Distant large acute epidural hematoma after closed cerebrospinal fluid tapping through the anterior fontanelle: A case report and its pathogenesis
- Department of Neurosurgery, Cairo University, Cairo, Egypt.
DOI:10.25259/SNI_921_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Ahmed A. M. Ezzat, Mohamed A. R. Soliman, Mohammad Baraka, Mohamed El Shimy, Adham Ezz, Ehab El Refaee. Distant large acute epidural hematoma after closed cerebrospinal fluid tapping through the anterior fontanelle: A case report and its pathogenesis. 17-Feb-2021;12:59
How to cite this URL: Ahmed A. M. Ezzat, Mohamed A. R. Soliman, Mohammad Baraka, Mohamed El Shimy, Adham Ezz, Ehab El Refaee. Distant large acute epidural hematoma after closed cerebrospinal fluid tapping through the anterior fontanelle: A case report and its pathogenesis. 17-Feb-2021;12:59. Available from: https://surgicalneurologyint.com/surgicalint-articles/10594/
Background: Cerebrospinal fluid (CSF) infection is one of the most common and serious complications of shunt placement. The CSF shunt infections are preferably treated with intravenous antibiotics, infected shunt removal, repeated tapping (infants) or placement of an external ventricular drainage (EVD) device, and placement of a new shunt once the CSF is sterile. The tapping through the anterior fontanelle is commonly used instead of the EVD in developing countries to manage CSF infection in open anterior fontanelle patients. To the best of our knowledge, this would be considered the first reported case of distant epidural hematoma after closed ventricular tapping.
Case Description: We report a case of 6-months child with Chiari malformation (Type II) presenting to us with a shunt infection with possible obstruction. CSF was aspirated for examination through a tap through the anterior fontanelle followed by the development of extradural hemorrhage far from the tapping site.
Conclusion: EDH after a transfontanellar ventricular tap can rapidly evolve and lead to patient death. This report raises the awareness of the neurosurgeons to this possible complication that can happen and leads to major complications. Monitoring the conscious level would be needed after ventricular tapping to detect this possible complication.
Keywords: Acute epidural hematoma, Anterior fontanelle, Cerebrospinal fluid tapping, Distant, Transfontanellar
Ventriculoperitoneal shunt (VPS) is the most common procedure used for the management of hydrocephalus. Epidural hematoma (EDH) is a common disease and represents serious risks if not quickly diagnosed and managed. The preferred treatment of cerebrospinal fluid (CSF) shunt infections involves intravenous antibiotics, infected shunt removal, repeated ventricular tapping in infants, or preferably placement of an external ventricular drainage (EVD) device followed by placement of a new shunt once the CSF is sterile.[
The occurrence of EDH following ventricular drainage procedures is rare (0.4%)[
A 6-months child with Chiari II malformation who is otherwise medically free presented to us at the age of 4 months with lumbar meningomyelocele (MMC) and hydrocephalic changes operated on initially by right posterior parietal Chhabra medium pressure contoured VP shunt (G. Surgiwear Ltd., India) at the time of presentation. The MMC was repaired in the same session by direct repair and closure in layers. Two months after surgery, he developed fever, malaise, bulging, and tense anterior fontanelle and was diagnosed with a shunt infection after the VP shunt valve tap showed a CSF TLC of 150 cells/mm3 mainly polymorphs, as well as the culture and sensitivity, showed Staphylococcus aureus. This was managed by intravenous vancomycin 200 mg 3 times a day for 1 week with closed ventricular tapping (about 40 ml passively tapped using gravity [pressure gradient] over 20 min using a 20 F cannula after good sterilization) with leaving the shunt in place. The tapping was done 2 times (3 days apart). The 2nd day after the last tap, the child was sleepy with poor oral feeding. Urgent CT brain showed a 36.3 cc right parietal EDH [
VP shunt is the most common surgical procedure in the treatment of hydrocephalus worldwide.[
Pathophysiology of EDH formation
EDH can occur after several cranial procedures, as the epidural space is violated. Decreased intracranial pressure (ICP) after craniotomies or CSF diversion procedures would allow the collection of a hematoma in the subdural or the epidural space.[
The frontoparietal lobes are the most common locations of EDH. This may be attributed to the loose attachment of the dura in this region to the cranial vault.[
EVD was first described by Dandy.[
Release of CSF after lumbar punctures has been previously reported to cause the development of hemorrhage. In most cases, it would cause a spinal epidural hematoma, however, it was previously reported to cause intracranial hemorrhage.[
The cortex collapse as the etiology of hematomas should be taken into consideration as it can lead to traction forces on the middle meningeal artery or its branches which are slightly adherent to the skull.[
It seems that the 40 ml over 20 min lead to EDH may be attributed to rapid dilated ventricles decompression with dura mater stripping from the bone leading to an acute EDH. In addition, the longstanding hydrocephalus associated with the decreased brain parenchyma thickness has led to the event. Till now, it is unavoidable to use the ventricular tapping technique in the CSF infection management in open fontanelle infants in lower income countries settings. Furthermore, there are no guidelines on the indications, precautions, contraindications, tapping volume, and speed of the tap in the literature. We are calling neurosurgeons from lower income countries that are using this technique to report their techniques and outcomes to set guidelines for this technique to avoid future complications.
To the best of our knowledge, we present the first reported EDH after a ventricular tap through the anterior fontanelle, which can rapidly evolve and lead to patient death. Neurosurgeons must be aware of such complications that can happen despite the slow CSF tapping. Clinical monitoring of the conscious level is essential to detect this hazard and manage it properly. Furthermore, we are calling for further studies, especially from low resource countries to present their experience on the clinical outcomes and techniques of the transfontanellar tapping to prevent this unfortunate incident in the future.
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