American Journal of Clinical Neurology and Neurosurgery

Vol. 1, No. 2, 2015, pp. 77-80

http://www.aiscience.org/journal/ajcnn

Intraoperative Contralateral Massive Extradural

Hematoma Development During Decompressive
Craniectomy and Evacuation of Traumatic Acute
Subdural Hematoma Causing Brain Bulge:
Management
Guru Dutta Satyarthee*, A. K. Mahapatra

Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narayan Apex Trauma Centre, New Delhi, India

Abstract
Sequential development of extradural hematoma (EDH) during decompressive craniotomy and evacuation for acute subdural
hematoma (ASDH) causing massive brain bulge is rare, it may represent to be first indication of hematoma development.
About thirty seven cases are published in the form of isolated case report till date. Management is debated, as first to carry out
exploratory burr-hole or necessity of getting CT scan head or intraoperative ultrasonography imaging to ascertain the diagnosis.
Authors report a 40-year male, who developed EDH on contralateral side during evacuation of traumatic acute subdural
hematoma during intraoperative period, wound was closed, patient was directly shifted to CT scan suit and got CT scan
revealed ED, underwent evacuation of EDH by retuning back with good outcome. Awareness of occurrence of EDH
development as a cause of massive intraoperative brain - bulge, which is not getting relieved on routine anaesthetic measure,
may need urgent CT scan or at least intraoperative ultrasonography imaging is to diagnose early and provide appropriate
management.

Keywords
Intraoperative, Extradural Hematoma, Brain Bulge, Decompressive Craniectomy

Received: July 6, 2015 / Accepted: July 26, 2015 / Published online: August 5, 2015
@ 2015 The Authors. Published by American Institute of Science. This Open Access article is under the CC BY-NC license.
http://creativecommons.org/licenses/by-nc/4.0/

intra-parenchymal bleed, hydrocephalus enlargement or

1. Introduction rarely but important causes are formation of ASDH, EDH on
contralateral side. Authors report an interesting case of severe
Development of extra-axial haematoma on contralateral
head injury with ASDH, who developed acute brain bulge
hemisphere during craniotomy surgery for evacuation of
intraoperatively during decompressive craniectomy, NCCT
traumatic ASDH presenting with brain bulge is a potential
head revealed massive extradural hematoma, located on
life threatening complication, if existence of such occurrence
contralateral cerebral hemisphere associated with fracture of
not suspected. [1-8] It may present as extradural, subdural or
overlying calvarium to the surgical procedure, which
intracerebral hematoma. However, development of ASDH is
necessitated emergency evacuation. Current study
well reported in literature [3, 9]. However, incidence of EDH,
emphasizes getting immediate CT scan directly from
freshly developing is extremely rare, with paucity of
operating room and return back to carry out urgent
literature, only reported in the form of isolated case report [1,
evacuation of hematoma can be a life saving measure without
4-8]. Intraoperative brain bulge can be commonly caused due
wasting of valuable time and providing golden opportunity
to formation ipsilateral enlargement of hematoma volume or

* Corresponding author
E-mail address: duttaguru2002@yahoo.com (G. D. Satyarthee)
78 Guru Dutta Satyarthee and A. K. Mahapatra: Intraoperative Contralateral Massive Extradural Hematoma Development During
Decompressive Craniectomy and Evacuation of Traumatic Acute Subdural Hematoma Causing Brain Bulge: Management

for good neurological recovery.

2. Case Report
A-40-year male was brought in altered consciousness
following trauma six hour back to our emergency services.
Examination on arrival, vital stable with a G.C.S. Score of 8,
with papillary asymmetry, immediately intubated and kept on
ventilatory support. NCCT head showed thick left sided
ASDH causing with effacement of basal cisterns with
midline shift and significant mass effect (fig-1).
He underwent left frontotemporoprarieal scalp flap and
decompressive craniectomy. Brain was lax after hematoma
evacuation, however suddenly brain bulge noticed just prior
to beginning of dural closure, all routine measure was taken
to reduce he intracranial pressure, but no relief, so
development of hematomas was possibility as it was not Fig. 2. Post-operative CT scan head showing complete evacuation of
extradural and subdural hematoma.
responding to routine anaesthetic measure. Hence a decision
to get CT scan head after rapid wound closure was planned
and shifted to CT scan suit and back to O.T. following NCCT
head, which showed thick right sided parietal EDH with
gross mid line shift. Decompressive craniectomy with EDH
evacuation was carried out. He needed electively ventilated
for five days. He was discharged on tenth postoperative day
with GCS score of 14). (Fig-2). Subsequently he underwent
split autologus cryogenic preserved skull flap cranioplasty at
six months following first surgery (fig-3).

Fig. 3. CT scan with bone window showing cranioplasty utilizing autologus

split cryogenic preserved skull flap.

