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imaging and pathological study. J Neurol 1998;245:116‑22. 7. Bastos AC, Andermann F, Melancon D, Cendes F, Guberman A, Dubeau F, et al. Late‑onset temporal lobe epilepsy and dilatation of the hippocampal sulcus by an enlarged Virchow‑Robin space. Neurology 1998;50:784‑7.
abuse[5] and vasculopathies.[5,6] The surgical bed and the immediately surrounding areas are most often the site of this complication. However, there can be intracranial bleed away from the operative site “remote site bleed” following a neurosurgical procedure.
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Remote site bleed following removal of a space occupying lesion or drainage of cerebrospinal fluid (CSF) is a rare and dreaded complication. It carries significant morbidity and mortality. The location of remote site bleed can be epidural, subdural, or intracerebral [7,8] and can be supratentorial or infratentorial following a supratentorial or infratentorial surgery. van Gehuchten in 1937 described the first case of remote site bleed, a pontine hemorrhage secondary to a subtemporal decompression for a temporal lobe meningioma.[9] This report describes six patients with remote site bleed following a neurosurgical procedure and reviewed the published literature in this regard.
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137022
Received: 03‑06‑2014 Review completed: 10-06-2014 Accepted: 10‑06‑2014
Remote site intracranial hemorrhage: Our experience and review of literature Sir, Hemorrhage within the surgical bed frequently complicates a neurosurgical procedure. Postoperative hematoma in the absence of risk factors is reported to occur in about 0.6-1.4% of cases.[1,2] Known risk factors are coagulopathies and anticoagulant therapy,[3,4] alcohol
Remote site bleed is defined as intracranial bleed/hematoma at a site away from the primary surgery site. We retrospectively analyzed data of patients who underwent cranial neurosurgical procedure at our center. Six patients with remote site bleed in the post‑operative period were selected and their case records were reviewed [Table 1]. The demographic data, diagnoses, surgical procedure performed, cause of bleed, and final outcomes were reviewed. Patients with antecedent or postoperative coagulopathy were excluded from this study.
Table 1: Summary of our cases
Age/ Symptoms gender
Diagnosis
Procedure performed
Site of bleed
Type of bleed
Redo surgery
28 year/ Female
Headache, blurring of vision
Craniotomy and marsupialization
Supratentorial (Bilateral frontal)
EDH
50 year/ Female
Hearing loss, facial paresis, gait ataxia
Rt sylvian Fissure arachnoid cyst Lt vestibular schwannoma
Supratentorial (Diffuse)
SAH
20 year/ Male
Lt FTP acute subdural hematoma and underwent Lt FTP decompressive craniectomy, presented with skin flap bulge Hearing loss, facial paresis, gait ataxia
Lt FTP sudural hygroma
Lt RMSOC and tumor excision Intraoperative‑ Cerebellar bulge +, Ventriculostomy done Tapping of subdural fluid
Craniotomy and evacuation of hematoma VP shunt
Supratentorial (Diffuse)
Intraparenchymal None
3
Rt vestibular schwannoma
RtRMSOC and tumor excision
Supratentorial (Lt parieto‑temporal)
EDH
5
Cerebellar hematoma
MLSOC and evacuation of hematoma Lt frontal craniotomy and excision of tumor
Supratentorial (left fronto parieto temporal) Supratentorial (Rt frontal)
SDH
38 year/ Female 64 year/ Male 13 year/ Female
Sudden onset loss of consciousness GCS E2VtM4 Headache, blurring of vision
Lt lateral ventricular neurocytoma
EDH
Craniotomy and evacuation of hematoma Craniotomy and evacuation of hematoma Craniotomy and evacuation of hematoma
GOSat 6 months 5
4
4
5
GOS - Glasgow outcome score; EDH - Extradural hematoma; RMSOC - Retromastoid suboccipital craniotomy; SAH - Subarachnoid hemorrhage; FTP - Fronto‑ temporo‑parietal; MLSOC - Midline suboccipital craniotomy; SDH - Subdural hematoma; F - Female; M - Male
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Medline and Pubmed databases were searched for remote site bleed following cranial neurosurgery using key words like postoperative hematomas, remote hemorrhage, intracerebral hemorrhage, cerebellar hemorrhage, and supratentorial craniotomy, The search found 83 such patients. The data retrieved for analysis included: Indications for surgery, type of surgery done, site of remote bleed, interventions done, and outcomes.[12‑43]
of the patients varied from 6-83 years. Vascular etiology was the most common indication for surgery in the supratentorial lesions, whereas neoplastic etiology was the most common indication for surgery in infratentorial lesions. Site of bleed was supratentorial in 73% of patients with supratentorial surgeries, while all patients operated for infratentorial pathologies developed supratentorial bleed. Fifty percent of patients required operative intervention in the infratentorial group, whereas only 16% of the patients required operative
Case summaries of the six patients are provided in Table 1 and in the images [Figures 1-6]. The mean age of patients in this series was 35.5 years (range - 13-64 years) and male to female ratio was 1:2. Three patients each were operated for supratentorial and infratentorial pathology. Three patients were operated for tumors, and vestibular schwannoma was the primary pathology in two patients. All of the patients developed supratentorial bleed. Location of remote site bleed was extradural in 3 patients, and subarachnoid hemorrhage, subdural and intraparenchymal in one patient each. All but one patient had good outcome with Glasgow outcome score of 4 or 5. The data of the 89, 83 patients reported in the literature and six patients in this series is given in Tables 2-4. Age
a
b
Figure 3: (a) Non contrast CT axial section shows evidence of previous left sided decompressive craniectomy with subdural collection on the left side (b) Non contrast CT axial section shows presence of multiple intraparenchymal hematomas with subarachnoid and intraventricular haemorrhage
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b
c
d
Figure 2: (a) Contrast enhanced axial MRI shows left cerebellopontine angle acoustic neurinoma (b) Non contrast CT axial section shows evidence of left suboccipital craniectomy with evidence of subarachnoid hemorrhage and frontal region hematoma (c and d) 3-D reconstruction images of the digital subtraction angiography show no evidence of aneurysm or arteriovenous malformation
b
Figure 1: (a) T2 weighted MRI axial section shows large sylvian fissure arachnoid cyst present in the right side causing mass effect (b) Non contrast CT axial section shows bilateral frontal extradural hematoma with evidence of right temporal craniotomy
a
a
a
b
c Figure 4: (a) Contrast enhanced axial MRI shows left cerebellopontine angle acoustic neurinoma (b) Non contrast CT axial section shows left frontoparietal extradural hematoma (c) Non contrast CT axial section after evacuation of hematoma
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intervention in the supratentorial group. Outcome was worse in the patients operated for infratentorial group (44% patients died) as compared to supratentorial group (21% patient died).
