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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 4  |  Page : 435-437

Brainstem hemorrhage secondary to evacuation of chronic subdural hematoma


Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra, India

Date of Web Publication19-Sep-2014

Correspondence Address:
Atul Goel
Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra
India
Atul Goel
Department of Neurosurgery, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Parel, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.141222

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How to cite this article:
Rojas-Medina LM, Goel A, Rojas-Medina LM, Goel A. Brainstem hemorrhage secondary to evacuation of chronic subdural hematoma. Neurol India 2014;62:435-7

How to cite this URL:
Rojas-Medina LM, Goel A, Rojas-Medina LM, Goel A. Brainstem hemorrhage secondary to evacuation of chronic subdural hematoma. Neurol India [serial online] 2014 [cited 2020 Oct 30];62:435-7. Available from: https://www.neurologyindia.com/text.asp?2014/62/4/435/141222


Sir,

Although surgery on chronic subdural hematomas (CSDH) usually has a rewarding outcome, it is not exempted from complications. We report an extremely rare case where there was remote brainstem hemorrhage following drainage of subdural hematoma.

A 58-year-old man was admitted to our hospital with history of severe headache and vomiting of 4-days duration. He was on low-dose aspirin and clopidogrel for coronary heart disease and a known patient of hypertension and diabetes. There had been no prior head trauma. Preoperative coagulation parameters (prothrombin time, partial thromboplastin time, anti-thrombin III, bleeding time, platelet count) were within normal limits. Magnetic resonance imaging showed bilateral chronic subdural hematoma (CSDH) [Figure 1]. Surgery was performed under local anesthesia with patient in supine position. One each frontal burr hole were drilled. Hematoma was thin, liquefied, and xanthochromic. The hematoma was evacuated slowly and the region was gently irrigated until clear fluid returned. Approximately 150 ml of blood clot was evacuated from each side. There was no active bleeding point. The procedure was uneventful and during the entire procedure patient said that the headache had improved. However, as he was being wheeled out of operation theater, he complained of severe headache and slurred speech. Within few minutes, he lapsed into unconsciousness. The blood pressure at this time was 270/140 mm of mercury. An emergent computed tomography (CT) scan showed bilateral frontoparietal convexity acute subdural hemorrhage. The patient was rushed to the operation theater and mini-craniotomies were done around the region of previous burr-hole and large subdural clots were evacuated from both sides. The time for the burr-holes and subsequent craniotomies and the time for CT scan were about 3 hours. Following the craniotomy, the patient improved transiently and moved limbs, but remained unconscious. He was electively ventilated. At 3 hours post-operation, he was deeply comatosed with dilated pupils. A repeat CT scan showed large amount of air in the subdural spaces and evidence of brainstem and fourth ventricle hemorrhage [Figure 2]. He continued to be unconscious and subsequently succumbed.
Figure 1: T2-weighted axial MRI of the brain showing bilateral chronic subdural hematoma with effacement and mass effect

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Figure 2: Axial plain CT image showing evacuation of bilateral subdural hematoma with air in the cavity. Also seen is hemorrhage in the brainstem and the fourth ventricle

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CSDHs are common neurosurgical problems and treatment includes evacuation of the hematoma by burr-hole drainage. [1],[2],[3],[4] The results of surgery are gratifying and recurrence of subdural hematoma is low. Postoperative complications though rare, include re-accumulation, re-hemorrhage, cerebral edema, infection, seizures, and intracerebral hemorrhage (ICH). ICH is a well-known complication of supratentorial neurosurgery. [5] However, ICH following evacuation of a subdural hematoma is a rare clinical event. ICH following evacuation of the subdural hematoma may be on the same side of evacuation or on the contralateral side, [6],[7] infratentorial, [8],[9],[10],[11] and extremely rarely cerebellar or intraaxial brain stem. [4],[12],[13],[14]

Our literature search showed reports of only four cases of brainstem hemorrhage after evacuation of CSDH. In all cases, the subdural hematoma was on both sides. Two cases of brainstem hemorrhage were detected at autopsy; [4],[13] one patient died during the hospital stay [14] and the fourth patient gradually improved. [12] In general, brainstem hematoma following drainage of subdural hematoma has a high mortality [Table 1]. The site and size of the hematoma that resulted in death has not been clearly specified in the reported cases.

