The Journal of Craniofacial Surgery • Volume 25, Number 6, November 2014

Correspondence

Ayse Irem Mert, MD Department of Plastic and Reconstructive Surgery Haydarpasa Training and Research Hospital Istanbul, Turkey

REFERENCES

FIGURE 1. Elevation of the orbicularis muscle flap.

FIGURE 2. Suture suspension of the muscle flap.

results in postoperative period are the common goals of these techniques. Subciliary insicision is one of the most commonly used among these approaches. There are several articles in the literature pointing out that subciliary incision may cause more complications than other incisions. Ectropion, entropion, lid edema, hypertophic scar, and scleral show are the complications that could be encountered.2,3 The incidence of ectropion and scleral show can be decreased evidently by performing muscular canthopexy during closure. We have retrospectively analyzed 97 patients who had been treated between May 2006 and March 2014 for zygomatic fracture. Subciliary incision was used for exploration of the orbitozygomatic region and was combined with buccal and Gillies incisions when needed. After leaving 4 mm of tarsal orbicularis, a muscle-skin flap approach was used for reaching the orbital rim, which has been previously described by Converse. After reconstruction of the bone, a small muscle flap of 1  0.5 cm was removed from the lateral portion of the orbicularis muscle on the skin-muscle flap (Fig. 1). Muscular canthopexy is performed to the lateral orbital rim with the muscle flap (Fig. 2). There had not been any entropion and ectropion observed in these patients. All eye movements were watched naturally, and there was no diplopia and lid edema. Only 4 of these patients had scleral show (4.1%). Obvious scar tissue has been observed in 2 patients (1.9%). Subciliary, subtarsal, and transconjonctival approaches are the incisions that are used for the exploration of the orbital region. Many authors believe that subciliary incision causes more complications than other incisions.4 However, adding a muscular canthopexy during closure effectively decreases the rate of complications that can occur with the subciliary incision. Nesibe Sinem Ciloglu, MD Department of Plastic and Reconstructive Surgery Haydarpasa Training and Research Hospital Istanbul, Turkey [email protected]

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1. Ridgway EB, Chen C, Çolakoglu S, et al. The ıncidence of lower eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal, subciliary, and transconjunctival ıncisions. Plast Reconstr Surg 2009;124:1578 2. Salgarelli AC, Bellini P, Landini B, et al. A comparative study of different approaches in the treatment of orbital trauma: an experience based on 274 cases. Oral Maxillofac Surg 2010;14:23–27 3. Kim YK, Kim JW. Evaluation of subciliary ıncision used in blowout fracture treatment: pretarsal flattening after lower eyelid surgery. Plast Reconstr Surg 2010;125:1475–1479 4. Rohrich RJ, Janis JE, Adams WP. Subciliary versus subtarsal approaches to orbitozygomatic fractures. Plast Reconstr Surg 2003;111:1705–1708

Chronic Subdural Hematoma Due to Dural Metastasis of Gastric Adenocarcinoma Progressing Rapidly With Uncal Herniation To the Editor: Nontraumatic subdural hematoma (SDH), which accounts for 2.6% of all cases of SDH, has various causes, including vascular disorders, coagulopathies, intracranial hypotension, meningitis, and dural metastases of malignant tumors.1 Chronic SDH due to dural metastases of extraneuronal malignancies is extremely rare, and the most widely accepted explanation for SDH formation is the theory of tumor embolization.1–5 Herein, we report a case of chronic SDH due to dura metastasis of gastric adenocarcinoma progressing rapidly with uncal herniation, and the possible mechanisms of SDH formation in these patients were investigated and reviewed. A 55-year-old woman presented with headache and numbness of the left limbs for 2 days without history of head trauma. Neurologic examination showed decreased sensation on the left side. She had a history of gastric adenocarcinoma and underwent subtotal gastrectomy, Roux-en-Y gastrojejunostomy anastomosis, and D2 lymph node dissection 2 years ago. The resected specimen showed type IV advanced adenocarcinoma at the pylorus. Postoperative adjuvant chemotherapy was administrated for 6 periods as routine, and follow-up tests revealed no recurrence of the abdomen. On admission, cranial computed tomography (CT) showed a chronic SDH along the right cerebral convexity, which caused mass effect with slight left-sided midline shift (Fig. 1A). Laboratory data were unremarkable except coagulation abnormalities (slightly prolonged prothrombin time and partial thromboplastin time and slightly elevated fibrinogen level). However, 20 hours later, the patient had a sudden deteriorate in consciousness. On examination, the Glasgow Coma Scale was E2V2M5, and his right pupil was dilated to 5 mm with nonreactive to light. Emergent cranial CT scans revealed that the chronic SDH enlarged obviously, which caused uncal herniation with upper brainstem compression (Fig. 1B). Subsequently, the © 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