hemostasis. [16] Compared to them intracerebral haemorrhage occurring “remote” from the site of craniotomy is a rare neurosurgical complication and can
We observed that mortality in patients where intervention was needed (47%) was higher in comparison to patients managed conservatively (10.7%). This might be because of larger size of hematomas and poor neurological condition of the patients who underwent some sort of intervention. Postoperative surgical site hematomas can be a life threatening complication in neurosurgery and are commonly due to inadequate intraoperative
a
a
b
c
b Figure 5: (a) Non contrast CT axial sectionshows right cerebellar hematoma (b) Non contrast CT axial section shows left frontoparietal acute subdural hematoma
Figure 6: (a) Contrast enhanced axial MRI shows left lateral ventricular neurocytoma with hydrocephalous (b) Non contrast CT axial section shows right frontal extradural hematoma (c) Non contrast CT axial section after evacuation of hematoma
Table 2: Summary of remote site bleed patients operated for infratentorial pathologies in literature
Author (year), age/sex Haines (1978)[27] 65/F Haines (1978)[27] 41/F Haines (1978)[27] 55/F Haines (1978),[27] 64/F Haines (1978)[27], 62/F Kobayashi (1983)[28] Standefer (1984),[29] 55/M Standefer (1984),[29] 59/F Harders (1985),[30] 44/F Harders (1985),[30] 51/F Harders (1985),[30] 58/M Harders (1985),[30] 72/M Harders (1985),[30] 32/F Seiler (1986),[21] 66/F Seiler (1986),[21] 64/F Seiler (1986),[21] 59/F Kalfas (1988) 14 patients Ciric (1996)[31] Konig (1997),[15] 37/M Tandon (2004)[23] Tandon (2004)[23] Borkar (2013),[32] 6/F Present series, 50/F Present series, 64/M Present series, 38/F
Neuralgia Neuralgia Neuralgia Neuralgia Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Vascular Tumor Tumor Tumor Tumor Miscellaneous Tumor
Lesion
Site of bleed
Management
Outcome
Tic douloreux Tic douloreux IX nerve neuralgia Anesthesia dolorosa Acoustic schwannoma Acoustic schwannoma Parotid cancer Post fossa meningioma Post fossa meningioma Acoustic schwannoma Post fossa meningioma Cerebellar metastases Acoustic schwannoma Acoustic schwannoma Post fossa meningioma Acoustic schwannoma Post fossa tumor Acoustic neuroma Rtocc AVM Acoustic Neuroma Brainstem glioma Post fossa tumor Acoustic Neuroma Cerebellar Hematoma Acoustic Neuroma
ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Intraventricular ST/Brainstem ST, IT/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/SDH ST/EDH ST/Parenchymal ST/Parenchymal ST/Parenchymal ST ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/EDH ST/SAH ST/SDH ST/EDH
Evacuation Conservative ND Evacuation VD Conservative ND ND Conservative Conservative Conservative Evacuation Evacuation Conservative Evacuation Evacuation ND ‑ ND Conservative Evacuated Conservative VP shunt Evacuated Evacuated
Fair Fair Died Fair Died Fair Died Died Died Poor Fair Poor Died Poor Died Poor ND ND Died Died Died Good GOS 4 GOS 4 GOS 5
ST - Supratentorial; IT - Infratentorial; SDH - Subdural hematoma; EDH - Extradural hematoma; SAH - Subarachnoid hemmorhage; VD - Ventricular decompression; VP - Ventriculoperitoneal; Rt - Right; AVM - Arteriovenous malformation; GOS - Glasgow outcome score; ND - Not described
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Table 3: Summary of remote side bleed patients operated for supratentorial pathologies in literature
Author (year), age/ gender Yasargil (1977)[33] Yasargil (1977)[33] Heros (1980)[34] Heros (1980)[34] Modesti (1982)[35], 14/M Waga (1983),[36] 42/M Waga (1983)[36] Waga (1983)[36] Waga (1983)[36] Miyamoto (1985),[37] 56/M Konig (1987),[15] 56/M Konig (1987),[15] 54/F Konig (1987),[15] 42/F Konig (1987),[15] 59/F Kalfas (1988)[1] Yoshida (1990),[38] 54/M Yoshida (1990),[38] 43/M Yoshida (1990),[38] 59/M Van Calenberg (1993)[39], 50/M Van Calenberg (1993)[39], 58/M Brisman (1996),[40] 55/M Brisman (1996),[40] 24/F Brisman (1996),[40] 73/M Papanstassiou (1996)[12], 53/M Papanstassiou (1996)[12], 49/M Papanstassiou (1996),[12] 47/F Papanstassiou (1996)[12], 55/M Papanstassiou (1996)[12], 54/F Ciric (1996)[31] Toczek (1996),[25] 29/M Toczek (1996),[25] 52/M Toczek (1996),[25] 38/M Toczek (1996),[25] 17/M Konig (1997),[15] 37/M Konig (1997),[15] 40/F Rapana (1997),[13] 63/F Kaplan (1999),[41] 83/F Koller (1999),69/M Koller (1999)[42], 59/M Koller (1999), 72/M Yacubian (1999),[26] 29/M Yacubian (1999),[26] 10/M Yacubian (1999)[26] van Roost (1999)[43] van Roost (1999)[43] Tomii (1999)[44] Tomii (1999),[44] 34/F Tomii (1999),[44] 51/F Marquardt (2002),[17] 31/M Marquardt (2002),[17] 42/M Marquardt (2002),[17] 60/M
