Neurochirurge 19 (1976), 118-121 © Georg Thieme Verlag Stuttgart
Traumatic Intracerebral Haematoma: complication of skull caliper traction Case report B. Borovich, M.D., Y. Doron, M.D., E. Charbit, M.D., E. Peyser, M.D.
Summary Recently, a unique case8' of traumatic intracerebral haematoma complicating the insertion of skull calipers, has been observed. It is assumed it was due to: 1. the accidental penetration of the burr into the skull, while making the insertion hole for the caliper; 1. the failure to grip the skull with the special metal sleeve, the Blackburn skull caliper is provided with, so that the end plates were free to move in and out of the skull in this restless patient. The correct diagnosis was made only after severe uncal herniation had developed. The reasons for missing the correct diagnosis within useful time for proper treatment are considered to be: 1. carotid angiography performed too early in the process of haematoma formation: 2. the vascular displacements were only slight and not fully diagnostic; 3. a recognized complication, extradural haematoma, had already been excluded. Key-words: fracture dislocation of the cerebral spine - skeletal traction - intracerebral haematoma
Zusammenfassung Kürzlich wurde ein einmaliger Fall eines traumatischen intrazerebralen Hämatoms nach Anlegen eines Extensionsbügels am Schädel beobachtet. Es konnte gesichert werden, daß es zustande kam 1. durch die versehentliche Penetration des Bohrers in das Schädelinnere während des Anlegens des Bohrloches für den Bügel, 2. durch Weglassen des speziellen Metallschutzes, mit dem der Blackburn-Schädelbügel versehen ist, so daß bei der unruhigen Patientin die Enden sich frei im Schädel hin und her bewegen konnten. Die exakte Diagnose wurde erst gestellt, als sich eine Uncushernie entwickelt hatte. Die Gründe für die zu späte Diagnose sind: 1. Die CarotisAngiographie wurde zu früh während der Häma-
tomentwicklung durchgeführt. 2. die vaskulären Dislokationen waren nur sehr gering und nicht ausreichend diagnostisch zu verwerten, 3. eine mögliche Komplikation, ein extradurales Hämatom, war ausgeschlossen worden.
Insertion of skull calipers for t h e t r e a t m e n t of fracture dislocation of the cervical spine is considered a benign p r o c e d u r e . It is hardly associated w i t h any m o r b i d i t y o r mortality. Cranial a n d intracranial complications of the m e t h o d are m e n t i o n e d neither in the stand a r d t e x t b o o k s of n e u r o s u r g e r y (6, 15, 18), n o r in articles devoted t o the m a n a g e m e n t of t r a u m a t o the cervical spine (4, 7, 8, 10, 11). Infection constitutes t h e m a i n neurosurgical complication, m o s t l y osteitis at t h e insertion p o i n t (5, 17). Intracranial infection is very u n u s u a l (1, 9, 16, 17). Intracranial h a e m a t o m a is almost n o t mentioned a m o n g t h e complications. Hooper (12) found o n e case of e x t r a d u r a l h a e m a t o ma. Weisl (17) adds a similar case and a personal c o m m u n i c a t i o n from McCaul (14). Beckett a n d Gordon (1) stressed t h a t e x t r a d u r a l h a e m a t o m a is possible in c o n n e x i o n w i t h t h e * Charles G. Drake, J. Neurosurg. 19, 1962, p. 489 briefly mentions a patient who had this lesion, among three patients sent to his service with complications from the application of calipers. "However, the second had a penetrating brain wound with an intracerebral clot, and, in the third, the point had torn the middle meningeal artery . . . "
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Department of Neurosurgery and Department of Pathology, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel
119
J. M., a 45-year-old woman, was admitted to another hospital on July 13, 1975, after sustaining an injury while engaged in physical exercises. At the end of a turn on her head, she suddenly felt an intense pain in her neck. On examination at the nearest hospital, she was conscious and there was weakness of the right upper extremity and diminished sensation in the left one. X-rays of the cervical spine showed a fracture dislocation at the C3-C4 level. Skull traction with Blackburn's skull caliper was immediately instituted. The surgeon's notes revealed that while making the burr hole on the right side, the burr slipped and penetrated the cranial cavity. Shortly
afterwards the patient became progressively somnolent and at times restless. About six hours later she was transferred to our department. On admission she was drowsy, restless, but able to answer questions, and had a left hemiparesis. She vomited, the pulse rate was 64/minute, and the blood pressure was 150/80. An intracranial haematoma was suspected and an emergency carotid angiogram was done and interpreted as normal (Fig. 1 and 2). Supportive treatment was given and traction was continued. The patient's condition deteriorated gradually and a few hours later she suddenly developed bilateral fixed pupils and respiratory arrest. She expired 36 hours after admission. Post mortem examination: The temporal squama and theduramater were perforated on both sides by the end plates of the skull tongs. On the right side there were a small subdural haematoma of no surgical significance, a subarachnoid haemorrhage and blood in the Sylvian fissure. Also on the right side there was a small laceration of the cortex, at the level of the parietal operculum in the vicinity of the Sylvian vein, immediately under the perforated dura. The brain was swollen and bilateral uncal and amygdalar herniations were evident. During
Fig. 1
Fig. 1 and 2: Right carotid angiography a-p (1) and lateral (2) view.
