Multiple remote epidural hematomas following pineal gland tumor resection

Multiple different remote epidural hematomas after craniotomy: A case report

BACKGROUND

Epidural hematoma is one of the common postoperative complications after craniotomy. However, multiple remote epidural hematomas in different sites, including supratentorial and infratentorial regions, are exceedingly rare.

CASE SUMMARY

We present a rare case in which three remote epidural hematomas occurred after craniotomy. A 21-year-old woman was admitted with a headache for 1 mo, vomiting, and rapid vision loss for 1 wk. Brian magnetic resonance imaging indicated a right thalamic tumor. The intraoperative diagnosis was a cystic tumor, posterior cerebral artery aneurysm, and vascular malformation. The operation was successful. Unfortunately, the patient developed three extradural hematomas within 48 h. Family members consented to the first two hematoma evacuations but refused the third.

CONCLUSION

More attention should be paid to this kind of rare complication. Adequate preoperative evaluation is important, especially for acute patients. Monitoring neural function and early computed tomography scanning of the brain after surgery should be highlighted.

Calvarial diploic venous channels: delineation with maximal intensity projection technique

PURPOSE

To date, very few studies have explored the three-dimensional architecture of calvarial diploic venous channels (CDVCs). This study aimed to characterize the three-dimensional architecture of CDVCs using maximum intensity projection (MIP) images based on contrast-enhanced magnetic resonance imaging (MRI).

METHODS

A total of 77 patients with intact calvarial hemispheres and underlying dura mater and dural sinuses underwent contrast-enhanced MRI. Among them, we extracted the data of 49 with at least a part of the major CDVC pathways identified on the MIP images for analysis.

RESULTS

On serial contrast-enhanced MRI images, the CDVCs were commonly detected as curvilinear structures with inhomogeneous diameters and tributaries, while the MIP images delineated the three-dimensional architecture of the developed CDVC pathways. More than such CDVC pathway was entirely delineated on the right in 67.3% and on the left in 71.4%, most frequently in the frontal and temporal regions, with their connecting sites to the sphenoparietal and superior sagittal sinuses. The morphology, distribution, and course of the identified CDVCs were highly variable. In 55.1%, the CDVCs formed fenestrations that were variable in size, shape, and number.

CONCLUSIONS

The developed CDVC pathways may be characterized by morphological variability and fenestrations. Thin-sliced, contrast-enhanced MRI is useful to depict diploic veins, while MIP images allow for better appreciation of the entire course of the developed CDVC pathways. Traumatic and intraoperative disconnection between the dura mater overlying the dural sinuses and the adjacent inner table of the skull can cause epidural venous bleeding.

Postoperative subdural hematoma as a rare complication of non-traumatic craniotomy: Two cases report

RATIONALE

Postoperative intracranial hemorrhage is a serious and even fatal complication after non-traumatic craniotomy, in which epidural hematoma and intracerebral hematoma are relatively common. Postoperative subdural hematoma is rare, and its pathogenic mechanism remains unclear.

PATIENT CONCERNS

In the present study, we report 2 cases with postoperative subdural hematoma after non-traumatic craniotomy.

DIAGNOSES

The diagnosis of acute subdural hematoma (aSDH) was rendered according to the imaging features.

INTERVENTIONS

Hematoma evacuation was performed immediately.

OUTCOMES

Two months later, the first patient continued to have impaired consciousness and sensorimotor deficiency in the right extremities. And the second one remained unconscious and continued to have sensorimotor disturbance in the right extremities after 6 weeks of rehabilitation.

LESSONS

Neurosurgeons should be aware of potential subdural hematoma after non-traumatic craniotomy, since this condition is usually latent and associated with poor prognosis. Early identification and surgical evacuation should be highlighted.

