Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Non-traumatic, non-arterial origin delayed Epidural Hematoma after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure.

The possible causes include sudden decompression of ventricular pressure in the supratentorial compartment, rupture of cortical veins in the sitting positioncoagulopathy, hemodynamic fluctuations during surgery, and position-related ischemia 1).

The lowering of the ventricular pressure by the ventricular tapduring the operation may play significant role in the formation of the extradural hematoma.

The younger age of the cases and the long history of increased intracranial pressure were stressed in the literature2).

Wolfsberger et al., stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 3).

Avci et al., from Mersin, reported a case during removal of a huge Posterior fossa dermoid cyst 4).

Pandey et al., from Bangalore reported in 2008 a large bifrontal extradural hematoma following posterior fossa surgery for a vermian medulloblastoma5).

Tsugane et al., reported five cases of the supratentorial extradural hematomas secondary to the posterior fossa craniectomy.

The site of the hematoma was far from the operative field and two cases showed acute course and three were rather mild. The symptoms of this complication were the unsuspected sensorium disturbance, anisocoria and the non-functioning ventricular drainage. Two cases died of this complication and two were severely disabled 6).

Multiple Supratentorial Epidural Hematomas

Tyagi et al., from Bangalore published Multiple Remote Sequential Supratentorial Epidural Hematoma7).

Wolfsberger et al., from Vienna published a 31-year-old female who presented with a history of chronic hydrocephalus due to fourth-ventricular plexus papilloma. Following resection of the posterior fossa tumor with intraoperative placement of a ventricular drainage, she consecutively developed four supratentorial epidural haematomas at different locations, all necessitating evacuation. The clinical manifestations ranged from subtle neurological deficits to signs of tentorial herniation; the ultimate outcome was complete recovery. Rapid tapering of CSF pressure after long-standing hydrocephalus and clotting disorders could be implicated as causative factors. They stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 8).

References

1) , 5)

Pandey P, Madhugiri VS, Sattur MG, Devi B I. Remote supratentorial extradural hematoma following posterior fossa surgery. Childs Nerv Syst. 2008 Jul;24(7):851-4. doi: 10.1007/s00381-007-0573-5. Epub 2008 Jan 31. PubMed PMID: 18236051.
2) , 6)

Tsugane R, Sugita K, Sato O. [Supratentorial extradural hematomas following posterior fossa craniectomy (author’s transl)]. No Shinkei Geka. 1976 Apr;4(4):401-3. Japanese. PubMed PMID: 944882.
3) , 8)

Wolfsberger S, Gruber A, Czech T. Multiple supratentorial epidural haematomas after posterior fossa surgery. Neurosurg Rev. 2004 Apr;27(2):128-32. Epub 2003 Dec 2. PubMed PMID: 14652780.
4)

Avci E, Dagtekin A, Baysal Z, Karabag H. Intraoperative supratentorial epidural haematoma during removal of a huge posterior fossa dermoid cyst. Neurol Neurochir Pol. 2010 Nov-Dec;44(6):609-13. PubMed PMID: 21225525.
7)

Tyagi G, Bhat DI, Indira Devi B, Shukla D. “Multiple Remote Sequential Supratentorial Epidural Hematomas – An Unusual and Rare Complication Following Posterior Fossa Surgery”. World Neurosurg. 2019 May 6. pii: S1878-8750(19)31225-2. doi: 10.1016/j.wneu.2019.04.228. [Epub ahead of print] PubMed PMID: 31071445.

Pipeline embolization device for posterior circulation aneurysm

Pipeline embolization device for posterior circulation aneurysm

The use of the pipeline embolization device (PED) for posterior circulation aneurysms remains controversial. In a meta-analysis, Liang et al., from the Beijing Tiantan Hospital and Beijing Tsinghua Changgung Hospital, aimed to explore the safety and efficacy of PED for these aneurysms. Meta regression was used to identify predictors for incomplete aneurysm occlusion and procedure-related complications.

PubMedWeb of Science, and OVID databases were searched to identify all published references evaluating the treatment effect of PED for posterior circulation aneurysms. Only studies written in English, reporting original data, and including more than 10 cases were considered for inclusion. Patient demographics, aneurysm characteristics, angiographic, and clinical outcomes were extracted. A random effects model was adopted to pool the obliteration rates and complications rates across selected studies. Finally, they conducted meta-regression analysis to identify the predictors of the angiographic outcomes.