Hoen method of skull traction but do not add cases. The possibility of intracerebral haematoma is not mentioned in the literature, although it is admitted that skull calipers may penetrate the brain (1, 9). Extensive reviews on traumatic intracerebral haematomas also fail to mention insertion of skull tongs among its causes (2, 3, 13).
Case Report
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Traumatic Intracerebral Haematoma
B. Borovich, Y. Doron, E. Cbarbit, E. Peyser
manipulation of the brain for photographic purposes, an intracerebral haematoma (35 gr. of blood clots), was squeezed out from the right parietal lobe (Fig. 3). Coronal sections of the brain revealed a right parietal haematoma and a Sylvian haemocistern communicating between them and with the lateral ventricle. The section at the level of the mamillary bodies showed a direct relationship between the laceration of the cortex under the end plate of the skull caliper and the intracerebral haematoma. Sections through the brain stem showed small haemorrhages and severe oedema. In the neck there was a fracture dislocation of C3 on the C4 vertebra and a few epidural clots; at the same level the cord was very soft and flattened in the antero-posterior direction. Discussion The end plate of skull calipers usually lies in the diploe, between the inner and outer
tables of the skull. If this position is kept throughout, the only dangers are the slipping out of the caliper and infection. When the extradural space is reached by accident or on purpose, as in the Hoen method of skull traction (1), or as some surgeons prefer with the Blackburn skull caliper (9), an extradural haematoma may be produced (1, 12, 14, 17). In the present case many things went wrong and made the development of an intracerebral haematoma possible. The first thing was the »losing of ground« of the surgeon during the making of the burr hole, which possibly went on to perforate the dura and damage the cortex in the vicinity of a big cortical vein (drowsiness started to appear shortly afterwards). The second mishap was the extradural positioning of the end plates coupled with the overseight to screw tight the special metal sleeve the Blackburn caliper is supplied with, so that the skull can be firmly gripped between this sleeve and the end plate. This
Fig. 3: Coronal sections of the brain with intracerebral haematoma.
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120
Traumatic Intracerebral Haematoma permitted free movement of the end plates in and out of the skull. It is thought that in this restless patient, this contributed to further damage to the cortex and its veins. Finally, the correct diagnosis was not made before a catastrophic uncal herniation appeared. The misleading factors were the slightness of the vascular displacements on arteriography and the exclusion of an extra-
121
dural hemorrhage. Had the carotid angiography not been made so early in the evolution of the haematoma, the displacements would have been more evident, and the diagnosis would have been made at a useful time. The fact that intracerebral haemorrhage was not known as a possible complication, may have played some part in missing the diagnosis.