Lesion Site of Management Outcome bleed V V V V M V M V V T T V T T V V V V V
IT IT IT IT ST IT ST ST ST ST ST ST ST ST ST IT ST ST ST, IT
ND ND ND ND VD Conservative ‑ ‑ ‑ ND Conservative VD VD VD ‑ VD Conservative VD VD
Died Died Died Died Died Fair Died Poor ND ND Died Fair Dead Fair ND Fair Fair Poor Fair
T
ST
Conservative
Good
V T T V
ST, IT IT ST ST
VD, Evacuation Conservative Conservative Evacuation
Died Good Good Died
V
ST, IT
VD
Fair
V
ST, IT
VD
Fair
V
ST
VD, Evacuation Good
T
ST
VD, Evacuation Poor
T E E E E V V T M V M M E E E E E T V V T
ST ST ST, IT ST ST ST ST ST ST ST ST ST ST, IT ST ST IT IT ST ST ST ST
ND Conservative Conservative VD Conservative ND VD Evacuation VD Evacuation VD VD, Evacuation Conservative Conservative Conservative ND ND Conservative Conservative Conservative VD, Evacuation
ND Good Good Good Good Dead Good Dead Dead Dead Good Dead Good Good Good Good Good Good Good Fair Fair
T
ST
Conservative
Good
M
ST
VD, Evacuation Poor
Contd... 332
Table 3: Contd....
Author (year), age/ gender Marquardt (2002),[17] 73/M Marquardt (2002),[17] 49/M Marquardt (2002),[17] 44/M Marquardt (2002),[17] 51/M Marquardt (2002),[17] 51/F Marquardt (2002),[17] 51/F Borkar (2013),[32] 18/M Borkar (2013),[32] 19/M Borkar (2013),[32] 50/F Borkar (2013),[32] 50/M Present series, 28/F Present series, 20/M Present series, 13/F
Lesion Site of Management Outcome bleed T
ST, IT
Conservative
Poor
V
ST
Conservative
Good
T
ST
VD
Fair
T
ST
VD
Dead
T T T T M TR M M T
ST ST ST ST ST IT ST ST ST
VD Conservative Evacuation Evacuation Evacuation VD Evacuation Conservative Evacuation
Good Good Good Good Good Died GOS 5 GOS 3 GOS 5
V - Vascular; T - Tumor; E - Epilepsy; TR - Trauma; M - Miscellaneous; ST - Supratentorial; IT - Infratentorial; VD - Ventricular decompression; GOS - Glasgow coma score; ND - Not described; F - Female; M - Male
Table 4: Comparison of patients in two groups
Variable Total no of patients Age range Gender Male Female Etiology Tumors Vascular Epilepsy Miscellaneous Neuralgia Site of bleed Supratentorial Infratentorial Both Intervention Conservative Evacuation Ventricular drainage Evacuation+ V entricular drainage Outcome Good Fair Poor Died Died with conservative management Died with evacuation
Supratentorial Infratentorial P value surgery surgery 64 10-83 years
25 6-72 years
69% (n=36) 31% (n=16)
21% (n=4) 79% (n=15)
33% (n=21) 37% (n=24) 14% (n=9) 16% (n=10) ‑
90% (n=19) 5% (n=1) ‑ 5% (n=1) 4
73% (n=47) 16% (n=10) 11% (n=7)
25 (100%) 0 0
39% (n=20) 16% (n=8) 33% (n=17) 12% (n=6)
44% (n=8) 50% (n=9) 6% (n=1) ‑
47% (n=25) 23% (n=12) 9% (n=5) 21% (n=11) 5% (1/20)
17% (n=4) 22% (n=5) 17% (n=4) 44% (n=10) 25% (2/8)
60% (5/8)
33% (3/9)
0.72
0.63
0.82
lead to significant morbidity and mortality.[1,3] Different mechanisms have been proposed to explain such a rare occurrence. The only common implicating factor among the 89 patients reviewed was sudden decompression in Neurology India | May-Jun 2014 | Vol 62 | Issue 3
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case of chronically elevated intracranial pressure (ICP). The other possible factors for postoperative remote site bleed are coagulation disorders and hypertension. However, only one patient in our series had hypertension. Transient hypertensive peaks during the recovery from anesthesia have in the past been considered as an important risk factor. More recently, this theory has been partly refuted as only some patients had documented high (200 mmHg) blood pressure levels in the perioperative period.[17] Some authors [16,18,19] consider that aggressive intraoperative dehydration andCSF removal together with acute obstruction of the venous outflow, can cause brain shift that contributes to intracerebral hemorrhage. It is also hypothesized that the tissue thromboplastin released from the injured brain tissue in severe traumatic brain injury (TBI) leads to a local consumptive coagulopathy.[2] The same can happen due to extensive blood loss during surgery and transfusion reactions. The loss of substantial CSF volume during surgery appears to play a central role in the pathophysiological development of remote site hematoma. Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure with subsequent rupture of veins.[19,20] Substantial loss of CSF leads to sagging of the cerebellum away from the tentorium and thus stretching of the cerebellar veins with an increase in the transmural pressure[21] or it may be due to jugular vein compression by the transverse process of atlas in extended neck position.