AJNS_115_12R11

CASE REPORT
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3 Postoperative hematoma involving brainstem, 2
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5 peduncles, cerebellum, deep subcortical white 4
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7 matter, cerebral hemispheres following chronic 6
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9 subdural hematoma evacuation 8
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11 Mohana Rao Patibandla, Amit K. Thotakura1, Dinesh Shukla, Anirudh K. Purohit, 11
12 Gokul chowdary Addagada, Manisha Nukavarapu2 12
13 Department of Neurosurgery, Nizam’s Institute of Medical Sciences, Hyderabad, 1NRI Medical College, Mangalagiri, 2Guntur 13
14 Medical College, Guntur, Andhra Pradesh, India 14
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17 ABSTRACT
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18 Among the intracranial hematomas, chronic subdural hematomas (CSDH) are the most benign with a mortality rate of 18
19 0.5-4.0%. The elderly and alcoholics are commonly affected by CSDH. Even though high percentage of CSDH patients 19
20 improves after the evacuation, there are some unexpected potential complications altering the postoperative course with 20
21 neurological deterioration. Poor outcome in postoperative period is due to complications like failure of brain to re-expand, 21
22 recurrence of hematoma and tension pneumocephalus. We present a case report with multiple intraparenchymal hemorrhages 22
23 in various locations like brainstem, cerebral and cerebellar peduncles, right cerebellar hemisphere, right thalamus, right
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24 capsulo-ganglionic region, right corona radiata and cerebral hemispheres after CSDH evacuation. Awareness of this
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25 potential problem and the immediate use of imaging if the patient does not awake from anesthesia or if he develops new
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26 onset focal neurological deficits, are the most important concerns to the early diagnosis of this rare complication.
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27 Key words: Chronic SDH evacuation, intra-axial hemorrhage, intraparenchymal hemorrhage, postoperative hemorrhage 27
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30 Introduction and cerebellar peduncles, right cerebellar hemisphere, right 30
31 thalamus, right capsulo-ganglionic region, right corona radiata 31
Among the intracranial hematomas, chronic subdural and cerebral hemispheres after CSDH evacuation. This case is
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hematomas (CSDH) are the most benign with a mortality rate of unique in that it involved almost all the territories of the brain.
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0.5-4.0%.[1-3] The elderly and alcoholics are commonly affected
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35 by CSDH. Even though high percentage of CSDH patients Case Report
improves after the evacuation, there are some unexpected
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36 A 48-year-old man known hypertensive with blood pressure 36
potential complications altering the postoperative course
37 under control was admitted to our institution 6 weeks after 37
with neurological deterioration. Spontaneous intracerebral
38 minor head trauma caused by fall. He had complained of 38
hematoma (ICH) following evacuation of the CSDH is rare, but
39 progressive frontal headache and became confused. There was 39
potentially lethal complication with a reported incidence of
40 no history of vomiting, weakness, sensory complaints and 40
0.7-4.0%.[2-5] Review of literature showed 28 cases. We present a
41 bowel or bladder disturbances. Glasgow Coma Scale (GCS) of the 41
case report with multiple hemorrhages in brainstem, cerebral
42 patient was E4M6V4 (14/15). A computerized tomography (CT) 42
43 scan showed bilateral fronto-temporo-parietal large, mixed 43
Access this article online
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Quick Response Code: dense, CSDHs with multiple septations. There was ventricular
45 Website: 45
compression on left side with shift of the midline structures to
46 www.asianjns.org 46
right [Figure 1]. The subdural collections were treated through
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left fronto-temporo-parietal craniotomy, excision of membranes
48 DOI: 48
with evacuation of subdural hematoma on left side and
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evacuation of the subdural hematoma with burr holes on right
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side followed by closed-system drainage. During the surgery he
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had transient increases in arterial pressure up to 180/100 mmHg
52 Address for correspondence: 52
with fluctuations. In the immediate post operative period,
53 Dr. Mohana Rao Patibandla, Department of Neurosurgery, 53
54 Nizam’s Institute of Medical Sciences, Hyderabad - 500 082, patient could not be extubated with GCS of E1M2VT. Patient
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Andhra Pradesh, India. E-mail: drpatibandla@gmail.com had spontaneous respirations with stable blood pressure but

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 Patibandla, et al.: Postoperative intra axial hemorrhage in chronic SDH

