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Table of Contents    
LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 5  |  Page : 1372-1373

Fatal Subcutaneous Hematoma: A Rare Case


1 Department of Neurosurgery, Burns and Trauma Center, Ben Arous, University of Medicine of Tunis, Tunis, Tunisia
2 Department of Neurosurgery, National Institute of Neurology Mongi Ben Hamida, University of Medicine of Tunis, Tunis, Tunisia

Date of Web Publication19-Nov-2019

Correspondence Address:
Dr. Ghassen Gader
Department of Neurosurgery, Burns and Trauma Center, Ben Arous, University of Medicine of Tunis
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.271253

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How to cite this article:
Gader G, Rkhami M, Ben Salem M, Kallel J, Zammel I. Fatal Subcutaneous Hematoma: A Rare Case. Neurol India 2019;67:1372-3

How to cite this URL:
Gader G, Rkhami M, Ben Salem M, Kallel J, Zammel I. Fatal Subcutaneous Hematoma: A Rare Case. Neurol India [serial online] 2019 [cited 2019 Dec 7];67:1372-3. Available from: http://www.neurologyindia.com/text.asp?2019/67/5/1372/271253




Sir,

Postoperative subcutaneous hematomas are common complications of cranial surgery. Usually they do not hinder the prognosis given their benignity and the ease of their care. We report a case of postoperative subcutaneous hematoma revealed by severe neurologic manifestations and will discuss the causes of this complication as well as ways to prevent it.

We report the case of a 54-year-old male patient with no previous pathological history injured during a road accident causing severe cranio-spinal trauma with an initial Glasgow Coma Scale (GCS) of 5 and paraplegia. Initial brain imaging revealed an acute subdural hematoma. The patient was operated through an evacuation of the hematoma by a large decompressive craniectomy. Cerebral turgor led to perform an enlargement plasty of the dura mater with tight suture, and made it impossible to put the flap back, hence its insertion into the abdomen. Nine days later, the patient recovered a perfect state of consciousness, but remained paraplegic due to the spinal trauma (medullary section at the level of T7–T8). Three months post-operation, the patient presented with thrombophlebitis of the left lower limb requiring anticoagulation based on antivitamin K. Six months post-operation the patient was rehospitalized for replacement of the cranial flap. Overlap between antivitamin K, low-molecular-weight-heparin as well as prothrombine index (TP) correction were performed over five days. At the time of surgery, TP was 68%. This rate was considered to be acceptable because the surgery was in the area. The perioperative bleeding was under acceptable limits. The flap was replaced as per as the classical technique, fixed by eight transosseous knots made of nylon 1.0. The wound was closed in customary fashion over an epidural suction drainage (Redon drain n 14). The immediate postoperative course was uneventful. The drain was removed two days after the surgery containing 200 cc of pure blood; the shape of the scar was good, with no bun or cerebrospinal fluid leakage. But the patient kept a small subcutaneous collection whose renitence was suggestive of a hematoma. No postoperative computed tomography (CT) scan was performed initially. The patient was then transferred to internal medicine for evaluation of his thrombotic pathology and reintroduction of anticoagulant therapy. Four days post-operation, the patient presented with a sudden alteration of the state of consciousness with a GCS of 7 and a right anisocoria. A brain CT scan showed a large subcutaneous hematoma causing a depression of the craniectomy flap, as well as temporal engagement [Figure 1]. TP was at the high of 15% and the international normalized ratio (INR) 5.4. After transfusion with fresh frozen plasma and PPSB, the patient was reoperated for evacuation of the subcutaneous hematoma, detachment of the depressed bone flap which was put back in the abdomen for fear of a new recurrence given the context of disorders of hemostasis not yet cured. The perioperative aspect was that of uncoagulated pure blood collection. The wound was closed over an n-14 suction drain. The postoperative TP was 70%. The postoperative course was marked by the reappearance 18 hours after surgery of a new anisocoria. The drain brought back 70 cc of pure blood. New imaging showed a recurrence of subcutaneous bleeding directly compressing the cerebral parenchyma [Figure 2], hence a surgical revision for evacuation of the bloody collection [Figure 3]. The patient remained comatose for 37 days before presenting a progressive recovery of his state of consciousness. He was extubated at day 41 postoperation and was discharged on day 55 postoperation without sequelae added to those kept after the first trauma.
Figure 1: Axial section of a brain CT scan showing a subcutaneous bleeding compressing the craniectomy flap that has sunk into the skull creating a cerebral herniation. We note the presence of sediment of liquid-liquid level in the subcutaneous collection witnessing of a bleeding of different ages

