Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Technical Note
Techniques in Neurosurgery
Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Search in posts
Search in pages
Filter by Categories
Book Review
Brief Report
Case Report
Case Series
Commentary
Editorial
Erratum
Guest Editorial
Images
Images in Neurology
Images in Neuroscience
Images in Neurosciences
Letter to Editor
Letter to the Editor
Letters to Editor
Letters to the Editor
Media and News
None
Notice of Retraction
Obituary
Original Article
Point of View
Position Paper
Review Article
Short Communication
Technical Note
Techniques in Neurosurgery
View/Download PDF

Translate this page into:

Commentary
5 (
3
); 308-309

Commentary

Address for correspondence: Christian von der Brelie, Department of Neurosurgery, Unfallkrankenhaus Berlin, Warenerstrasse 7, 12683 Berlin, Germany. E-mail: Christian.vonderBrelie@ukb.de

Read COMMENTARY-ARTICLE associated with this -

Licence

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Disclaimer:
This article was originally published by Medknow Publications & Media Pvt Ltd and was migrated to Scientific Scholar after the change of Publisher; therefore Scientific Scholar has no control over the quality or content of this article.

In the article “Dreaded complications of mistaken identity - Hygroma vs. effusion following decompressive craniotomy,” the authors describe a case of a patient who underwent decompressive hemicraniectomy (DCHC) after a severe head injury.[1] The reconstruction of the calvaria was performed four years later after DCHC. CAT scan on re-admission showed a hypodense subdural fluid collection. A lumbar drainage was inserted preoperatively so that the flap sunk to the level of the adjacent skull. We think that this approach should be reconsidered since draining CSF might even lead to an increase of the subdural fluid collection since the “vis a tergo” force represented by the brain is decreased.[2]

The patient subsequently underwent cranioplasty. Postoperatively, the patient developed a substantial right-sided weakness with a 2/5 power. A CAT scan was performed showing persistent subdural fluid collection with radiological signs of acute hemorrhage and significant mass effect. This constellation of symptoms and imaging implicates that no subdural inspection was performed during the cranioplasty procedure. Furthermore, manipulation of the tissue might have lead to a small brain contusion, which caused small hemorrhage. In our opinion, an intraoperative revision of the subdural space should have been performed. This could have been done by a tiny dural incision or even by insertion of a Cushing's needle. By this step, subdural collection could have been diagnosed as either being a hygroma or being a chronic subdural hematoma. Simultaneously, a certain amount of fluid could have been evacuated so that the bone flap could have properly been placed in.

Revision surgery was performed; the dura was opened. The dura was described as being massively thickened, which is not an astonishing finding since the DHC was performed your years ago. Subdural revision showed a chronic subdural hematoma, which was covered by a typical membrane. A second complication occurred; the scalp flap was infected. This is not unusual since the revision was done under emergency conditions. Emergency neurosurgical procedures have a higher potential for infectious complications.[3]

The colleagues discussed the need for acquiring imaging in order to differentiate between the different entities of subdural fluid collection since it might not be evident in cases of chronic subdural hematoma and subdural hygroma.[4] The authors are right in their statement that the need to drain a hygroma is very seldom since they are rarely symptomatic. Nonetheless, the need of acquiring an MRI to differentiate the entity of subdural fluid collection is seldomly given.

In the presented case, we think that the preoperative insertion of a lumbar drainage was not useful. We would rather favor a different approach and perform an intraoperative subdural inspection, which would enable the surgeon to analyze the fluid as well as reduce the space occupying effect that the fluid would cause, if the calvaria are restored.

Overall, we think that one should try to perform cranioplasty surgery within the first six months after DCHC, but of course, we are aware that this might not be easy to organize.

References

  1. , , . Dreaded complications of mistaken identity - hygroma vs effusion/hematoma following decompressive craniotomy. J Neurosci Rural Pract 2014. 2014;5:305-7.
    [Google Scholar]
  2. , , . A case of chronic subdural hematoma following lumbar drainage for the management of iatrogenic cerebrospinal fluid rhinorrhea: Pitfalls and lessons. Ear Nose Throat J. 2013;92:513-5.
    [Google Scholar]
  3. , , , , , , . Operative intracranial infection following craniotomy. Neurosurg Focus. 2008;24:E10.
    [Google Scholar]
  4. , , , , , , . Traumatic acute subdural hygroma mimicking acute subdural hematoma. J Clin Neurosci. 2004;11:311-3.
    [Google Scholar]

    Fulltext Views
    18

    PDF downloads
    0
    View/Download PDF
    Download Citations
    BibTeX
    RIS
    Show Sections