[22] Cerebellar “sag” as a result of CSF hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, has also been proposed to be the most likely pathophysiological cause of remote cerebellar hematoma. [23] Pin site extradural hematoma (EDH) is a also a known etiology for remote site bleed.[24] In our first patient, who developed bilateral extradural hemorrhage, it is quite probable that sudden decompression of the long standing arachnoid cyst and subsequent volume loss could have led to stripping of the dura on either side leading to extradural hematoma. Patient during the first surgery was not positioned using three pin or Mayfield clamp therefore pinsite hematoma was ruled out. It is difficult to predict the cause of such diffuse subarachnoid hemorrhage in our second patient following posterior fossa surgery but probable mechanism can be due to sudden changes in the intracranial dynamics in the sitting position or due to rapid tapering of cerebrospinal fluid pressure after Neurology India | May-Jun 2014 | Vol 62 | Issue 3
long standing hydrocephalous may cause disruption of subcortical veins or even capillaries. [10‑14] The possibility of coexisting aneurysm or arteriovenous malformations was ruled out by digital subtraction angiography (DSA). In our third case with multiple intraparenchymal hematomas following subdural tap, we believe that due to sudden removal of the CSF and subsequent intracranial hypotension a critical increase in the transluminal pressure of the veins or venules can result in tearing of these vessels.[13,15] In our fourth case, it is difficult to ascertain the cause of extradural hematoma. One possible cause can be sudden change in the intracranial dynamics due to rapid tapering of cerebrospinal fluid pressure. Other plausible cause can be pin site hematoma as Mayfield clamp was used in this patient. Similar mechanisms can be at play in the rest of the two patients. Various other major causes of remote site bleed cited in literature are intraoperative rotation or extension of the head,[13,15,18] arterial hypertension and disturbance of coagulation profile due to use of heparin[21] or valproic acid.[25,26] We routinely perform CT scan of our post‑operative patients after 4 hours of cranial surgery. Therefore, it is difficult to predict that whether these bleeds occurred in the early postoperative period or occurred intraoperatively. One retrospective study on cerebellar hemorrhages after supratentorial surgery had reported these to be a postoperative event rather than an intraoperative one.[15] We strongly advocate screening of all major neurosurgical cases for coagulation, bleeding diathesis and hypertension. While positioning undue neck compression should be avoided to prevent intracranial venous hypertension. Mayfield or three pin fixation needs to be carefully done to prevent breach of inner cortex of skull. During surgery, whenever possible, sudden decompression of brain should be avoided. Cases where massive blood loss is expected, use of preoperative embolization, intraprocedural use of cell saver and even staging of the procedure is warranted to prevent consumptive coagulopathy. In case of sudden rise of ICP or brain becoming tense during surgery in a otherwise relaxed brain, an immediate postoperative CT scan is warranted to rule out remote site bleed. We perform early postoperative scan in all our cases at about 4 hours after surgery. Clinicians need to keep a high index of suspicion to diagnose this fatal complication at an early stage. In a patient with delayed reversal and
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deteriorating Glasgow comma scale (GCS) after surgery, CT is performed at the earliest to rule out this cause. Wide fluctuations in the blood pressure in the operative and postoperative periods should be avoided. In patients with remote site bleed, workup of complete coagulation profile before surgical intervention is highly warranted, Decision to evacuate remote site hematoma should be tailored based on clinical, radiological, and coagulation profile. In patients with deranged coagulation profile, appropriate corrections should be done before any surgical intervention. External ventricular drain or twist drill may be the options in patients who are likely to deteriorate due to abnormal coagulation profile.
Kanwaljeet Garg, Vivek Tandon, Sumit Sinha, Ashish Suri, Ashok Kumar Mahapatra1, Bhawani Shankar Sharma Departments of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 1All India Institute of Medical Sciences, Bhubneshwar, Odisha, India E‑mail: [email protected]
16. 17. 18. 19. 20. 21. 22. 23. 24.
