Postoperative epidural haematomas associated with hydrocephalus caused by intraoperative overdrainage of cerebrospinal fluid: two case reports with a literature review of 19 cases

Abstract

We report two cases with postoperative epidural haematomas (EDHs) associated with hydrocephalus and discuss the cause of haematoma development on the basis of a literature review. A 13-year-old boy presented with obstructive hydrocephalus caused by a sellar mass lesion. Multifocal EDHs occurred after partial resection of the lesion via a transcallosal approach following ventricular drainage. In the second case, a 26-year-old man who had a history of ventriculoperitoneal shunting for congenital hydrocephalus presented with hydrocephalus caused by ventricular catheter obstruction. An EDH occurred after replacement of the ventricular catheter with a new burr hole opening. On the basis of a review of 19 cases including our two cases, the authors concluded that postoperative EDH development associated with hydrocephalus was mostly caused by intraoperative overdrainage of cerebrospinal fluid, resulting in rapid shrinkage of the brain with dilation of the epidural space, a situation that may have caused dural venous bleeding.

Shunt Overdrainage: Reappraisal of the Syndrome and Proposal for an Integrative Model

“…Overdrainage of CSF may appear in an acute manner. Postoperative extradural hematoma [42] and the development of posterior reversible encephalopathy [43] have been described, caused by intraoperative overdrainage of CSF with rapid reduction in ICP as a result of a craniotomy or CSF diversion procedure. Regarding chronic overdrainage, we should always consider a silent period of asymptomatic (radiological) overdrainage of variable duration.…”

“…In the initial phase of ventricular emptying, extra-axial collections of fluid or blood may appear, hypodense, isodense or hyperdense on CT depending on the acute, subacute or chronic blood content [42,60]. Although most patients show small ventricles on imaging, moderate-or normal-sized ventricles are also found [61].…”

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…8 To limit potential for Clostridium difficile diarrhea and antimicrobial-resistant organisms, as well as lack of efficacy, antibiotics are not routinely recommended for the duration of the EVD. 8 Although there are no guidelines or consensus statements regarding intraoperative periprocedural 67 Neural injury 68 Infection (0%-28% EVD, 0%-50% LD) 8,69-75 Malposition 2,76 Occlusion and malfunction [77][78][79] Overdrainage of CSF Subdural or epidural hematoma [80][81][82][83] Rebleeding from a ruptured cerebral aneurysm 84 Intracranial hypotension [85][86][87] Cerebellar tonsillar herniation 79,[88][89][90][91] Paradoxical herniation 92 Pneumocephalus 79,93 Iatrogenic vascular injury (arteriovenous fistula, cerebral pseudoaneurysm) 94 Fracture of catheters, 95 with retained fragment of catheter 96,97 Inadvertent injections of drugs into EVDs [98][99][100][101][102][103][104][105] Postdural puncture headache 106 CSF indicates cerebrospinal fluid; EVD, external ventricular drain; LD, lumbar drain. administration of antibiotics before LD placement for aortic and nonaortic surgery, this task force recommends following standards such as those used for EVD insertion and management.…”

“…These patients may be at risk of intracranial complications such as high ICP during intrahospital transport (IHT) because of direct patient movement and stimulation and/or discontinuation of ICP treatment. However, change in patient position can also lead to CSF overdrainage and result in complications such as rebleeding of intracranial aneurysm, [131][132][133] subdural hemorrhage from disruption of bridging veins, [80][81][82] and reverse brain herniation. 92 Anesthesiology providers are often involved in the transport of these patients to and from the ICU and to angiography and/or to and from the OR.…”

Spontaneous hemispheric ventricular collapse and subarachnoid haemorrhages in a dog with congenital hydrocephalus internus

“…The increased intracranial pressure in dogs with hydrocephalus causes progressive compromise of cerebral vessels, lacerations of the periventricular white matter, focal destruction of the ependymal lining and can lead to permanent neuronal injury and severe white matter atrophy [2,7,8]. Overdrainage and collapse of the hemispheres is a potential severe complication after surgical treatment of internal hydrocephalus using ventriculoperitoneal shunts in humans [9,10] and animals [3,11]. The development of subarachnoid haemorrhages and hematomas secondary to hemispheric ventricular collapse leads to acute progression of neurological signs and decompressive surgery is the first choice of treatment in human patients [12,13] and animals [14].…”