- Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
Ali Tayebi Meybodi
Department of Neurosurgery, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
DOI:10.4103/2152-7806.131182Copyright: © 2014 Meybodi AT This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Meybodi AT, Saberi H. Expanding contralateral epidural hematoma causing acute intraoperative brain swelling. Surg Neurol Int 21-Apr-2014;5:57
How to cite this URL: Meybodi AT, Saberi H. Expanding contralateral epidural hematoma causing acute intraoperative brain swelling. Surg Neurol Int 21-Apr-2014;5:57. Available from: http://sni.wpengine.com/surgicalint_articles/expanding-contralateral-epidural-hematoma-causing-acute-intraoperative-brain-swelling/
We have read with enthusiasm the recent paper by Drs Solomiichuk and Drizhdov,[
The presented case is a 28-year-old male with anisocoria and depressed level of consciousness (Glasgow Coma Scale, 5) after head trauma. The initial computed tomography (CT) image provided in the paper shows a low CT cut [
(a) The brain CT showing left frontal base intracerebral hematoma; (b) The reconstructed 3D CT showing the extent of craniectomy performed in the first operation not including the inferior temporal region. (Both images are reprinted from the original paper by Solomiichuk & Drizhdov[
Another important finding to be respected is the presence of small blebs of pneumocephalus in the right occipital region as well as scant epidural hematoma in the right posterior parietal region. This sign may alarm the operating team to suspect the evolution/expansion of contralateral hematoma, in case the evacuation of the left sided frontal mass is accompanied by uncontrollable cerebral swelling during surgery.
The authors state that they have observed an acute brain swelling during evacuation of the frontal hematoma. A sign that we think should be respected in a timely fashion. Unexplained brain swelling during craniotomy should prompt the physician to look for a definitive cause.[
The suggestion of the authors to obtain the CT in the next 24 h needs some form of clarification. We think that the contralateral epidural hematoma as presented by authors is not ‘delayed’; rather, it has expanded right at the time the frontal hemorrhage was evacuated as the tamponade effect of the hemorrhage prevented a small epidural hematoma underneath the contralateral skull fracture to enlarge. Thus, we do support the idea of taking immediate postoperative CT in cases of acute refractory intraoperative cerebral swelling for timely diagnosis and treatment of remote lesions. Nevertheless, in certain circumstances, taking and immediate postoperative CT is not feasible (e.g. due to unstable hemodynamics). In such cases we would perform the postoperative CT as soon as possible, and would not wait until the ominous clinical sign of anisocoria appears. However, since the authors were not able to take immediate postoperative CT, the concept of ‘delayed’ contralateral hematoma can neither be proven nor refuted in this very case.
Another issue to be respected is the rationale for decompressive craniectomy for the secondary contralateral epidural hematoma. Generally, epidural hematomas do not produce as much swelling of the underlying cortex as do subdural hematomas. Furthermore, in this particular case, the authors have previously performed a decompressive craniectomy on the left side to let the brain swell outwards instead of producing deleterious raised intracranial pressure. This safety window seems wide enough to preclude them from doing a craniectomy on the second operation. Placement of an external ventricular drain would nicely let them monitor the intracranial pressure while the excess cerebrospinal fluid could easily egress during the first critical days after operation. This is, of course, again dependent on the available equipments to the surgical team; something that we realize might not be readily accessible by the surgeons in some developing countries, including ours.
1. Aarabi B, Hesdorffer DC, Ahn ES, Aresco C, Scalea TM, Eisenberg HM. Outcome following decompressive craniectomy for malignant swelling due to severe head injury. J Neurosurg. 2006. 104: 469-79
2. Marshall LF, Bowers-Marshall S, Klauber MR, van Berkum Clark M, Eisenberg HM, Jane JA. A new classification of head injury based on computerized tomography. J Nuerosurg. 1991. 75: S14-20
3. Reilly PL. Intra-operative brain swelling. Br J Neurosurg. 1990. 4: 3-4
4. 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-
5. Solomiichuk VO, Drizhdov KI. Contralateral delayed epidural hematoma following intracerebral hematoma surgery. Surg Neurol Int. 2013. 4: 134-