Fig. 1. Initial CT scan head showing thick acute subdural hematoma in left
frontotemporo-parietal region causing effacement of basal cistern, subfalcine
herniation and significant mass effect.
3. Discussion
Development of extra-axial haematoma in opposite
hemisphere in a sequential manner during craniotomy
surgery for evacuation posttraumatic ASDH can be caused by
epidural or subdural hematoma. Such occurrence is
extremely rare but presents a challenge for accurate and rapid
a diagnostic and surgical management.
Contralateral hemispherical evolution of ASDH development
during surgery is reported literature [3, 9,11]. However, EDH
evolution during craniotomy or decompressive craniectomy
surgery for traumatic SDH evacuation is still rarer. [1, 4, 6, 7]
In a review by Shen et al, found only 32 published cases,
who developed contralateral EDH during craniotomy for
traumatic acute SDH evacuation in 2013 [4]. However, exact
 American Journal of Clinical Neurology and Neurosurgery Vol. 1, No. 2, 2015, pp. 77-80
mechanism of contralateral epidural hematoma development
remains unknown. Various postulates are put forward to
explain the intraoperative development of EDH, causing
significant mass effect and brain bulge. Tomycz et al
postulated rapid brain shift caused by craniotomy lead to
shear stress on bridging veins of contralateral side, which
may got torn leading to formation of EDH and ongoing
collection of blood over time, may enlarge to cause brain
bulge during surgery, which is unresponsive to anaesthetic
mediation [9]. According to Takeuchi et al, early initial CT
scan is usually done within few hours following injury and
these scan may miss such hematoma development, which
may represent as natural course of evolution [4]. However,
Feuerman et al tried to define intraoperative hematoma as
occurrence of hematoma, which are not observed during
initial CT scan, but developing slowly following surgical
evacuation either during surgery or in the immediate
postoperative period [1].
According to chronology of evolution, such hematoma may
manifest either in the period after completion of surgery or
during intraoperatively. Former can present in the form of
delay reversal from anaesthesia or development of fresh
neurological deficit after recovery from surgery during
convalescence in the postoperative period. Further,
intraoperative development of EDH is much rarer, but can
occur during any stage of surgical procedure of intracranial
surgery i.e. bone flap elevation or following dura opening or
during evacuation of hematoma phase, may present with
catastrophic brain bulge as occurred in the current case.
Various factors have been incriminated to promote the
evolution of epidural hematoma formation are usage of
osmotic dehydrating agent during intraoperative period,
hyperventilation, CSF rhinorrhoea, otorhorea, and presence
of fracture of skull and may act either alone or in
combination causing loss of temponade causing enlargement
of EDH and leading to mass effect and rise in intracranial
pressure. Authors also reported an interesting case, who
developed contralateral epidural hematoma without overlying
calvarial fractures as the source of EDH, was bleeding from
superior saggital sinus [3]. In current case, fracture of
overlying calvarium, compression and temponade effect of
left sided ASDH with midline shift probably prevented
contralateral extradural hematomas from developing but
following evacuation of first hematoma led to decrease in
intracranial tension, loss of temponade effect, increase
intracranial circulation flow aggravated stripping of dura
promoting arterial bleed causing attainment of massive size
leading to intraoperative malignant brain bulge. Huang et al.
observed remote EDH development in patients, who
underwent unilateral decompressive hemicraniectomy for
trauma, presence of remote skull fracture and absent
79
contusion are independent risk factors and further observed
such remote EDH development is devastating, timely CT
scan head and urgent evacuation of hematoma are efficient
and important factors determinig neurological outcome [2].
If acute brain bulge noticed intraoperatively, which fails to
respond well to the anaesthetic maneuver routinely practiced
i.e. head elevation, infusion of osmotic agent, diuretics,
maintaining air way patency, avoidance of over-rotation of
head, hyperventilation, switching over to total intravenous
anaesthetic agent anaesthesia and in such resistant brain bulge.
Routine intraoperative neurosurgical manoeuvre should be
applied first to control further brain bulge, cisternal CSF
release, ventricular tapping to release CSF are surgical adjunct.
Another important indicator of remote bleeding during
craniotomy is progressive brain bulge with recurrent oozing or
venous bleeding in the surgical cavity causing repetitive failure
to secure hemostasis. But in few cases, brain continue to bulge
and not responding favourably to either surgical or anaesthetic
maneuver, a possibility of remote hemorrhage should be kept.
Awareness of such remote hematoma occurrence is very
essential for neurosurgeons.
Ascertaining the causes of brain bulge and providing
appropriate remedial measure is very important requiring
urgent neuro-imagings. It can be diagnosed with
intraoperative ultrasonography or CT scan or exploratory
burr hole placement without imaging study or getting CT
scan first and planning of subsequent surgery depends on
immediate availability of CT scan or Ultrasound machine.
However, CT scan of head is time consuming in addition
requires shifting out and in off the operating room unless or
institution having Intraoperative mobile CT scanner.
Management depends upon mass effect, size of hematoma,
rate of progression of mass effect, effect of anaesthetic
measure. A large acute EDH requires evacuation; however
small contralateral EDH collection developing or detected in
postoperative period can be monitored however, our case
needed urgent surgical intervention. Singh et al advocated
intraoperative anaesthetic measure, rapid closure of scalp
wound without placing bone and getting immediate CT scan
head and immediately shifting to operating room without
delay and craniotomy with evacuation of extradural
hematoma [5].
4. Conclusion
Acute brain budge during surgery may be first indication of
developing contralateral extraxial collections or parenchymal
contusions in severe head injury. Authors advocate getting
rapid imaging is paramount importance, either intraoperative
ultrasonography or urgent CT scan for proper diagnosis is
important.
80 Guru Dutta Satyarthee and A. K. Mahapatra: Intraoperative Contralateral Massive Extradural Hematoma Development During
Decompressive Craniectomy and Evacuation of Traumatic Acute Subdural Hematoma Causing Brain Bulge: Management
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