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137027
Received: 31‑01‑2014 Review completed: 04‑03‑2014 Accepted: 02‑06‑2014
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imaging and pathological study. J Neurol 1998;245:116‑22. 7. Bastos AC, Andermann F, Melancon D, Cendes F, Guberman A, Dubeau F, et al. Late‑onset temporal lobe epilepsy and dilatation of the hippocampal sulcus by an enlarged Virchow‑Robin space. Neurology 1998;50:784‑7.
abuse[5] and vasculopathies.[5,6] The surgical bed and the immediately surrounding areas are most often the site of this complication. However, there can be intracranial bleed away from the operative site “remote site bleed” following a neurosurgical procedure.
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Remote site bleed following removal of a space occupying lesion or drainage of cerebrospinal fluid (CSF) is a rare and dreaded complication. It carries significant morbidity and mortality. The location of remote site bleed can be epidural, subdural, or intracerebral [7,8] and can be supratentorial or infratentorial following a supratentorial or infratentorial surgery. van Gehuchten in 1937 described the first case of remote site bleed, a pontine hemorrhage secondary to a subtemporal decompression for a temporal lobe meningioma.[9] This report describes six patients with remote site bleed following a neurosurgical procedure and reviewed the published literature in this regard.
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Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137022
Received: 03‑06‑2014 Review completed: 10-06-2014 Accepted: 10‑06‑2014
Remote site intracranial hemorrhage: Our experience and review of literature Sir, Hemorrhage within the surgical bed frequently complicates a neurosurgical procedure. Postoperative hematoma in the absence of risk factors is reported to occur in about 0.6-1.4% of cases.[1,2] Known risk factors are coagulopathies and anticoagulant therapy,[3,4] alcohol
Remote site bleed is defined as intracranial bleed/hematoma at a site away from the primary surgery site. We retrospectively analyzed data of patients who underwent cranial neurosurgical procedure at our center. Six patients with remote site bleed in the post‑operative period were selected and their case records were reviewed [Table 1]. The demographic data, diagnoses, surgical procedure performed, cause of bleed, and final outcomes were reviewed. Patients with antecedent or postoperative coagulopathy were excluded from this study.
Table 1: Summary of our cases
Age/ Symptoms gender
Diagnosis
Procedure performed
Site of bleed
Type of bleed
Redo surgery
28 year/ Female
Headache, blurring of vision
Craniotomy and marsupialization
Supratentorial (Bilateral frontal)
EDH
50 year/ Female
Hearing loss, facial paresis, gait ataxia
Rt sylvian Fissure arachnoid cyst Lt vestibular schwannoma
Supratentorial (Diffuse)
SAH
20 year/ Male
Lt FTP acute subdural hematoma and underwent Lt FTP decompressive craniectomy, presented with skin flap bulge Hearing loss, facial paresis, gait ataxia
Lt FTP sudural hygroma
Lt RMSOC and tumor excision Intraoperative‑ Cerebellar bulge +, Ventriculostomy done Tapping of subdural fluid
Craniotomy and evacuation of hematoma VP shunt
Supratentorial (Diffuse)
Intraparenchymal None
3
Rt vestibular schwannoma
RtRMSOC and tumor excision
Supratentorial (Lt parieto‑temporal)
EDH
5
Cerebellar hematoma
MLSOC and evacuation of hematoma Lt frontal craniotomy and excision of tumor
Supratentorial (left fronto parieto temporal) Supratentorial (Rt frontal)
SDH
38 year/ Female 64 year/ Male 13 year/ Female
Sudden onset loss of consciousness GCS E2VtM4 Headache, blurring of vision
Lt lateral ventricular neurocytoma
EDH
Craniotomy and evacuation of hematoma Craniotomy and evacuation of hematoma Craniotomy and evacuation of hematoma
GOSat 6 months 5
4
4
5
GOS - Glasgow outcome score; EDH - Extradural hematoma; RMSOC - Retromastoid suboccipital craniotomy; SAH - Subarachnoid hemorrhage; FTP - Fronto‑ temporo‑parietal; MLSOC - Midline suboccipital craniotomy; SDH - Subdural hematoma; F - Female; M - Male
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Medline and Pubmed databases were searched for remote site bleed following cranial neurosurgery using key words like postoperative hematomas, remote hemorrhage, intracerebral hemorrhage, cerebellar hemorrhage, and supratentorial craniotomy, The search found 83 such patients. The data retrieved for analysis included: Indications for surgery, type of surgery done, site of remote bleed, interventions done, and outcomes.[12‑43]
of the patients varied from 6-83 years. Vascular etiology was the most common indication for surgery in the supratentorial lesions, whereas neoplastic etiology was the most common indication for surgery in infratentorial lesions. Site of bleed was supratentorial in 73% of patients with supratentorial surgeries, while all patients operated for infratentorial pathologies developed supratentorial bleed. Fifty percent of patients required operative intervention in the infratentorial group, whereas only 16% of the patients required operative
Case summaries of the six patients are provided in Table 1 and in the images [Figures 1-6]. The mean age of patients in this series was 35.5 years (range - 13-64 years) and male to female ratio was 1:2. Three patients each were operated for supratentorial and infratentorial pathology. Three patients were operated for tumors, and vestibular schwannoma was the primary pathology in two patients. All of the patients developed supratentorial bleed. Location of remote site bleed was extradural in 3 patients, and subarachnoid hemorrhage, subdural and intraparenchymal in one patient each. All but one patient had good outcome with Glasgow outcome score of 4 or 5. The data of the 89, 83 patients reported in the literature and six patients in this series is given in Tables 2-4. Age
a
b
Figure 3: (a) Non contrast CT axial section shows evidence of previous left sided decompressive craniectomy with subdural collection on the left side (b) Non contrast CT axial section shows presence of multiple intraparenchymal hematomas with subarachnoid and intraventricular haemorrhage
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b
c
d
Figure 2: (a) Contrast enhanced axial MRI shows left cerebellopontine angle acoustic neurinoma (b) Non contrast CT axial section shows evidence of left suboccipital craniectomy with evidence of subarachnoid hemorrhage and frontal region hematoma (c and d) 3-D reconstruction images of the digital subtraction angiography show no evidence of aneurysm or arteriovenous malformation
b
Figure 1: (a) T2 weighted MRI axial section shows large sylvian fissure arachnoid cyst present in the right side causing mass effect (b) Non contrast CT axial section shows bilateral frontal extradural hematoma with evidence of right temporal craniotomy
a
a
a
b
c Figure 4: (a) Contrast enhanced axial MRI shows left cerebellopontine angle acoustic neurinoma (b) Non contrast CT axial section shows left frontoparietal extradural hematoma (c) Non contrast CT axial section after evacuation of hematoma
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intervention in the supratentorial group. Outcome was worse in the patients operated for infratentorial group (44% patients died) as compared to supratentorial group (21% patient died).
