediate post-DC complications.[2],[13],[14],[15]

Another possible way of picking up an imminent contralateral EDH would be to extend the CT angiography study, commonly done as part of polytrauma evaluation, to include the brain, which may detect a leak from an MMA tear. This would enable a simultaneous exploration of the contralateral fracture segment to control the arterial bleed through a mini-craniotomy.

  Conclusion Top

Strategies to anticipate the occurrence/progression of remote EDH is paramount in the management of TBI patients who undergo DC. A thorough evaluation of CT brain (with three-dimensional reconstruction) to identify all the skull fractures and potential bleeding sources, is valuable before embarking on surgery. Another strategy is gradual decompression of the brain by performing a guarded durotomy. A follow-up CT scan, after 24–48 h following DC, to look for delayed remote hematoma, is mandatory. An immediate concurrent EDH is primarily due to loss of tamponade over an injured meningeal artery, while a delayed concurrent EDH is probably due to loss of tamponade on an injured venous sinus or vein. An immediate concurrent EDH probably carries a poorer prognosis as compared to a delayed concurrent EDH.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Huang YH, Lee TC, Lee TH, Yang KY, Liao CC. Remote epidural hemorrhage after unilateral decompressive hemicraniectomy in brain-injured patients. J Neurotrauma 2013;30:96-101.  Back to cited text no. 1
Shen J, Pan JW, Fan ZX, Zhou YQ, Chen Z, Zhan RY, et al. Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: Five new cases and a short literature review. Acta Neurochir (Wien) 2013;155:335-41.  Back to cited text no. 2
Meguins LC, Sampaio GB, Abib EC, Adry RA, Ellakkis RF, Ribeiro FW, et al. Contralateral extradural hematoma following decompressive craniectomy for acute subdural hematoma (the value of intracranial pressure monitoring): A case report. J Med Case Rep 2014;8:153.  Back to cited text no. 3
Satyarthee GD. Intraoperative contralateral extradural hematoma development during decompressive craniectomy and evacuation of traumatic acute subdural hematoma causing brain Bulge management. Am J Clin Neurol Neurosurg 2015;1:77-80.  Back to cited text no. 4
Wen L, Li QC, Wang SC, Lin Y, Li G, Gong JB, et al. Contralateral haematoma secondary to decompressive craniectomy performed for severe head trauma: A descriptive study of 15 cases. Brain Inj 2013;27:286-92.  Back to cited text no. 5
Flordelís Lasierra JL, García Fuentes C, Toral Vázquez D, Chico Fernández M, Bermejo Aznárez S, Alted López E, et al. Contralateral extraaxial hematomas after urgent neurosurgery of a mass lesion in patients with traumatic brain injury. Eur J Trauma Emerg Surg 2013;39:277-83.  Back to cited text no. 6
Saberi H, Meybodi AT, Meybodi KT, Habibi Z, Mirsadeghi SM. Delayed post-operative contralateral epidural hematoma in a patient with right-sided acute subdural hematoma: A case report. Cases J 2009;2:6282.  Back to cited text no. 7
Su TM, Lee TH, Chen WF, Lee TC, Cheng CH. Contralateral acute epidural hematoma after decompressive surgery of acute subdural hematoma: Clinical features and outcome. J Trauma 2008;65:1298-302.  Back to cited text no. 8
Mohindra S, Mukherjee KK, Gupta R, Chhabra R, Gupta SK, Khosla VK, et al. Decompressive surgery for acute subdural haematoma leading to contralateral extradural haematoma: A report of two cases and review of literature. Br J Neurosurg 2005;19:490-4.  Back to cited text no. 9
Boviatsis EJ, Korfias S, Kouyialis AT, Sakas DE. Epidural haematoma after evacuation of contralateral subdural haematoma. Ir J Med Sci 2004;173:217-8.  Back to cited text no. 10
Cohen JE, Rajz G, Itshayek E, Umansky F. Bilateral acute epidural hematoma after evacuation of acute subdural hematoma: Brain shift and the dynamics of extraaxial collections. Neurol Res 2004;26:763-6.  Back to cited text no. 11
Shen J, Fan Z, Ji T, Pan J, Zhou Y, Zhan R, et al. Contralateral acute subdural hematoma following traumatic acute subdural hematoma evacuation. Neurol Med Chir (Tokyo) 2013;53:221-4.  Back to cited text no. 12
Jiang YZ, Lan Q, Wang QH, Song DL, Lu H, Wu WJ, et al. Gradual and controlled decompression for brain swelling due to severe head injury. Cell Biochem Biophys 2014;69:461-6.  Back to cited text no. 13
Stiver SI. Complications of decompressive craniectomy for traumatic brain injury. Neurosurg Focus 2009;26:E7.  Back to cited text no. 14
Mitchell P, Tseng M, Mendelow AD. Decompressive craniectomy with lattice duraplasty. Acta Neurochir (Wien) 2004;146:159-60.  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3]

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