1 Beckett Howorth, M., J. Gordon Pétrie: Injuries of the Spine. Baltimore, The Williams and Wilkins Co. (1964) 100-106 2 Borovich, B.: Hematomas Cerebrales Traumáticos. Monografía. Montevideo, Uruguay, 71 pp. Facultad de Medicina, 1968 3 Borovich, B.: Hematoma cerebral lobar traumático. Acta Neurol. Lat. Amer. 15 (1969) 214-223 4 Campbell's Operative Orthopedics, 4th ed., Vol. 1, p. 498-500. Ed. by A. H. Crensbau, S. Louis, The C. V. Mosby Co., 1963 5 Crutchfield, W. C: 1933, cited by Weisl, H. 6 Davis, L., R. A. Davis: Neurocirurgia. Mexico, Editorial Interamericana S.A. (1965) 386, 393-394 7 Guttmann, L.: Initial treatment of traumatic paraplegia and tetraplegia, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 80-92 8 Harris, P.: Some neurosurgical aspects of traumatic paraplegia, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 101-111 9 Harris, P., P. H. T. Wu: The management of patients with injuries of the cervical spine using Blackburn skull calipers and the Stryker turning frame. Paraplegia 4 (1965) 278-287 10 Holdsworth, F. W.: Early orthopedic treatment of pa-
11 12 13 14 15
16 17 18
tients with spinal injuries, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 93-100 Holdwortb, F. W.: Fractures, Dislocations, and fracturedislocations of the spine. J. of Bone and Joint Surg., (Amer.) (1970) 52-A, 1534-1551 Hooper, R.: Observations on extradural hemorrhages. British J. of Surg. 47 (1959) 71-87 Jamieson, K. G., J. D. N. Yelland: Traumatic intracerebral hematoma. Report of 63 surgically treated cases. J. of Neurosurg. 37 (1972) 528-532 McCaul, 1.: 1965, cited by Weist, H. Scarff, ]. E.: Injuries of the vertebral column and spina] cord, in Brock, S. (ed.), Injuries of the Brain and Spina! Cord, New York, Springer Publ. Co. Inc., 4th ed. (I960) 530-589 Victor, D. I., M. J. Brcsnan, R. B. Keller: Brain abscess complicating the use of Halo traction. J. of Bone and Joint Surg. (Amer.) 55-A (1973) 635-639 Weisl, H.: Unusual complications of skull caliper traction. J. of Bone and Joint Surg. (Amer.) 54-B (1972) 143-145 White, } . R., D. Yashon: General care of cervical spine injuries, skeletal traction, in Youmans, ]. R. (ed.), Neurological Surgery, Philadelphia, W. B. Saunders (1973) 1062
Dr. D. Borovich, Department of Neurosurgery and Department of Pathology, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel
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Keferences
Traumatic Intracerebral Haematoma: complication of skull caliper traction Case report B. Borovich, M.D., Y. Doron, M.D., E. Charbit, M.D., E. Peyser, M.D.
Summary Recently, a unique case8' of traumatic intracerebral haematoma complicating the insertion of skull calipers, has been observed. It is assumed it was due to: 1. the accidental penetration of the burr into the skull, while making the insertion hole for the caliper; 1. the failure to grip the skull with the special metal sleeve, the Blackburn skull caliper is provided with, so that the end plates were free to move in and out of the skull in this restless patient. The correct diagnosis was made only after severe uncal herniation had developed. The reasons for missing the correct diagnosis within useful time for proper treatment are considered to be: 1. carotid angiography performed too early in the process of haematoma formation: 2. the vascular displacements were only slight and not fully diagnostic; 3. a recognized complication, extradural haematoma, had already been excluded. Key-words: fracture dislocation of the cerebral spine - skeletal traction - intracerebral haematoma
Zusammenfassung Kürzlich wurde ein einmaliger Fall eines traumatischen intrazerebralen Hämatoms nach Anlegen eines Extensionsbügels am Schädel beobachtet. Es konnte gesichert werden, daß es zustande kam 1. durch die versehentliche Penetration des Bohrers in das Schädelinnere während des Anlegens des Bohrloches für den Bügel, 2. durch Weglassen des speziellen Metallschutzes, mit dem der Blackburn-Schädelbügel versehen ist, so daß bei der unruhigen Patientin die Enden sich frei im Schädel hin und her bewegen konnten. Die exakte Diagnose wurde erst gestellt, als sich eine Uncushernie entwickelt hatte. Die Gründe für die zu späte Diagnose sind: 1. Die CarotisAngiographie wurde zu früh während der Häma-
tomentwicklung durchgeführt. 2. die vaskulären Dislokationen waren nur sehr gering und nicht ausreichend diagnostisch zu verwerten, 3. eine mögliche Komplikation, ein extradurales Hämatom, war ausgeschlossen worden.