hemostasis. [16] Compared to them intracerebral haemorrhage occurring “remote” from the site of craniotomy is a rare neurosurgical complication and can
We observed that mortality in patients where intervention was needed (47%) was higher in comparison to patients managed conservatively (10.7%). This might be because of larger size of hematomas and poor neurological condition of the patients who underwent some sort of intervention. Postoperative surgical site hematomas can be a life threatening complication in neurosurgery and are commonly due to inadequate intraoperative
a
a
b
c
b Figure 5: (a) Non contrast CT axial sectionshows right cerebellar hematoma (b) Non contrast CT axial section shows left frontoparietal acute subdural hematoma
Figure 6: (a) Contrast enhanced axial MRI shows left lateral ventricular neurocytoma with hydrocephalous (b) Non contrast CT axial section shows right frontal extradural hematoma (c) Non contrast CT axial section after evacuation of hematoma
Table 2: Summary of remote site bleed patients operated for infratentorial pathologies in literature
Author (year), age/sex Haines (1978)[27] 65/F Haines (1978)[27] 41/F Haines (1978)[27] 55/F Haines (1978),[27] 64/F Haines (1978)[27], 62/F Kobayashi (1983)[28] Standefer (1984),[29] 55/M Standefer (1984),[29] 59/F Harders (1985),[30] 44/F Harders (1985),[30] 51/F Harders (1985),[30] 58/M Harders (1985),[30] 72/M Harders (1985),[30] 32/F Seiler (1986),[21] 66/F Seiler (1986),[21] 64/F Seiler (1986),[21] 59/F Kalfas (1988) 14 patients Ciric (1996)[31] Konig (1997),[15] 37/M Tandon (2004)[23] Tandon (2004)[23] Borkar (2013),[32] 6/F Present series, 50/F Present series, 64/M Present series, 38/F
Neuralgia Neuralgia Neuralgia Neuralgia Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Tumor Vascular Tumor Tumor Tumor Tumor Miscellaneous Tumor
Lesion
Site of bleed
Management
Outcome
Tic douloreux Tic douloreux IX nerve neuralgia Anesthesia dolorosa Acoustic schwannoma Acoustic schwannoma Parotid cancer Post fossa meningioma Post fossa meningioma Acoustic schwannoma Post fossa meningioma Cerebellar metastases Acoustic schwannoma Acoustic schwannoma Post fossa meningioma Acoustic schwannoma Post fossa tumor Acoustic neuroma Rtocc AVM Acoustic Neuroma Brainstem glioma Post fossa tumor Acoustic Neuroma Cerebellar Hematoma Acoustic Neuroma
ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Intraventricular ST/Brainstem ST, IT/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/SDH ST/EDH ST/Parenchymal ST/Parenchymal ST/Parenchymal ST ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/Parenchymal ST/EDH ST/SAH ST/SDH ST/EDH
Evacuation Conservative ND Evacuation VD Conservative ND ND Conservative Conservative Conservative Evacuation Evacuation Conservative Evacuation Evacuation ND ‑ ND Conservative Evacuated Conservative VP shunt Evacuated Evacuated
Fair Fair Died Fair Died Fair Died Died Died Poor Fair Poor Died Poor Died Poor ND ND Died Died Died Good GOS 4 GOS 4 GOS 5
ST - Supratentorial; IT - Infratentorial; SDH - Subdural hematoma; EDH - Extradural hematoma; SAH - Subarachnoid hemmorhage; VD - Ventricular decompression; VP - Ventriculoperitoneal; Rt - Right; AVM - Arteriovenous malformation; GOS - Glasgow outcome score; ND - Not described
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Table 3: Summary of remote side bleed patients operated for supratentorial pathologies in literature
Author (year), age/ gender Yasargil (1977)[33] Yasargil (1977)[33] Heros (1980)[34] Heros (1980)[34] Modesti (1982)[35], 14/M Waga (1983),[36] 42/M Waga (1983)[36] Waga (1983)[36] Waga (1983)[36] Miyamoto (1985),[37] 56/M Konig (1987),[15] 56/M Konig (1987),[15] 54/F Konig (1987),[15] 42/F Konig (1987),[15] 59/F Kalfas (1988)[1] Yoshida (1990),[38] 54/M Yoshida (1990),[38] 43/M Yoshida (1990),[38] 59/M Van Calenberg (1993)[39], 50/M Van Calenberg (1993)[39], 58/M Brisman (1996),[40] 55/M Brisman (1996),[40] 24/F Brisman (1996),[40] 73/M Papanstassiou (1996)[12], 53/M Papanstassiou (1996)[12], 49/M Papanstassiou (1996),[12] 47/F Papanstassiou (1996)[12], 55/M Papanstassiou (1996)[12], 54/F Ciric (1996)[31] Toczek (1996),[25] 29/M Toczek (1996),[25] 52/M Toczek (1996),[25] 38/M Toczek (1996),[25] 17/M Konig (1997),[15] 37/M Konig (1997),[15] 40/F Rapana (1997),[13] 63/F Kaplan (1999),[41] 83/F Koller (1999),69/M Koller (1999)[42], 59/M Koller (1999), 72/M Yacubian (1999),[26] 29/M Yacubian (1999),[26] 10/M Yacubian (1999)[26] van Roost (1999)[43] van Roost (1999)[43] Tomii (1999)[44] Tomii (1999),[44] 34/F Tomii (1999),[44] 51/F Marquardt (2002),[17] 31/M Marquardt (2002),[17] 42/M Marquardt (2002),[17] 60/M
Lesion Site of Management Outcome bleed V V V V M V M V V T T V T T V V V V V