Remote Intracranial Hemorrhage Secondary to Brain Tumor Surgery

Postoperative remote intracranial hemorrhage (rICH) secondary to craniotomy surgery is an extremely rare but catastrophic complication. The present study aimed to investigate the incidence and the possible pathophysiological mechanism of rICH after brain tumor surgery. The clinical data from 9 rICH cases among 4588 patients undergoing brain tumor surgery were collected retrospectively. Remote intracranial hemorrhage occurred in 9 cases, including 6 cases of remote epidural hemorrhage (rEDH), 2 cases of remote subdural hemorrhage (rSDH), and 1 case of remote cerebellar hemorrhage (rCBH). Among the 9 cases, 2 were males and 7 were females, with an age range of 22 to 63 years (mean of 44.3 years). The incidence of rICH in the patients with ventricular system opening/drainage (4/258) was much higher than the patients without ventricular system opening/drainage (5/4330), and the difference was statistically significant (P < 0.01). Hematoma evacuation was performed in 7 patients with serious neurological status or massive hematoma. The outcome for most of the rICH cases was good, and the Glasgow outcome scale scores of 4-5 were found in 8 cases with a 3-month-long follow-up. Our results suggest that brain tumor surgery with ventricular system opening/drainage was more susceptible to rICH. Paying particlular attention to gradual reduction of intracranial pressure and avoiding excessive loss of cerebrospinal fluid may aid to prevent the occurrence of rICH. The authors suggest that a high index of suspicion, a prompt diagnosis, and emergent management is of vital importance to achieve good prognosis for rICH patients secondary to brain tumor surgery.

Multiple Remote Sequential Supratentorial Epidural Hematomas-An Unusual and Rare Complication After Posterior Fossa Surgery

BACKGROUND

Postoperative hemorrhage is a serious complication of intracranial surgery. Epidural hematomas (EDHs) are one of the common forms of bleeding after surgery, with ≤12% of patients requiring re-exploration. However, distant or remote site EDHs have been rare, in particular, those in a supratentorial location after infratentorial surgery.

CASE DESCRIPTION

We report an unusual complication of surgery for fourth ventricular outlet obstruction. A young male patient developed multiple sequential supratentorial EDHs after posterior fossa surgery. He required 2 re-explorations after the primary surgery for evacuation of the EDHs within 24 hours. In the available data, we found only 28 such reported cases previously. Only 2 additional cases have been reported to have sequential EDHs after surgery. Various theories have been postulated, ranging from sudden intracranial pressure decompression, pin site hematoma, and shunt site bleeding due to dural stripping. None has been proven to definitively explain the complication.

CONCLUSIONS

We wished to highlight this unusual complication of posterior fossa surgery, with an emphasis on rapid computed tomography scanning of the brain for patients in the early postoperative period with any neurological deterioration. Early radiological detection and timely intervention can be lifesaving.

Remote intracranial hemorrhage following surgery for giant orbitofrontal growing skull fracture: A lesson learnt

Growing skull fracture is an extremely rare complication of pediatric head injury, especially in infants. Repair of the dural tear early in the course of development of growing skull fracture has been suggested for a better outcome. Surgical repair of large, tense growing skull fractures, especially those in the communication of the ventricles can lead to potentially life-threatening complications. The author reports a rare case of remote intracranial hemorrhage following surgery for large, tense growing skull fracture in a 12-year-old girl and discusses the likely pathogenesis and possible ways to avoid this life-threatening complication.

Thoracic spinal subdural hematoma complicating anterior cervical discectomy and fusion: case report

A spinal subdural hematoma is a rare clinical entity with considerable consequences without prompt diagnosis and treatment. Throughout the literature, there are limited accounts of spinal subdural hematoma formation following spinal surgery. This report is the first to describe the formation of a spinal subdural hematoma in the thoracic spine following surgery at the cervical level. A 53-year-old woman developed significant paraparesis several hours after anterior cervical discectomy and fusion of C5–6. Expeditious return to operating room for anterior cervical revision decompression was performed, and the epidural hematoma was evacuated without difficulty. Postoperative imaging demonstrated a subdural hematoma confined to the thoracic level, and the patient was returned to the operating room for a third surgical procedure. Decompression of T1–3, with evacuation of the subdural hematoma was performed. Postprocedure, the patient’s sensory and motor deficits were restored, and, with rehabilitation, the patient gained functional mobility. Spinal subdural hematomas should be considered as a rare but potential complication of cervical discectomy and fusion. With early diagnosis and treatment, favorable outcomes may be achieved.