Insertion of skull calipers for t h e t r e a t m e n t of fracture dislocation of the cervical spine is considered a benign p r o c e d u r e . It is hardly associated w i t h any m o r b i d i t y o r mortality. Cranial a n d intracranial complications of the m e t h o d are m e n t i o n e d neither in the stand a r d t e x t b o o k s of n e u r o s u r g e r y (6, 15, 18), n o r in articles devoted t o the m a n a g e m e n t of t r a u m a t o the cervical spine (4, 7, 8, 10, 11). Infection constitutes t h e m a i n neurosurgical complication, m o s t l y osteitis at t h e insertion p o i n t (5, 17). Intracranial infection is very u n u s u a l (1, 9, 16, 17). Intracranial h a e m a t o m a is almost n o t mentioned a m o n g t h e complications. Hooper (12) found o n e case of e x t r a d u r a l h a e m a t o ma. Weisl (17) adds a similar case and a personal c o m m u n i c a t i o n from McCaul (14). Beckett a n d Gordon (1) stressed t h a t e x t r a d u r a l h a e m a t o m a is possible in c o n n e x i o n w i t h t h e * Charles G. Drake, J. Neurosurg. 19, 1962, p. 489 briefly mentions a patient who had this lesion, among three patients sent to his service with complications from the application of calipers. "However, the second had a penetrating brain wound with an intracerebral clot, and, in the third, the point had torn the middle meningeal artery . . . "
Downloaded by: University of British Columbia. Copyrighted material.
Department of Neurosurgery and Department of Pathology, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel
119
J. M., a 45-year-old woman, was admitted to another hospital on July 13, 1975, after sustaining an injury while engaged in physical exercises. At the end of a turn on her head, she suddenly felt an intense pain in her neck. On examination at the nearest hospital, she was conscious and there was weakness of the right upper extremity and diminished sensation in the left one. X-rays of the cervical spine showed a fracture dislocation at the C3-C4 level. Skull traction with Blackburn's skull caliper was immediately instituted. The surgeon's notes revealed that while making the burr hole on the right side, the burr slipped and penetrated the cranial cavity. Shortly
afterwards the patient became progressively somnolent and at times restless. About six hours later she was transferred to our department. On admission she was drowsy, restless, but able to answer questions, and had a left hemiparesis. She vomited, the pulse rate was 64/minute, and the blood pressure was 150/80. An intracranial haematoma was suspected and an emergency carotid angiogram was done and interpreted as normal (Fig. 1 and 2). Supportive treatment was given and traction was continued. The patient's condition deteriorated gradually and a few hours later she suddenly developed bilateral fixed pupils and respiratory arrest. She expired 36 hours after admission. Post mortem examination: The temporal squama and theduramater were perforated on both sides by the end plates of the skull tongs. On the right side there were a small subdural haematoma of no surgical significance, a subarachnoid haemorrhage and blood in the Sylvian fissure. Also on the right side there was a small laceration of the cortex, at the level of the parietal operculum in the vicinity of the Sylvian vein, immediately under the perforated dura. The brain was swollen and bilateral uncal and amygdalar herniations were evident. During
Fig. 1
Fig. 1 and 2: Right carotid angiography a-p (1) and lateral (2) view.
Hoen method of skull traction but do not add cases. The possibility of intracerebral haematoma is not mentioned in the literature, although it is admitted that skull calipers may penetrate the brain (1, 9). Extensive reviews on traumatic intracerebral haematomas also fail to mention insertion of skull tongs among its causes (2, 3, 13).
Case Report
Downloaded by: University of British Columbia. Copyrighted material.
Traumatic Intracerebral Haematoma
B. Borovich, Y. Doron, E. Cbarbit, E. Peyser
manipulation of the brain for photographic purposes, an intracerebral haematoma (35 gr. of blood clots), was squeezed out from the right parietal lobe (Fig. 3). Coronal sections of the brain revealed a right parietal haematoma and a Sylvian haemocistern communicating between them and with the lateral ventricle. The section at the level of the mamillary bodies showed a direct relationship between the laceration of the cortex under the end plate of the skull caliper and the intracerebral haematoma. Sections through the brain stem showed small haemorrhages and severe oedema. In the neck there was a fracture dislocation of C3 on the C4 vertebra and a few epidural clots; at the same level the cord was very soft and flattened in the antero-posterior direction. Discussion The end plate of skull calipers usually lies in the diploe, between the inner and outer
tables of the skull. If this position is kept throughout, the only dangers are the slipping out of the caliper and infection. When the extradural space is reached by accident or on purpose, as in the Hoen method of skull traction (1), or as some surgeons prefer with the Blackburn skull caliper (9), an extradural haematoma may be produced (1, 12, 14, 17). In the present case many things went wrong and made the development of an intracerebral haematoma possible. The first thing was the »losing of ground« of the surgeon during the making of the burr hole, which possibly went on to perforate the dura and damage the cortex in the vicinity of a big cortical vein (drowsiness started to appear shortly afterwards). The second mishap was the extradural positioning of the end plates coupled with the overseight to screw tight the special metal sleeve the Blackburn caliper is supplied with, so that the skull can be firmly gripped between this sleeve and the end plate. This
Fig. 3: Coronal sections of the brain with intracerebral haematoma.