IT IT IT IT ST IT ST ST ST ST ST ST ST ST ST IT ST ST ST, IT
ND ND ND ND VD Conservative ‑ ‑ ‑ ND Conservative VD VD VD ‑ VD Conservative VD VD
Died Died Died Died Died Fair Died Poor ND ND Died Fair Dead Fair ND Fair Fair Poor Fair
T
ST
Conservative
Good
V T T V
ST, IT IT ST ST
VD, Evacuation Conservative Conservative Evacuation
Died Good Good Died
V
ST, IT
VD
Fair
V
ST, IT
VD
Fair
V
ST
VD, Evacuation Good
T
ST
VD, Evacuation Poor
T E E E E V V T M V M M E E E E E T V V T
ST ST ST, IT ST ST ST ST ST ST ST ST ST ST, IT ST ST IT IT ST ST ST ST
ND Conservative Conservative VD Conservative ND VD Evacuation VD Evacuation VD VD, Evacuation Conservative Conservative Conservative ND ND Conservative Conservative Conservative VD, Evacuation
ND Good Good Good Good Dead Good Dead Dead Dead Good Dead Good Good Good Good Good Good Good Fair Fair
T
ST
Conservative
Good
M
ST
VD, Evacuation Poor
Contd... 332
Table 3: Contd....
Author (year), age/ gender Marquardt (2002),[17] 73/M Marquardt (2002),[17] 49/M Marquardt (2002),[17] 44/M Marquardt (2002),[17] 51/M Marquardt (2002),[17] 51/F Marquardt (2002),[17] 51/F Borkar (2013),[32] 18/M Borkar (2013),[32] 19/M Borkar (2013),[32] 50/F Borkar (2013),[32] 50/M Present series, 28/F Present series, 20/M Present series, 13/F
Lesion Site of Management Outcome bleed T
ST, IT
Conservative
Poor
V
ST
Conservative
Good
T
ST
VD
Fair
T
ST
VD
Dead
T T T T M TR M M T
ST ST ST ST ST IT ST ST ST
VD Conservative Evacuation Evacuation Evacuation VD Evacuation Conservative Evacuation
Good Good Good Good Good Died GOS 5 GOS 3 GOS 5
V - Vascular; T - Tumor; E - Epilepsy; TR - Trauma; M - Miscellaneous; ST - Supratentorial; IT - Infratentorial; VD - Ventricular decompression; GOS - Glasgow coma score; ND - Not described; F - Female; M - Male
Table 4: Comparison of patients in two groups
Variable Total no of patients Age range Gender Male Female Etiology Tumors Vascular Epilepsy Miscellaneous Neuralgia Site of bleed Supratentorial Infratentorial Both Intervention Conservative Evacuation Ventricular drainage Evacuation+ V entricular drainage Outcome Good Fair Poor Died Died with conservative management Died with evacuation
Supratentorial Infratentorial P value surgery surgery 64 10-83 years
25 6-72 years
69% (n=36) 31% (n=16)
21% (n=4) 79% (n=15)
33% (n=21) 37% (n=24) 14% (n=9) 16% (n=10) ‑
90% (n=19) 5% (n=1) ‑ 5% (n=1) 4
73% (n=47) 16% (n=10) 11% (n=7)
25 (100%) 0 0
39% (n=20) 16% (n=8) 33% (n=17) 12% (n=6)
44% (n=8) 50% (n=9) 6% (n=1) ‑
47% (n=25) 23% (n=12) 9% (n=5) 21% (n=11) 5% (1/20)
17% (n=4) 22% (n=5) 17% (n=4) 44% (n=10) 25% (2/8)
60% (5/8)
33% (3/9)
0.72
0.63
0.82
lead to significant morbidity and mortality.[1,3] Different mechanisms have been proposed to explain such a rare occurrence. The only common implicating factor among the 89 patients reviewed was sudden decompression in Neurology India | May-Jun 2014 | Vol 62 | Issue 3
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case of chronically elevated intracranial pressure (ICP). The other possible factors for postoperative remote site bleed are coagulation disorders and hypertension. However, only one patient in our series had hypertension. Transient hypertensive peaks during the recovery from anesthesia have in the past been considered as an important risk factor. More recently, this theory has been partly refuted as only some patients had documented high (200 mmHg) blood pressure levels in the perioperative period.[17] Some authors [16,18,19] consider that aggressive intraoperative dehydration andCSF removal together with acute obstruction of the venous outflow, can cause brain shift that contributes to intracerebral hemorrhage. It is also hypothesized that the tissue thromboplastin released from the injured brain tissue in severe traumatic brain injury (TBI) leads to a local consumptive coagulopathy.[2] The same can happen due to extensive blood loss during surgery and transfusion reactions. The loss of substantial CSF volume during surgery appears to play a central role in the pathophysiological development of remote site hematoma. Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure with subsequent rupture of veins.[19,20] Substantial loss of CSF leads to sagging of the cerebellum away from the tentorium and thus stretching of the cerebellar veins with an increase in the transmural pressure[21] or it may be due to jugular vein compression by the transverse process of atlas in extended neck position.[22] Cerebellar “sag” as a result of CSF hypovolemia, causing transient occlusion of superior bridging veins within the posterior fossa and consequent hemorrhagic venous infarction, has also been proposed to be the most likely pathophysiological cause of remote cerebellar hematoma. [23] Pin site extradural hematoma (EDH) is a also a known etiology for remote site bleed.