Programmed intermittent epidural boluses for maintenance of labor analgesia: an impact study

INTRODUCTION

The aim of this impact study was to compare the analgesic efficacy and side effect profile of programmed intermittent epidural boluses (PIEB)+patient-controlled epidural analgesia (PCEA) to continuous epidural infusion (CEI)+PCEA for maintenance labor analgesia after the introduction of PIEB at our institution.

METHODS

We conducted a retrospective analysis after replacing the background CEI with PIEB for our labor PCEA. Pre-change pump settings were CEI 12mL/h with PCEA (12mL bolus, lockout 15min); PIEB settings were a 9mL bolus every 45min with PCEA (10mL bolus, lockout 10min). We compared medical records of all women receiving epidural or combined spinal-epidural labor analgesia for vaginal delivery for two months before PIEB implementation to a two-month period of PIEB utilization following a five-month introductory familiarization period. The primary outcome was the proportion of women requiring rescue clinician boluses.

RESULTS

Fewer patients in the PIEB group required rescue clinician boluses compared to the CEI group (12% vs. 19%, P=0.012). Time to first rescue bolus request and total bolus dose were not different. Peak (median [IQR]) pain scores were 2[0-5] with CEI and 0[0-4] with PIEB. There was no difference in instrumental delivery rates.

CONCLUSIONS

Using PIEB compared to CEI as the background maintenance epidural analgesia method in conjunction with PCEA reduced the number of women requiring clinician rescue boluses while providing comparable labor analgesia. The findings of this clinical care impact study confirm the results of randomized controlled studies and suggest PIEB may be a preferable technique to CEI for the maintenance of labor analgesia.

Remote Postoperative Epidural Hematoma after Brain Tumor Surgery

A postoperative epidural hematoma (EDH) is a serious and embarrassing complication, which usually occurs at the site of operation after intracranial surgery. However, remote EDH is relatively rare. We report three cases of remote EDH after brain tumor surgery. All three cases seemed to have different causes of remote postoperative EDH; however, all patients were managed promptly and showed excellent outcomes. Although the exact mechanism of remote postoperative EDH is unknown, surgeons should be cautious of the speed of lowering intracranial pressure and implement basic procedures to prevent this hazardous complication of brain tumor surgery.

Postoperative epidural haematomas associated with hydrocephalus caused by intraoperative overdrainage of cerebrospinal fluid: two case reports with a literature review of 19 cases

We report two cases with postoperative epidural haematomas (EDHs) associated with hydrocephalus and discuss the cause of haematoma development on the basis of a literature review. A 13-year-old boy presented with obstructive hydrocephalus caused by a sellar mass lesion. Multifocal EDHs occurred after partial resection of the lesion via a transcallosal approach following ventricular drainage. In the second case, a 26-year-old man who had a history of ventriculoperitoneal shunting for congenital hydrocephalus presented with hydrocephalus caused by ventricular catheter obstruction. An EDH occurred after replacement of the ventricular catheter with a new burr hole opening. On the basis of a review of 19 cases including our two cases, the authors concluded that postoperative EDH development associated with hydrocephalus was mostly caused by intraoperative overdrainage of cerebrospinal fluid, resulting in rapid shrinkage of the brain with dilation of the epidural space, a situation that may have caused dural venous bleeding.

Arterial vascularization of the pineal gland

PURPOSE

The arterial vascularization of the pineal gland (PG) remains a debatable subject. This study aims to provide detailed information about the arterial vascularization of the PG.

METHODS

Thirty adult human brains were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. The dissections were carried out using a surgical microscope. The diameters of the branches supplying the PG at their origin and vascularization areas of the branches of the arteries were investigated.

RESULTS

The main artery of the PG was the lateral pineal artery, and it originated from the posterior circulation. The other arteries included the medial pineal artery from the posterior circulation and the rostral pineal artery mainly from the anterior circulation. Posteromedial choroidal artery was an important artery that branched to the PG. The arterial supply to the PG was studied comprehensively considering the debate and inadequacy of previously published studies on this issue available in the literature.

CONCLUSIONS

This anatomical knowledge may be helpful for surgical treatment of pathologies of the PG, especially in children who develop more pathology in this region than adults.