1 showed right-sided pupil dilatation without reaction to light. disorders, which were negative. The patient was further 1
2 Immediately patient shifted to magnetic resonance imaging managed conservatively. On postoperative day 3 imaging was 2
3 (MRI) which showed multiple large mixed intensity areas repeated which showed no increase in hematoma and decrease 3
4 involving brainstem, cerebral and cerebellar peduncle, right of pneumocephalus. After a complicated postoperative course 4
5 cerebellar hemisphere, right thalamus, right capsulo-ganglionic he expired on postoperative day 7. 5
6 region, right corona radiata and adjacent frontal lobe causing 6
Discussion 7
7 effacement of 3rd and 4th ventricles [Figure 2] with blooming
8 of all these areas in gradient images [Figure 3] suggestive Review of literature showed spontaneous ICHs complicating
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9 of intraparenchymal hemorrhages. MRI also showed right surgical evacuation of CSDHs. Following the evacuation of
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10 subdural hematoma intra-axial hemorrhages were noted
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frontal pneumocephalus. Patient was evaluated for coagulation
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26 Figure 1: Preoperative computerized tomogram showing bilateral fronto-temporo-parietal subdural hematomas with multiple septations
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41 Figure 2: Immediate postoperative MRI showing multiple mixed intensity lesions with edema and pneumocephalus with ventricular compression
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54 Figure 3: Postoperative MRI gradient images showing blooming of the lesions in Figure 2 suggestive of hemorrhages 54

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 Patibandla, et al.: Postoperative intra axial hemorrhage in chronic SDH