The Journal of Craniofacial Surgery • Volume 25, Number 6, November 2014

FIGURE 1. Preoperative and postoperative cranial CT scans of the patient with chronic SDH due to dural metastasis. A, Cranial CT scans on admission showed a chronic SDH along the right cerebral convexity, which caused mass effect with slight left-sided midline shift. B, CT scans 20 hours after admission revealed that the chronic SDH enlarged obviously, which caused uncal herniation with upper brainstem compression. C, CT scans after operation showed that the SDH was evacuated completely through a right frontoparietal craniectomy.

hematoma was evacuated through a right frontoparietal craniectomy (Fig. 1C). During surgery, an abnormal highly vascular neomembrane adherent to the inner dura was noted and sent for histopathologic examination (Fig. 2). Histopathologic examination revealed the dura containing the nests metastatic adenocarcinomatous cells with cytokeratin- and epithelial membrane antigen-positive in immunohistochemical staining (Fig. 3). Thus, the diagnosis metastasis of gastric adenocarcinoma of the dura mater was made. Systemic bone scan then showed that numerous sites of metastases involved the scapula, humerus, sternum, vertebrae, and pelvis, except for the skull bone (Fig. 4). The postoperative course was uneventful, and the patient was still alive with a 4-month-long follow-up. The dural metastasis of extraneuronal malignancy has been detected in approximately 10% of autopsy cases, and its frequency is highest in patients with breast cancer, followed by lung cancer, melanoma, and gastrointestinal cancer.4 Rarer still is the occurrence of SDH due to dural metastasis of a malignant tumor, and its incidence is around 0.02% of autopsy cases.4,6 It was reported that the most common histologic type for SDH due to dural metastasis was adenocarcinoma, and the most common primary tumor was gastric adenocarcinoma, followed by prostate cancer, breast cancer, and lung cancer.2 The pathophysiology of the spread of extraneuronal malignancies to the dura can be related to the direct extension of calvarial metastases to the dura or a combination of both arterial and venous dissemination.1,7 Concerning the mechanisms of SDH formation due to dura metastasis, there are several theories. The most widely accepted explanation is the theory of tumor embolization, first proposed by Russel et al.1–5 The dura consists of a dense outer layer and a loose areolar inner layer. Veins in the inner layer drain into the veins of the outer layer and eventually into the calvarial veins. Obstruction of the veins in the outer layer by tumor cells can cause dilation and rupture of veins in the inner layer, thus leading to the formation of SDH. Furthermore, histologic evidence of tumoral invasion of dural vessels was evident in almost all cases, suggesting that the formation of SDH was due to dural vascular obstruction.6

FIGURE 2. Intraoperative images of the neomembrane. An abnormal highly vascular neomembrane adherent to the inner dura was noted.

Correspondence

FIGURE 3. Histopathologic and immunochemistry examinations of the abnormal neomembrane. Histopathologic examination revealed the highly vascular neomembrane containing the nests metastatic adenocarcinomatous cells (A, 200; B, 400) with cytokeratin- and epithelial membrane antigen-positive in immunohistochemical staining (C, 200; D, 200).

An angiodesmoplastic response to a tumor was another theory of SDH formation due to dura metastasis.1,8 Infiltration of the dura by malignant cells can induce an angiodesmoplastic reaction, resulting in the formation of an abnormal neomembrane that is highly vascular, into which hemorrhage can occur more easily.8 In the present case, an abnormal neomembrane adherent to the inner dura with malignant cells infiltrated was demonstrated (Fig. 2), and we suggest that the highly vascular neomembrane contributed to the large SDH and the rapid deteriorating clinical status. Furthermore, it has been pointed out that a tendency to bleed, especially concurrent disseminated intravascular coagulation resulted from the primary malignancy, is a big trigger for SDH.4,6 Tasaki et al9 reported that 70% of patients with dural metastasis had tumor embolism in dural vessels, and half of them also had blood coagulation impairment. The combination of metastases in dural vessels with a coagulation defect can easily lead to a large SDH. In accordance with all mechanisms mentioned previously, the clinical progression in such instances may be rapid and dramatic. Just as the present case, the neurologic status may deteriorate into a syndrome of uncal herniation within minutes to hours.10 The diagnosis of dural metastasis can be difficult because of the masking effect of SDH. On the basis of the previous reports, many cases of dural metastasis may have been diagnosed during the second

FIGURE 4. Systemic bone scans of the patient. Systemic bone scan indicated that numerous sites of metastases involved the scapula, humerus, sternum, vertebrae, and pelvis, except for the skull bone.

