Contralateral Development of Acute Subdural Hematoma Following Surgery for Chronic Subdural Hematoma —

Case Report—

Katsuhiko HARADA, Katsuyasu OHTSURU, Kenji NAKAYAMA, Shigeyuki TAKAGI, Minoru SHIGEMORI*, Takayuki TOKUNAGA*, Yasuo SUGITA* and Ryuichiroh TORIGOE** Department

of Neurosurgery,

Omuta City Hospital,

Omuta, Fukuoka;

*Department of Neurosurgery , Kurume University School of Medicine, Kurume, Fukuoka, **Department of Neurosurgery , Institute of Neuroscience, St. Mary's Hospital, Kurume, Fukuoka

Abstract An unusual

case of acute

in a 71-year-old dural

space

bleeding branous

similar

subdural

The acute to the

hematoma subdural

outer

developed

hematoma

membrane

of

hematoma,

resulting

Key words:

and

in the acute subdural

this

separation

subdural

then

hematoma,

outer

membrane,

Case

Report

A 71-year-old male fell and strongly struck while fishing on May 12, 1991. He struck again on a shelf on May 28. He complained February present

chronic

of chronic

subdural

over a membranous

subdural

hematoma.

hematoma

layer

in the sub

Intraoperatively,

17, 1992;

address:

Accepted

K. Harada, Kurume,

M.D., Fukuoka,

damaged

the bridging

vein

and

superior

sagittal

his head his head of gait

May

25,

Department Japan.

postoperative

complication

disturbance and headache on June 3. A diagnosis of right chronic subdural hematoma was made based on precontrast computed tomographic (CT) scans on June 5 (Fig. 1 left). He was then referred to our department. On admission, neurological examination revealed slight left hemiparesis. On June 6, closed-system drainage of the hematoma was performed via one burr hole under local anesthesia. Postoperatively, he was kept at strict bed rest with the head of the bed level to avoid rapid decompression. The next day, precontrast CT scans showed a newly developed high-density area over the left frontal convexity, suggesting acute epidural hematoma (Fig. 1 right). Although neurological examination revealed no ab normalities, the hematoma was removed via a left craniectomy on June 9.

Sequelae of surgery for chronic subdural hematoma include possible recurrence of the hematoma, and development of tension pneumocephalus2'6) and in tracerebral hematoma.3) We report an unusual case of acute subdural hematoma occurring after drainage of a contralateral chronic subdural hematoma. The possible mechanism forming acute subdural hematoma on the opposite side is dis cussed.

Received

drainage

hematoma.

Introduction

Author's

the

after

was located

from the bridging vein and oozing from the superior sagittal sinus were observed. The mem layer probably separated from the dura mater following decompression after drainage of the

contralateral sinus,

male.

1992 of Neurosurgery,

Institute

of Neuroscience,

St. Mary's

Hospital,

Fig. 1 left: Precontrast CT scan 1 day before admis sion, demonstrating a right chronic subdural hematoma. right: Precontrast CT scan after the first operation, showing a newly developed high-density area over the left frontal con vexity suggesting an epidural hematoma.

The hematoma

was located

in the subdural

space

(Fig. 2 upper), between the dura and a brownish thick membrane similar to the outer membrane of the chronic subdural hematoma (Fig. 2 middle). This membrane adhered slightly to the frontal, tem poral, and parietal dura and was extremely hemor rhagic. Bleeding from the bridging vein and oozing from the superior sagittal sinus were also observed (Fig. 2 lower). There was no membranous tissue like the inner membrane of the chronic subdural hema toma on the brain surface. Histological examina tion showed that the membrane consisted of rich blood vessels, connective tissue, and fibrous cells with hemosiderin deposits and infiltration of vari ous cells (Fig. 3). The postoperative course was satisfactory, and he was discharged without sequelae. Discussion The outer membrane of the chronic subdural hematoma is important in the formation and enlarge ment of chronic hematoma.4,',') Sato et al.') found that an experimental artificial subdural dead space formed a neomembrane similar to the outer mem brane of chronic subdural hematoma. Apfelbaum et al.') also formed subdural membranes experimental ly, but did not observe subdural hematoma forma tion. Kitamura and Fukui5) observed a membranous tissue similar to the outer membrane of chronic sub dural hematoma at a second craniotomy. Therefore, regardless of whether the hematoma is present, a membrane similar to the outer membrane may exist.