Downloaded by: University of British Columbia. Copyrighted material.
120
Traumatic Intracerebral Haematoma permitted free movement of the end plates in and out of the skull. It is thought that in this restless patient, this contributed to further damage to the cortex and its veins. Finally, the correct diagnosis was not made before a catastrophic uncal herniation appeared. The misleading factors were the slightness of the vascular displacements on arteriography and the exclusion of an extra-
121
dural hemorrhage. Had the carotid angiography not been made so early in the evolution of the haematoma, the displacements would have been more evident, and the diagnosis would have been made at a useful time. The fact that intracerebral haemorrhage was not known as a possible complication, may have played some part in missing the diagnosis.
1 Beckett Howorth, M., J. Gordon Pétrie: Injuries of the Spine. Baltimore, The Williams and Wilkins Co. (1964) 100-106 2 Borovich, B.: Hematomas Cerebrales Traumáticos. Monografía. Montevideo, Uruguay, 71 pp. Facultad de Medicina, 1968 3 Borovich, B.: Hematoma cerebral lobar traumático. Acta Neurol. Lat. Amer. 15 (1969) 214-223 4 Campbell's Operative Orthopedics, 4th ed., Vol. 1, p. 498-500. Ed. by A. H. Crensbau, S. Louis, The C. V. Mosby Co., 1963 5 Crutchfield, W. C: 1933, cited by Weisl, H. 6 Davis, L., R. A. Davis: Neurocirurgia. Mexico, Editorial Interamericana S.A. (1965) 386, 393-394 7 Guttmann, L.: Initial treatment of traumatic paraplegia and tetraplegia, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 80-92 8 Harris, P.: Some neurosurgical aspects of traumatic paraplegia, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 101-111 9 Harris, P., P. H. T. Wu: The management of patients with injuries of the cervical spine using Blackburn skull calipers and the Stryker turning frame. Paraplegia 4 (1965) 278-287 10 Holdsworth, F. W.: Early orthopedic treatment of pa-
11 12 13 14 15
16 17 18
tients with spinal injuries, in Harris, P. (ed.), Spinal Injuries, Proceedings of a Symposium, Edinburgh, The Royal College of Surgeons (1963) 93-100 Holdwortb, F. W.: Fractures, Dislocations, and fracturedislocations of the spine. J. of Bone and Joint Surg., (Amer.) (1970) 52-A, 1534-1551 Hooper, R.: Observations on extradural hemorrhages. British J. of Surg. 47 (1959) 71-87 Jamieson, K. G., J. D. N. Yelland: Traumatic intracerebral hematoma. Report of 63 surgically treated cases. J. of Neurosurg. 37 (1972) 528-532 McCaul, 1.: 1965, cited by Weist, H. Scarff, ]. E.: Injuries of the vertebral column and spina] cord, in Brock, S. (ed.), Injuries of the Brain and Spina! Cord, New York, Springer Publ. Co. Inc., 4th ed. (I960) 530-589 Victor, D. I., M. J. Brcsnan, R. B. Keller: Brain abscess complicating the use of Halo traction. J. of Bone and Joint Surg. (Amer.) 55-A (1973) 635-639 Weisl, H.: Unusual complications of skull caliper traction. J. of Bone and Joint Surg. (Amer.) 54-B (1972) 143-145 White, } . R., D. Yashon: General care of cervical spine injuries, skeletal traction, in Youmans, ]. R. (ed.), Neurological Surgery, Philadelphia, W. B. Saunders (1973) 1062
Dr. D. Borovich, Department of Neurosurgery and Department of Pathology, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel
Downloaded by: University of British Columbia. Copyrighted material.
Keferences