The pathogenesis of postoperative hemorrhage after evacuation of CSDH is not clear and can only be speculated. [6],[7],[8],[9],[10],[11],[15] Rapid evacuation of hematoma, increase in cerebral blood flow, alteration in vascular autoregulation, damage of small fragile vessel secondary to increased intracranial pressure or damage directly to a vessel following transtentorial herniation may be the possible mechanisms. Altered coagulation parameters and a massive air reflux into the cranial cavity through the drainage hole may pose additional risk. Other mechanism, though less possible, is a traumatic small contusion not detected in CT scan or MRI In all cases it may be mandatory to rule out secondary pathology like arteriovenous malformation, cavernous malformation and neoplasm. Rapid drainage of CSDH increases mobility of the intracranial structures and can lead to remote site hemorrhage. Associated high blood pressure could be an initiating factor. A hypertensive crisis with or without raised intracranial pressure may cause a direct brain stem hematoma unrelated to surgical manipulation. Another unlikely but posible cause of remote site hemorrhagic infarction could be a phenomenon simulating deep venous thrombosis.
Table 1: Cases reported with brain stem hemorrhage after drainage CSDH

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Okuchi et al. [15] reported a patient with oculomotor nerve paresis and brain stem symptoms following evacuation of bilateral CSDH and speculated that the complication is probably related to rapid decompression. Stefini et al. [5] reported a patient with ruptured intracranial aneurysm after evacuation with craniotomy of left CSDH. Aneurysmal rupture was probably caused by the alterations in the intracranial pressure dynamics following the evacuation of the clot.

In our patient, although there were no significant hematological abnormalities, long-term use low-dose aspirin and clopidogrel could have altered the coagulation profile that might have led to hemorrhage. The other possible causes include increase in cerebral blood flow, alteration in autoregulation, possible damaged vessel, and supratentorial decompression.

 
  References Top

1.Kotwica Z, Brzezinski J. Chronic subdural haematoma treated by by burr holes and closed system drainage: Personal experience in 131 patients. Br J Neurosurg 1991;5:461-5.  Back to cited text no. 1
    
2.Richter HP, Klein HJ, Schafer M. Chronic subdural haematoma treated by enlarge burr hole craniotomy and closed system drainage. Retrospective study of 120 patients. Acta Neurochir (Wien) 1984;71:179-88.  Back to cited text no. 2
    
3.Sambasivan M. An overview of chronic subdural hematoma: Experience with 2300 cases. Surg Neurol 1997;47:418-22.  Back to cited text no. 3
    
4.Robinson RG. Chronic subdural hematoma: Surgical management in 133 patients. J Neurosurg 1984;61:263-8.  Back to cited text no. 4
    
5.Stefini R, Ghitti F, Bergomi R, Catenacci E, Latronico N, Mortini P. Uncommon presentation of ruptured intracranial aneurysm during surgical evacuation of chronic subdural hematoma: Case report. Surg Neurol 2008;69:89-92.  Back to cited text no. 5
    
6.Cohen-Gadol AA. Remote contralateral intraparenchymal hemorrhage after overdrainage of a chronic subdural hematoma. Int J Surg Case Rep 2013;4:834-6.  Back to cited text no. 6
    
7.Kim JK, Kim SW, Kim SH. Intracerebral hemorrhage following evacuation of a chronic subdural hematoma. J Korean Neurosurg Soc 2013;53:108-11.  Back to cited text no. 7
    
8.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. 8
    
9.Kollatos C, Konstantinou D, Raftopoulos S, Klironomos G, Messinis L, Zampakis P, et al. Cerebellar hemorrhage after supratentorial burr hole drainage of a chronic subdural hematoma. Hippokratia 2011;15:370-2.  Back to cited text no. 9
    
10.Ulivieri S, Oliveri G. Intracerebral haemorrhage following surgical evacuation of chronic subdural haematoma: Case report. G Chir 2008;29:233-4.  Back to cited text no. 10
    
11.Vega Basulto S, Mosqueda Betancourt G, Gutiérrez Muñoz F, Vega Trenado A, Rivero García C. Postoperative intracerebral hematoma. An unusual complication of chronic subdural hematoma. Rev Neurol 2004;38:497-8.  Back to cited text no. 11
    
12.Park KJ, Kang SH, Lee HK, Chung YG. Brain stem hemorrhage following burr hole drainage for chronic subdural hematoma-case report. Neurol Med Chir (Tokyo) 2009;49:594-7.  Back to cited text no. 12
    
13.McKissock W. Subdural haematoma. A review of 389 cases. Lancet 1960;1:1365-9.  Back to cited text no. 13
    
14.Alcalá-Cerra G, Gutiérrez-Paternina JJ, Niño-Hernández LM, Polo-Torres C, Romero-Ramírez H, Sabogal-Barrios R. Intracerebral hemorrhages following drainage of chronic subdural hematomas. Rev Med Inst Mex Seguro Soc 2011;49:547-50.  Back to cited text no. 14
    
15.Okuchi K, Fujioka M, Maeda Y, Kagoshima T, Sakaki T. Bilateral chronic subdural hematomas resulting in unilateral oculomotor nerve paresis an brain stem symptoms after operation. Neurol Med Chir (Tokyo) 1999;39:367-71.  Back to cited text no. 15
    


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