Fig. 2

Intraoperative photograph, demonstrating a subdural hematoma (upper), a membrane below the subdural hematoma (middle), and bleeding from the bridging vein and oozing from the superior sagittal sinus (lower; arrow). F: falx.

However, whether this type of neomembrane can cause chronic subdural hematoma is unknown. In our case, although CT showed a newly devel oped high-density area over the left frontal con vexity suggesting epidural hematoma, the intraop erative finding revealed a subdural hematoma over the thick membrane. Histological findings suggested that this membrane corresponded to the relatively new outer membrane of the chronic subdural hematoma, caused by the head trauma 28 days before the second operation. The membrane may

Fig.

3

Photomicrograph consists

of rich

abundant outer toma.

of the membrane. vessels,

fibrous

membrane HE stain,

cells, of

The tissue

connective

tissue,

corresponding

chronic

subdural

and to

the

hema

x 100.

have existed as an organized thin subdural toma or membranous tissue corresponding

hema to the

pre-chronic subdural hematoma over the right con vexity. The membrane probably became separated from the dura mater following decompression after drainage of the contralateral chronic subdural hematoma. Pre-existing brain atrophy may also have enhanced the effect of decompression after surgery. This separation then damaged the bridging vein and superior sagittal sinus, resulting in the acute hematoma (Fig. 4).

Fig. 4

Schematic

drawing

of development toma rior

over

the

sagittal

of the possible of

thick

the

acute

mechanism

subdural

membrane.

SSS:

hema supe

sinus.

References 1)

Apfelbaum perimental Neurosurg

RI,

Guthkelch

production 40: 336-346,

AN,

Shulman

of subdural 1974

K:

hematoma.

Ex

review.

J

2) Bremer AM, Nguyen TQ: Tension pneumocephalus after surgical treatment of chronic subdural hematoma: Report of three cases. Neurosurgery 11: 284-287, 1982 3)

Hayashi T, Kobayashi H, Sekino H: Intracerebral hematoma after evacuation of chronic subdural fluid collection. Report of three cases. Neurol Med Chir (Tokyo) 27: 1087-1092, 1987 (in Japanese)

4)

Ito H, Yamamoto S, Komai T, Mizukoshi H: Role of local hyperfibrinolysis in the etiology of chronic sub dural hematoma. J Neurosurg 45: 26-31, 1976

5)

Kitamura K, Fukui M: Chronic subdural hematoma: Clinical significance of sixty cases surgically verified. Fukuoka Igaku Zasshi 56: 629-636, 1985 (in Japanese) Markwalder T: Chronic subdural hematomas: A

6)

7)

J Neurosurg

54: 637-645,

Sato J, Masuzawa

H, Kanazawa

1981

I, Kamitani

perimental chronic subdural hematoma. Gaisho 9: 201-205, 1986 (in Japanese)

H: Ex Shinkei

8) Yamashima T, Shimoji T, Komai T, Kubota T, Ito H, Yamamoto S: Growing mechanism of chronic sub dural hematoma: Light and electron microscopic study on outer membranes of chronic subdural hematoma. Neurol Med Chir (Tokyo) 18 [Part II]: 743-752, 1978 (in Japanese)

Address reprint requests ment of Neurosurgery, Mary's Fukuoka

Hospital,

to: K. Harada, M.D., Depart Institute of Neuroscience, St.

422 Tsubukuhon-machi,

830, Japan.

Kurume,