[24] In our first patient, who developed bilateral extradural hemorrhage, it is quite probable that sudden decompression of the long standing arachnoid cyst and subsequent volume loss could have led to stripping of the dura on either side leading to extradural hematoma. Patient during the first surgery was not positioned using three pin or Mayfield clamp therefore pinsite hematoma was ruled out. It is difficult to predict the cause of such diffuse subarachnoid hemorrhage in our second patient following posterior fossa surgery but probable mechanism can be due to sudden changes in the intracranial dynamics in the sitting position or due to rapid tapering of cerebrospinal fluid pressure after Neurology India | May-Jun 2014 | Vol 62 | Issue 3
long standing hydrocephalous may cause disruption of subcortical veins or even capillaries. [10‑14] The possibility of coexisting aneurysm or arteriovenous malformations was ruled out by digital subtraction angiography (DSA). In our third case with multiple intraparenchymal hematomas following subdural tap, we believe that due to sudden removal of the CSF and subsequent intracranial hypotension a critical increase in the transluminal pressure of the veins or venules can result in tearing of these vessels.[13,15] In our fourth case, it is difficult to ascertain the cause of extradural hematoma. One possible cause can be sudden change in the intracranial dynamics due to rapid tapering of cerebrospinal fluid pressure. Other plausible cause can be pin site hematoma as Mayfield clamp was used in this patient. Similar mechanisms can be at play in the rest of the two patients. Various other major causes of remote site bleed cited in literature are intraoperative rotation or extension of the head,[13,15,18] arterial hypertension and disturbance of coagulation profile due to use of heparin[21] or valproic acid.[25,26] We routinely perform CT scan of our post‑operative patients after 4 hours of cranial surgery. Therefore, it is difficult to predict that whether these bleeds occurred in the early postoperative period or occurred intraoperatively. One retrospective study on cerebellar hemorrhages after supratentorial surgery had reported these to be a postoperative event rather than an intraoperative one.[15] We strongly advocate screening of all major neurosurgical cases for coagulation, bleeding diathesis and hypertension. While positioning undue neck compression should be avoided to prevent intracranial venous hypertension. Mayfield or three pin fixation needs to be carefully done to prevent breach of inner cortex of skull. During surgery, whenever possible, sudden decompression of brain should be avoided. Cases where massive blood loss is expected, use of preoperative embolization, intraprocedural use of cell saver and even staging of the procedure is warranted to prevent consumptive coagulopathy. In case of sudden rise of ICP or brain becoming tense during surgery in a otherwise relaxed brain, an immediate postoperative CT scan is warranted to rule out remote site bleed. We perform early postoperative scan in all our cases at about 4 hours after surgery. Clinicians need to keep a high index of suspicion to diagnose this fatal complication at an early stage. In a patient with delayed reversal and
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deteriorating Glasgow comma scale (GCS) after surgery, CT is performed at the earliest to rule out this cause. Wide fluctuations in the blood pressure in the operative and postoperative periods should be avoided. In patients with remote site bleed, workup of complete coagulation profile before surgical intervention is highly warranted, Decision to evacuate remote site hematoma should be tailored based on clinical, radiological, and coagulation profile. In patients with deranged coagulation profile, appropriate corrections should be done before any surgical intervention. External ventricular drain or twist drill may be the options in patients who are likely to deteriorate due to abnormal coagulation profile.
Kanwaljeet Garg, Vivek Tandon, Sumit Sinha, Ashish Suri, Ashok Kumar Mahapatra1, Bhawani Shankar Sharma Departments of Neurosurgery, All India Institute of Medical Sciences, New Delhi, 1All India Institute of Medical Sciences, Bhubneshwar, Odisha, India E‑mail: [email protected]
16. 17. 18. 19. 20. 21. 22. 23. 24.
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Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.137027
Received: 31‑01‑2014 Review completed: 04‑03‑2014 Accepted: 02‑06‑2014
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