1 in the following sites: Brainstem,[6] cerebellum,[7] cerebral with controlled re-expansion, careful control of the blood 1
2 hemispheres[8] ventricles.[9] Symptoms of the ICH appeared pressure lability with a gradual emergence from anesthesia. 2
3 in immediate postoperative period[4,10-13] or several days after 3
4 the event.[2,4,5,11,14] In all the cases the hematoma developed in Conclusions
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5 the ipsilateral hemisphere, but in our case the hematomas Awareness of this potential problem and the immediate use 5
6 were multiple and appeared bilaterally with large part on of imaging if the patient does not awake from anesthesia or 6
7 the contralateral side. This complication usually lead to the if the patient develops new onset focal neurological deficits 7
8 poor outcome in these patients [4,5,10-12] with a fatal outcome are the most important concerns to the early diagnosis of this 8
9 reported in one-third of the patients, with another third rare complication. Slow decompression of CSDHs, possibly 9
10 severely disabled.[4,5,11,14,15] with controlled re-expansion is advised and careful control 10
11 of the blood pressure lability with a gradual emergence from 11
12 The theory of rapid perioperative parenchymal shift causing
anesthesia. 12
13 direct vascular damage fit well with the phenomenon of
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ICH formation in our patient, who had previous bilateral
14 References 14
15 subdural collections with shift of the midline structures.
1. Sambasivan M. An overview of chronic subdural hematoma:
15
16 The pathogenic mechanism that seems most likely to be
Experience with 2300 cases. Surg Neurol 1997;47:418-22. 16
17 responsible for these hemorrhages may involve a sudden 2. Kotwica Z, Brzeziński J. Chronic subdural haematoma treated by burr 17
18 increase in cerebral blood flow combined with defective holes and closed system drainage: Personal experience in 131 patients. 18
19 vascular autoregulation. Labile hypertension and wide swings Br J Neurosurg 1991;5:461-5.
3. Richter HP, Klein HJ, Schäfer M. Chronic subdural haematomas 19
20 in blood pressure during operation, as in our patient, may
treated by enlarged burr-hole craniotomy and closed system 20
21 be contributory. Preoperative cerebral blood flow in patients drainage. Retrospective study of 120 patients. Acta Neurochir (Wien) 21
22 with CSDH is known to be uniformly decreased over the 1984;71:179-88.
4. Ramamurthi B, Ganapathi K, Ramamurthi R. Intracerebral hematoma
22
23 compressed brain. Surgical decompression allows cerebral 23
following evacuation of chronic subdural hematoma. Neurosurg Rev
24 blood flow to return to normal values.[16] We hope that 1989;12 Suppl 1:225-7. 24
25 sudden restoration of normal perfusion pressure in areas of 5. d’Avella D, De Blasi F, Rotilio A, Pensabene V, Pandolfo N.
25
defective cerebral vascular autoregulation due to subcortical Intracerebral hematoma following evacuation of chronic subdural
26 hematomas. Report of two cases. J Neurosurg 1986;65:710-2. 26
27 swelling underlying surface compression,[17] focal impedance 6. McKissock W, Richardson A, Bloom WH. Subdural haematoma. 27
28 of the venous drainage, or ischemic loss of CO2 reactivity[18] A review of 389 cases. Lancet 1960;1:1365-9. 28
might in turn lead to the vascular damage that resulted in 7. Chang SH, Yang SH, Son BC, Lee SW. Cerebellar hemorrhage after
29 29
burr hole drainage of supratentorial chronic subdural hematoma.
30 intraparenchymal hemorrhage. J Korean Neurosurg Soc 2009;46:592-5. 30
31 8. Brisman MH, Bederson JB, Sen CN, Germano IM, Moore F, Post KD. 31
Those previous theories are supported by recent Single Intracerebral hemorrhage occurring remote from the craniotomy site.
32 32
positron emission computed tomogram (SPECT) studies, which Neurosurgery 1996;39:1114-21.
33 9. Muneza S, Rasoloherimampiononiaina MR, Nduwamariya MJ. 33
showed there is ipsilateral cortical and subcortical hyperemia
34 Postoperative intracerebral and intraventricular hemorrhages 34
especially in the elderly age group.[19] Ogasawara et al.,
35 following removal of a chronic subdural hematoma. J Clin Neurosci
35
showed postoperatively, there is a progressive normalization 2009;16:1346-8.
36 10. Kotwica Z, Brzeziński J. Intracerebral hematoma as the complication 36
of the blood flow to these areas.[19] Physiological aging of
37 of the surgical removal of chronic subdural hematoma. Case report. 37
the vessels with increased fragility may not able to sustain
38 Neurol Psychiatr (Bucur) 1989;27:167-9. 38
the rapid alterations in the blood pressures in the immediate 11. Modesti LM, Hodge CJ, Barnwell ML. Intracerebral hematoma after
39 39
postoperative period. Seizures are an important factor in evacuation of chronic extracerebral fluid collections. Neurosurgery
40 1982;10:689-93. 40
these patients. Grunwald et al.[20] revealed an actually increased
41 12. Hayashi T, Kobayashi H, Sekino H. Intracerebral hematoma after 41
uptake in the epileptic focus following a Tc99 ECD SPECT scan. evacuation of chronic subdural fluid collection. Report of three cases.
42 42
Neurol Med Chir (Tokyo) 1987;27:1087-92.
43 Poor prognosis of the patient in the postoperative period is due 13. Missori P, Salvati M, Polli FM, Conserva V, Delfini R. Intraparenchymal 43
44 to complications like failure of brain to re-expand, recurrence haemorrhage after evacuation of chronic subdural haematoma. Report 44
45 of hematoma and tension pneumocephalus. Previous reports
of three cases and review of the literature. Br J Neurosurg 2002;16:63-6. 45
14. Ovül I, Oner K. Intracerebral hematoma after evacuation of chronic
46 showed the occurrence of postoperative hematoma in one of subdural hematoma. Neurochirurgia (Stuttg) 1988;31:160-1. 46
47 the location of the previously mentioned sites. The unique 15. Nakahara N, Masuzawa T, Kuno K, Sato F. Intracerebral hemorrhage 47
48 feature in this case report is occurrence of the hematoma in immediately following surgical treatment of chronic subdural 48
49 hematoma. Report of two cases. Neurol Med Chir (Tokyo)
all the above-mentioned locations. This may be due to the 1984;24:27-9. 49
50 large amount of SDH, long duration of symptoms along with 16. Brodersen P, Gjerris F. Regional cerebral blood flow in patients with 50
51 massive midline shift before evacuation, in turn those further chronic subdural hematomas. Acta Neurol Scand 1975;51:233-9. 51
52 17. Cook AW, Browder EJ, Carter WB. Cerebral swelling and ventricular
leads to changes in the perfusion of the brain. In this regard alterations following evacuation of intracranial extracerebral
52
53 we stress the need for slow decompression of CSDHs, possibly hematoma. J Neurosurg 1962;19:419-23. 53
54 54

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1 18. Spetzler RF, Wilson CB, Weinstein P, Mehdorn M, Townsend J, et al. Ictal and interictal brain SPECT imaging in epilepsy using 1
Telles D. Normal perfusion pressure breakthrough theory. Clin technetium-99 m-ECD. J Nucl Med 1994;35:1896-901.
2 2
Neurosurg 1978;25:651-72.
3 19. Ogasawara K, Koshu K, Yoshimoto T, Ogawa A. Transient hyperemia How to cite this article: ***
3
4 immediately after rapid decompression of chronic subdural hematoma. 4
5 Neurosurgery 1999;45:484-8; discussion 488-9. Source of Support: Nil, Conflict of Interest: None declared. 5
20. Grünwald F, Menzel C, Pavics L, Bauer J, Hufnagel A, Reichmann K, 6
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