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Figure 2: Axial section of a brain CT scan made during the second decompensation, the flap had been removed, and the subcutaneous liquid causes a mass effect on the brain

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Figure 3: Axial section of a brain CT scan performed after the second revision surgery showing the persistence of a discreet subcutaneous bleeding with return in place of the medial structures

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Bleeding during cranial surgery suites is one of the most common incidents occurring in 15% of patients.[1] Essentially represented by the hematomas of the operative site, subdural and epidural hematomas, these complications are particularly feared as they involve both functional (...) and vital prognosis.[1] On the other hand, postoperative subcutaneous hematomas are often anodyne bleedings whose management is limited to a simple oversight.

An exhaustive review of the literature did not yield any cases of postoperative subcutaneous hematomas responsible for serious neurological charts. Indeed, the singularity of this case lies in the unusual consequences of a subcutaneous hematoma, which due to its volume was able to drive the craniectomy flap in the cerebral parenchyma at first, then directly compress the brain a the second time to generate a brain herniation.

This phenomenon can be explained by two factors: the importance of bleeding and the mobility of the cranial flap. The large volume of the hematoma is thought to be due to the use of anticoagulants. The mobility of the flap would be explained by a lack of fixation, especially in the temporal region where it is technically difficult to reattach the bone.

Causes favoring subcutaneous hematoma are similar to those causing other bleedings. The width of the surgical wound, insufficiency of the drainage, disorders of hemostasis, antiplatelet therapy, poor quality of perioperative hemostasis, high blood pressure postoperatively and urgent surgery represent the most incriminated causes.[2–5]

In order to avoid such complications, it is recommended to correct hemostasis disorders before surgery. This is the same concerning blood pressure to avoid possible peaks that can cause postoperative bleeding.[6] In the perioperative period, the most perfect hemostasis should be obtained, drainage by a Redon of adapted vacuum caliber should be used to evacuate any residual collections, and good fixation of the flap should be observed to avoid any depression caused by an adjacent hematoma.[7]

Subcutaneous hematomas are one of the most frequent and benign complications of cranial surgeries. In very rare cases like ours, they can be life-threatening. Postoperative subcutaneous hematomas should be prevented and managed the same way as other complications are: by adequate anesthetic preparation and the situationally-appropriate surgical techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rapana E, Lamaidaa E, Pizza V. Multiple postoperative intracerebral haematomas remote from the site of craniotomy. Br J Neurosurg 1998;12:364-8.  Back to cited text no. 1
    
2.
Bruder N, Gouvitsos F, Pellissier D, Stordeur J. Réanimation encéphalique. In: EMC. Elsevier Masson SAS; 2006. p. 10. (Anesthésie-Réanimation).  Back to cited text no. 2
    
3.
Sawaya R, Hammoud M, Schoppa A. Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 1998;42:1044-55.  Back to cited text no. 3
    
4.
Elalamy I. Accidents des traitements anticoagulants oraux. EMC-Traité Urgence 2003;25:190.  Back to cited text no. 4
    
5.
Kurland DB, Khaladj-Ghom A, Stokum JA, Carusillo B, Karimy JK, Gerzanich V, et al. Complications Associated with Decompressive Craniectomy: A Systematic Review. Neurocrit Care 2015;23:292-304.  Back to cited text no. 5
    
6.
Mahajan C, Prabhakar H. Postoperative Hematoma. Complicat Neuroanesth 2016;141-4.  Back to cited text no. 6
    
7.
Schwarz F, Dünisch P, Walter J, Sakr Y, Kalff R, Ewald C. Cranioplasty after decompressive craniectomy: Is there a rationale for an initial artificial bone-substitute implant? A single-center experience after 631 procedures. J Neurosurg 2016;124:710-5.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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