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Case report

Compressive brainstem deformation resulting from subdural hygroma after neurosurgery: a case report

YU, Shu-qing; WANG, Ji-sheng; JI, Nan

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Acute and chronic subdural hygromas are common postoperative clinical complications of ventricular shunting, arachnoid cyst marsupialization and arachnoid cyst resection.1 This article introduces a case of subdural hygroma after resection of a space-occupying lesion in the left lateral ventricle that resulted in compressive brainstem deformation and reviewed the recent related literature. The conclusion is that in related surgical procedures, prevention of rapid cerebrospinal fluid loss and excessive fluctuations in intracranial pressure are especially important.

CASE REPORT

The patient was a 52-year-old man with a 5 month history of episodic headaches. He was admitted to our hospital on August 25, 2006 with a diagnosis of a “space-occupying lesion in the left lateral ventricle”.

On admission, the patient was alert and his speech was appropriate. The pupils were equal and reactive to light. There was good movement in all four limbs, and the muscle strength was grade V. Magnetic resonance imaging (MRI) showed a space-occupying lesion present in the left lateral ventricle, with accompanying left ventricular enlargement. An ependymoma was suspected. The patient had a 5 year history of hypertension with the highest recorded blood pressure of 160/100 mmHg. He did not take antihypertensive medications regularly.

Tumor resection by the left craniotomy-transcallosal route was performed under general anesthesia on August 29, 2006. The tumor, as observed during surgery, was approximately 3 cm × 3 cm × 3 cm in size, purplish-red, soft with indistinct margins and was well-vascularized. The entire tumor was resected. Postoperatively, the patient was mentally alert, but appeared fatigued. He had good movement in all four limbs. On day 5, his temperature increased to 38°C but examination of the cerebrospinal fluid obtained via lumbar puncture revealed no abnormalities. His temperature returned to normal on post-operative day 10. Twelve days after surgery the patient complained of headaches, which were occasionally accompanied by vomiting. A subcutaneous fluid accumulation was noted around the surgical site, and 30 ml of straw-colored clear fluid was drained by puncture. A repeat cranial computed tomography scan showed that a thin layer of subdural fluid was present bilaterally around the frontal lobes (Figure 1). Fourteen days after surgery, the patient's level of consciousness decreased. The pupil size were unequal (left:right = 2.5:3) with the right side pupil having a delayed response to light. The cerebrospinal fluid pressure, as measured by lumbar puncture, was 270 mmH2O. Fifteen days after surgery, the patient became unconscious and unresponsive to verbal stimuli. All four limbs were able to flex after stimulation. Sixteen days after surgery, the patient was deeply unconscious, and an MRI examination showed increased subdural fluid accumulation bilaterally, which was more prominent on the right (Figure 2A). The brainstem was severely deformed due to the pressure (Figure 2B). External drainage tubes were immediately placed subdurally on both sides, and the patient's conscious state improved slightly. Seventeen days after surgery, subdural fluid drainage was performed in theatre by right side trephination, and 80 ml of straw-colored clear fluid was drained. After trephination, the patient's mental state improved markedly. He gradually regained consciousness and became responsive to verbal stimuli. A repeat MRI examination showed that the brainstem pressure was alleviated and the brainstem morphology had returned to normal (Figure 3). Subdural external drainage tubes were removed 3 days later and suture removal was performed after another 4 days. The patient recovered completely and was able to walk out of the hospital on discharge.

Figure 1.
Figure 1.:
CT image shows a bilateral frontoapical subdural hygroma.
Figure 2. A:
Figure 2. A::
MRI image shows a bilateral frontoapical subdural hygroma, more cerebrospinal fluid than CT. B: MRI image shows compressive brainstem deformation. Mesencephalon, pons and medulla oblongata are all deformed.
Figure 3.
Figure 3.:
MRI image shows brainstem morphology has returned to normal.

DISCUSSION

Acute and chronic subdural hygromas are common postoperative clinical complications of ventricular shunting, arachnoid cyst marsupialization and arachnoid cyst resection.1 Tamburrini et al2 reported that in a group of 104 patients, the incidence of subdural hygromas after arachnoid cyst resection, which required further surgical intervention, was 10.2%. Analyzing possible causes, they thought that the sudden loss of cystic fluid resulted in tissue movement, with subsequent tearing of subdural capillaries. The hemorrhage gradually developed into a subdural hygroma. Staudinger et al3 reported that in a group of 50 bone marrow transplant patients, postoperative subdural hygromas occurred in 9 patients and the incidence was 18%. They thought that subdural hygromas resulted from intracranial hemorrhage in these patients and the contributing factors included intracranial vascular abnormalities and hematologic diseases such as thrombocytopenia and coagulopathies. Freudenstein et al4 reported on a group of 77 endoscopic surgery patients in whom postoperative subdural hygromas occurred in 2 patients. They also suspected subdural capillary tearing due to rapid cerebrospinal fluid loss, and the subsequent hemorrhage gradually developing into a subdural hygroma. In the above three studies, only subdural hygroma was reported as a postoperative complication, and it did not result in compressive brainstem deformation or symptoms, such as loss of consciousness. In our patient, subdural hygroma appeared 12 days after intraventricular tumor resection. Compressive brainstem deformation was observed 14 days after surgery and progressively worsened. After surgical intervention (trephination), the symptoms eased, and the brainstem morphology returned to normal. Analyzing possible causes, it was thought that because the tumor was intraventricular, the severe loss of cerebrospinal fluid during surgery resulted in tethering and tearing of subdural vessels, producing a subdural hygroma. Therefore, in related surgical procedures, prevention of rapid cerebrospinal fluid loss and excessive fluctuations in intracranial pressure are especially important.

REFERENCES

1. Gelabert-González M, Fernández-Villa J, Cutrín-Prieto J, Garcìa Allut A, Martínez-Rumbo R. Arachnoid cyst rupture with subdural hygroma: report of three cases and literature review. Childs Nerv Syst 2002; 18: 609–613.
2. Tamburrini G, Caldarelli M, Massimi L, Santini P, Di Rocco C. Subdural hygroma: an unwanted result of Sylvian arachnoid cyst marsupialization. Childs Nerv Syst 2003; 19: 159–165.
3. Staudinger T, Heimberger K, Rabitsch W, Schneider B, Greinix HT, Nowzad S, et al. Subdural hygromas after bone marrow transplantation: results of a prospective study. Transplantation 1998; 65: 1340–1344.
4. Freudenstein D, Wagner A, Ernemann U, Duffner F. Subdural hygroma as a complication of endoscopic neurosurgery-two case reports. Neurol Med Chir 2002; 42: 554–559.
Keywords:

brainstem; deformation; subdural hygroma; neurosurgery

© 2008 Chinese Medical Association