Original ArticleRisk Factors for the Development of Contralateral Epidural Hematoma Following Decompressive Craniectomy in Patients with Calvarial Skull Fracture Contralateral to the Craniectomy Site
Introduction
Decompressive craniectomy (DC) has been performed increasingly over the past years to control medically refractory intracranial hypertension in patients with severe traumatic brain injury (TBI), malignant middle cerebral infarction, and other central nervous diseases.1, 2, 3 Although DC is a potentially life-saving procedure for patients with severe TBI, it is associated with some potential complications.4, 5, 6, 7 One severe complication following DC is the development of an epidural hematoma contralateral to the craniectomy site.8, 9, 10, 11 This delayed contralateral epidural hematoma (CEDH) may present with intraoperative brain swelling, postoperative pupillary abnormalities, intractably increased intracranial pressure (ICP), or acute neurologic deterioration.8, 9, 10, 11 If not diagnosed, CEDH can cause serious consequences. In some previous studies,10, 11, 12 the presence of a skull fracture contralateral to the craniectomy site was considered a risk factor for the development of CEDH. Talbott et al. thought the calvarial fracture patterns on the preoperative computed tomography (CT) scan could predict the risk for CEDH development.12 However, interestingly, many patients with contralateral calvarial skull fracture did not develop CEDH following DC in clinical practice. Therefore we retrospectively reviewed a series of patients undergoing DC for acute TBI over a 5-year period. On the basis of a preoperative CT scan, patients with calvarial skull fracture contralateral to the craniectomy site were enrolled to determine the risk factors for the development of CEDH following DC. We aimed to improve the therapeutic strategy and outcome of this potentially devastating complication in patients undergoing DC for acute TBI.
Section snippets
Study Design
In this study, we retrospectively reviewed the medical records of 235 patients with acute TBI who underwent DC from 2008−2012. The indication for performing DC was marked swelling of the brain after evacuation of any type of intradural hemorrhagic lesion or increased ICP refractory to medical treatment in patients with ICP monitoring. The DC procedure entailed removal of a large portion of the skull bone. The underlying dura was opened widely to accommodate the swollen brain without performing
Results
After reviewing the medical records and radiographs, calvarial fractures contralateral to the craniectomy site on preoperative CT scans were observed in 72 patients who underwent DC for TBI. Among these patients, 13 of them developed CEDH following DC (Figure 2). The other 59 patients did not develop CEDH following DC. These 72 patients with calvarial fracture contralateral to the craniectomy site were enrolled to determine the risk factors for the development of CEDH following DC.
Among the 13
Discussion
The mechanism of CEDH development following DC in patients with contralateral calvarial skull fracture remains elusive. Occurrence of CEDH following DC may be due to relief of the tamponade effect on the contralateral epidural bleeding source, upon opening of the skull.17, 18 However, Piepmeier thought if this mechanism was operative, it would be anticipated that the occurrence of CEDH would be reported more frequently.19 As in our study, only 18% of patients with contralateral calvarial skull
Conclusions
CEDH following DC is a rare but dangerous complication in patients with acute TBI. Age and number of fracture-involved bone plate are significant risk factors for CEDH development following DC. Involvement of 2 or more bone plates of contralateral calvarial skull fracture in young adult may prompt an immediate postoperative CT scan to detect the occurrence of CEDH, irrespective of the operative findings and neurologic status. This may prevent devastating neurologic consequence from CEDH and
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Conflict of interest statement: The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this manuscript. All authors do not receive any source of funding.