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

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Correspondence

The Journal of Craniofacial Surgery • Volume 25, Number 6, November 2014

surgery for reaccumulated hematoma.2 Comparing with CT scans, magnetic resonance image is a better modality to delineate the probable underlying dural metastasis. For accurate diagnosis, biopsy of the involved dura and cytologic examination are mandatory.2 Treatments of chronic SDH associated with dural metastasis have been controversial.4 Burr hole irrigation was generally adopted to evacuate the chronic SDH before the accurate diagnosis of dural metastasis.3,4 However, burr hole irrigation alone is inadequate, and craniotomy is often performed to evacuate the reaccumulated hematoma.3,4 As the involved dura can be supposed as the main source of SDH formation, resection of the affected dura should be strongly recommended. Postoperative irradiation seems to be essential to control the residual tumor, but whether such treatment can prevent rebleeding is questionable, and cautious monitoring in the postoperative period is mandatory.2 Although the prognosis of SDH is usually quite good, the prognosis for SDH due to dural metastasis may become poor because of systemic metastases. It has been reported that SDH associated with dural metastasis causes a mortality rate of 69% within 3 weeks.4 Chronic SDH due to dural metastases of extraneuronal malignancies is extremely rare, we herein report a case of chronic SDH due to dura metastasis of gastric adenocarcinoma progressing rapidly with uncal herniation. It is suggested that an abnormal highly vascular neomembrane, which is an angiodesmoplastic response to the metastatic tumor, might contribute to the large SDH and the rapid deteriorating clinical status. We remind that the clinical progression in such instances may be rapid and dramatic. Xunhui Yuan, MD Department of Neurosurgery Yidu Central Hospital of Weifang Qingzhou, Shandong Province, China Hongyan Zhao, MD Department of Pharmacy Yidu Central Hospital of Weifang Qingzhou, Shandong Province, China Cuiling Zhao, MD Qingzhou Office, Qingzhou Shandong Province, China

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Hang Xiao, MD Gaoling Sun, MD Yun'an Bai, MD Department of Neurosurgery Yidu Central Hospital of Weifang Qingzhou, Shandong Province, China Jianyi Niu, MD Department of Neurology Yidu Central Hospital of Weifang Qingzhou, Shandong Province, China [email protected]

REFERENCES 1. Zheng JX, Tan TK, Kumar DS, et al. Subdural haematoma due to dural metastases from bronchogenic carcinoma in a previously well patient: an unusual cause of non-traumatic recurrent intracranial haematomata. Singapore Med J 2011;52:e66–e69 2. Kunii N, Morita A, Yoshikawa G, et al. Subdural hematoma associated with dural metastasis—case report. Neurol Med Chir (Tokyo) 2005;45:519–522 3. Kuan-Yin T, Dueng-Yuan H, Hsin IM. Subdural hematoma associated with skull and dural metastasis of gastric carcinoma: a case report. Turk Neurosurg 2013;23:796–799 4. Katsube T, Kikuchi T, Konnno S, et al. Subdural hematoma associated with dural metastasis of gastric carcinoma: report of two cases. Anticancer Res 2007;27:4339–4344 5. Dorsi MJ, Zenonos G, Hsu W, et al. Dural prostate adenocarcinoma metastasis with subdural hematoma mimicking the appearance of an epidural hematoma. Clin Neurol Neurosurg 2010;112:501–504 6. Ambiavagar PC, Sher J. Subdural hematoma secondary to metastatic neoplasm: report of two cases and a review of the literature. Cancer 1978;42:2015–2018 7. Shamim MS, Bari ME, Enam SA. Dural metastases presenting as an extradural hematoma: a rare presentation. J Pak Med Assoc 2005;55:509–510 8. Leech RW, Welch FT, Ojemann GA. Subdural hematoma secondary to metastatic dural carcinomatosis. Case report. J Neurosurg 1974;41:610–613 9. Tasaki K, Shima T, Matsumura S, et al. A case of subdural effusion secondary to dural metastasis of prostatic cancer: case report. No Shinkei Geka 1990;18:539–542 10. Rogers LR. Cerebrovascular complications in cancer patients. Neurol Clin 2003;21:167–192

© 2014 Mutaz B. Habal, MD

Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.

Chronic subdural hematoma due to dural metastasis of gastric adenocarcinoma progressing rapidly with uncal herniation.

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