12 studies, including 358 patients with 365 aneurysms were included. The pooled complete aneurysm obliteration rate was 82% (95% confidence interval [CI], 73%-90%) and the pooled procedure-related complication rate was 18% (95% CI, 14%-22%). Increasing age predicted incomplete obliteration of aneurysms after PED treatment in these patients (P=0.01).

PED is an alternative to treat intracranial aneurysms of the posterior circulation, achieving high complete occlusion rates, but less effective in senile patients. However, the risk of procedure-related complications is not negligible. Further larger and long-term follow-up studies are needed before definitive conclusions might be drawn 1).


From November 2015 to November 2016, 35 patients with 38 posterior circulation aneurysms were treated with the PED in this retrospective study. We evaluated the angiographic and clinical outcomes of these aneurysms at last follow-up, and made a comparison between anterior (n = 163) and posterior circulation (n = 38) aneurysms regarding the technical nuances, occlusion rate, complications rate, and time to occlusion to explore whether we should rationalize the use of the PED for these aneurysms.

With a median follow-up time of 5.5 months, complete occlusion was achieved in 33 aneurysms (91.7%). Aneurysms with stenosis parent artery tended to have lower occlusion rate (P = 0.064; odds ratio, 0.074; 90% confidence interval, 0.001-1.781), and V4 segment aneurysms tended to occlude themselves much faster than vertebrobasilar junction aneurysms (median, 148 vs. 246 days, respectively; P = 0.076). The periprocedural complication rate was 10.8%, and no major adverse events occurred. Compared with anterior circulation aneurysms, shorter procedure time (116.0 vs. 135.4 minutes, P = 0.012) and higher occlusion rate (91.4% vs. 72.8%, P = 0.023) were achieved for posterior circulation aneurysms. Besides, technical event rate (8.1% vs. 14.1%, P = 0.424) and complication rate (10.8% vs. 18.4%, P = 0.338) tended to be lower. Survival analysis indicated a shorter interval to complete occlusion for V4 segment aneurysms compared with anterior circulation (148 vs. 191 days, respectively; P = 0.047).

PED has a favorable performance at posterior circulation, and it is rational to expand the indication to include these aneurysms. However, a case-control study is still needed to further expatiate whether the PED has advantages over traditional endovascular treatment 2).


In 2018, a retrospective review of prospectively maintained databases at 8 academic institutions was performed for the years 2009 to 2016 to identify patients with posterior circulation aneurysms treated with PED placement.

A total of 129 consecutive patients underwent 129 procedures to treat 131 aneurysms; 29 dissecting, 53 fusiform, and 49 saccular lesions were included. At a median follow-up of 11 months, complete and near-complete occlusion was recorded in 78.1%. Dissecting aneurysms had the highest occlusion rate and fusiform the lowest. Major complications were most frequent in fusiform aneurysms, whereas minor complications occurred most commonly in saccular aneurysms. In patients with saccular aneurysms, clopidogrel responders had a lower complication rate than did clopidogrel nonresponders. The majority of dissecting aneurysms were treated in the immediate or acute phase following subarachnoid hemorrhage, a circumstance that contributed to the highest mortality rate in those aneurysms.

In the largest series till 2018, fusiform aneurysms were found to have the lowest occlusion rate and the highest frequency of major complications. Dissecting aneurysms, frequently treated in the setting of subarachnoid hemorrhage, occluded most often and had a low complication rate. Saccular aneurysms were associated with predominantly minor complications, particularly in clopidogrel nonresponders 3).


In 2015, a case series publication of Albuquerque et al. stated that patient selection is essential for safe and effective PED treatment of posterior circulation aneurysms. The PED is equally effective in achieving aneurysm obliteration with an acceptable risk profile as it is in the anterior circulation. Dolichoectatic aneurysms were not included in this treatment cohort. PED may be a preferable alternative to open surgical treatment of posterior circulation aneurysms 4).

