Chronic subdural hematoma surgery complications

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Chronic subdural hematoma surgery complications

The most frequent complication after chronic subdural hematoma (CSDH) is chronic subdural hematoma recurrence requiring reoperation. Although several definitions of recurrence have been proposed 1) one of the most consensual definitions of recurrence is the association between new clinical symptoms and hematoma revealed by CT scans. Thus, one can wonder whether a systematic CT scan is necessary after CSDH evacuation for a patient without symptoms.

Common postoperative complications include acute epidural and/or subdural bleeding, tension pneumocephalus, intracranial hematomas and ischemic cerebral infarction.

Failure of the brain to re-expand, pneumocephalus, incomplete evacuation, and recurrence of the fluid collection are the most frequently.

Recurrence

see Chronic subdural hematoma recurrence.

Seizures

Seizures (including intractable status epilepticus).

Intracerebral hemorrhage

Intracerebral hemorrhage (ICH): occurs in 0.7–5%. Very devastating in this setting: one–third of these patients die and one third are severely disabled

Brain herniation

Chronic subdural hematoma (CSDH) with brain herniation signs is rarely seen in the emergent department. As such, there are few cumulative data to analyze such cases.

Failure of postoperative cerebral reexpansion

A wide variation in postoperative drainage volumes is observed during treatment of chronic subdural hematoma (CSDH) with twist-drill or burr-hole craniostomy and closed-system drainage.

The postoperative drainage volumes varied greatly because of differences in the outer membrane permeability of CSDH, and such variation seems to be related to the findings on the CT scans obtained preoperatively. Patients with CSDH in whom there is less postoperative drainage than expected should be carefully observed, with special attention paid to the possibility of recurrence 2).

Patients with high subdural pressure showed the most rapid brain expansion and clinical improvement during the first 2 days. Nevertheless, a computerized tomography (CT) scan performed on the 10th day after surgery demonstrated persisting subdural fluid in 78% of cases. After 40 days, the CT scan was normal in 27 of the 32 patients. There was no mortality and no significant morbidity. A study suggests that well developed subdural neomembranes are the crucial factors for cerebral reexpansion, a phenomenon that takes at least 10 to 20 days. However, blood vessel dysfunction and impairment of cerebral blood flow may participate in delay of brain reexpansion. It may be argued that additional surgical procedures, such as repeated tapping of the subdural fluid, craniotomy, and membranectomy or even craniectomy, should not be evaluated earlier than 20 days after the initial surgical procedure unless the patient has deteriorated markedly 3).

Postoperative pneumocephalus

see Tension pneumocephalus after chronic subdural hematoma evacuation.

Remote cerebellar hemorrhage (RCH)

see Remote cerebellar hemorrhage.

Epidural hematoma

After chronic subdural hematoma evacuation surgery, the development of epidural hematoma is a very rare entity.

Akpinar et al. report the case of a 41-year-old man with an epidural hematoma complication after chronic subdural hematoma evacuation. Under general anesthesia, the patient underwent a large craniotomy with closed system drainage performed to treat the chronic subdural hematoma. After chronic subdural hematoma evacuation, there was epidural leakage on the following day.

Although trauma is the most common risk factor in young CSDH patients, some other predisposing factors may exist. Intracranial hypotension can cause EDH. Craniotomy and drainage surgery can usually resolve the problem. Because of rapid dynamic intracranial changes, epidural leakages can occur. A large craniotomy flap and silicone drainage in the operation area are key safety points for neurosurgeons and hydration is essential 4).

Intracranial subdural empyema

A case of intracranial subdural empyema following chronic subdural hematoma drainage 5).

Skin depression

see Skin depression after chronic subdural hematoma surgery.

Oculomotor nerve palsy

see Oculomotor nerve palsy in chronic subdural hematoma.

Pseudohypoxic brain swelling

Pseudohypoxic brain swelling (PHBS) is a rare and potentially fatal complication that may occur in patients following uneventful brain surgery. Fan presented a case of PHBS after chronic subdural hematoma surgery that developed after drilling and drainage. Neuroimaging findings, pathogenic factors, and therapy are also discussed 6).

References

1)

A. Chiari, K. Hocking, E. Broughton, C. Turner, T. Santarius, P. Hutchinson, A. Kolias, Core outcomes and common data elements in chronic subdural hematoma: a systematic review of the literature focused on reported outcomes, J.Neurotrauma 33 (2016) 1212–1219, https://doi.org/10.1089/neu.2015.3983.
2)

Kwon TH, Park YK, Lim DJ, Cho TH, Chung YG, Chung HS, Suh JK. Chronic subdural hematoma: evaluation of the clinical significance of postoperative drainage volume. J Neurosurg. 2000 Nov;93(5):796-9. PubMed PMID: 11059660.
3)

Markwalder TM, Steinsiepe KF, Rohner M, Reichenbach W, Markwalder H. The course of chronic subdural hematomas after burr-hole craniostomy and closed-system drainage. J Neurosurg. 1981 Sep;55(3):390-6. PubMed PMID: 7264730.
4)

Akpinar A, Ucler N, Erdogan U, Yucetas CS. Epidural Hematoma Complication after Rapid Chronic Subdural Hematoma Evacuation: A Case Report. Am J Case Rep. 2015 Jul 6;16:430-433. PubMed PMID: 26147957.
5)

Ovalioglu AO, Aydin OA. A case of subdural empyema following chronic subdural hematoma drainage. Neurol India. 2013 Mar-Apr;61(2):207-9. doi: 10.4103/0028-3886.111165. PubMed PMID: 23644343.
6)

Fan Q. Pseudohypoxic Brain Swelling after Drilling and Drainage for Chronic Subdural Hematoma. J Neurol Surg A Cent Eur Neurosurg. 2020 Oct 13. doi: 10.1055/s-0040-1712500. Epub ahead of print. PMID: 33049793.

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