References

1)

Liang F, Zhang Y, Yan P, Ma C, Liang S, Jiang C. Outcomes and complications after the use of the pipeline embolization device in the treatment of intracranial aneurysms of the posterior circulation: A systematic review and meta-analysis. World Neurosurg. 2019 Apr 5. pii: S1878-8750(19)30972-6. doi: 10.1016/j.wneu.2019.03.291. [Epub ahead of print] PubMed PMID: 30959253.
2)

Liang F, Zhang Y, Guo F, Zhang Y, Yan P, Liang S, Jiang Y, Jiang P, Jiang C. Use of Pipeline Embolization Device for Posterior Circulation Aneurysms: Single-Center Experiences with Comparison with Anterior Circulation Aneurysms. World Neurosurg. 2018 Apr;112:e683-e690. doi: 10.1016/j.wneu.2018.01.129. Epub 2018 Feb 2. PubMed PMID: 29410337.
3)

Griessenauer CJ, Ogilvy CS, Adeeb N, Dmytriw AA, Foreman PM, Shallwani H, Limbucci N, Mangiafico S, Kumar A, Michelozzi C, Krings T, Pereira VM, Matouk CC, Harrigan MR, Shakir HJ, Siddiqui AH, Levy EI, Renieri L, Marotta TR, Cognard C, Thomas AJ. Pipeline embolization of posterior circulation aneurysms: a multicenter study of 131 aneurysms. J Neurosurg. 2018 Apr 1:1-13. doi: 10.3171/2017.9.JNS171376. [Epub ahead of print] PubMed PMID: 29726768.
4)

Albuquerque FC, Park MS, Abla AA, Crowley RW, Ducruet AF, McDougall CG. A reappraisal of the Pipeline embolization device for the treatment of posterior circulation aneurysms. J Neurointerv Surg. 2015 Sep;7(9):641-5. doi: 10.1136/neurintsurg-2014-011340. Epub 2014 Aug 4. PubMed PMID: 25092926.

Posterior fossa epidural hematoma in children

Posterior fossa epidural hematoma in children

Clinical features

Because of the non-specific symptoms and the potential for rapid and fatal deterioration of Posterior fossa epidural hematoma in children, an early computed tomography (CT) scanning is necessary for all suspicious cases.

In nine cases.The clinical picture was dominated by headache, vomiting, and gait ataxia. An occipital fracture was seen in 77.7% of the patients. In all cases, the diagnosis was made by computed tomography. 1).

Treatment

see Review and Management Guidelines 2).

Although some patients have been successfully treated with conservative approach, most studies support timely management of posterior fossa epidural hematoma by surgical intervention in children.

The absence of an occipital skull fracture or the presence of normal pulse rate and blood pressure should not influence the decision. Lumbar puncture is absolutely contraindicated 3).

Little evidence is available regarding the feasibility of using trephination mini-craniectomy for traumatic PFEDH in children 4).

Outcome

The overall prognosis normally is excellent 5) 6) 7).

Torrential venous bleeding can be a major problem due to rupture of the adjacent sinuses. Timely intervention is crucial for achieving good outcome, keeping in view a low threshold for surgical evacuation 8).

Case series

References

1) , 7)

Ciurea AV, Nuteanu L, Simionescu N, Georgescu S. Posterior fossa extradural hematomas in children: report of nine cases. Childs Nerv Syst. 1993 Jul;9(4):224-8. PubMed PMID: 8402704.
2)

Kaushik S, Sandip C. Posterior Fossa Acute Extradural Hematoma in Children: Review and Management Guidelines. J Pediatr Neurosci. 2018 Jul-Sep;13(3):289-293. doi: 10.4103/JPN.JPN_86_18. Review. PubMed PMID: 30271459; PubMed Central PMCID: PMC6144610.
3)

Arkins TJ, McLennan JE, Winston KR, Strand RD, Suzuki Y. Acute posterior fossa epidural hematomas in children. Am J Dis Child. 1977 Jun;131(6):690-2. PubMed PMID: 868823.
5)

Chaoguo Y, Xiu L, Liuxun H, Hansong S, Nu Z. Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature. J Korean Neurosurg Soc. 2019 Mar;62(2):225-231. doi: 10.3340/jkns.2016.0506.007. Epub 2019 Feb 27. PubMed PMID: 30840978.
6)

Sencer A, Aras Y, Akcakaya MO, Goker B, Kiris T, Canbolat AT. Posterior fossa epidural hematomas in children: clinical experience with 40 cases. J Neurosurg Pediatr. 2012 Feb;9(2):139-43. doi: 10.3171/2011.11.PEDS11177. PubMed PMID: 22295917.
8)

Prasad GL, Gupta DK, Sharma BS, Mahapatra AK. Traumatic Pediatric Posterior Fossa Extradural Hematomas: A Tertiary-Care Trauma Center Experience from India. Pediatr Neurosurg. 2015;50(5):250-6. doi: 10.1159/000438488. Epub 2015 Aug 20. PubMed PMID: 26287640.
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