Extradural hematoma during craniotomy

Report of five cases

HENRY TROUPP, M.D.

Neurosurgical Clinic, Helsinki University Central Hospital, Helsinki, Finland

The author describes five instances of extradural hematoma that developed

during craniotomy. The hematomas extended basally from an original
craniotomy near the midline and four required immediate additional surgical
exposure. This rare complication should be remembered during craniotomy if
the brain appears to be swelling without obvious reason.

KEY WORDS eraniotomy intraoperative extradural hematoma

N January 25, 1965, during an opera- Case 2

tion aimed at an aneurysm of the left
internal carotid bifurcation, the front-
al lobe suddenly started to swell. Exposure
of the aneurysm was abandoned, and the
dura closed hurriedly. No apparent cause
for the swelling could be found at first;
however, an enormous extradural hematoma
extending backward from the posterior rim
of the frontal bone flap was ultimately
found. The original flap was closed and a
parietal one turned to remove the extradural
hematoma and provide access for hemosta-
sis. The patient did well, and the aneurysm
was clipped on February 1.
Since then we have seen four more cases
of this unpleasant type of operative compli-
cation. As the complication seems rare and
there is no mention of it in standard
textbooks, 4,6,7 a short description seems
worthwhile.
Case Reports
Case I
This was the 29-year-old woman men-
tioned in the introduction.
This 50-year-old woman had an ependy-
moma removed from the left lateral ven-
tricle through a frontal approach on March
22, 1968. As the frontal horn was being
explored, the brain appeared to be swelling.
A large extradural hematoma was found
extending posteriorly and basally from the
bone flap. The visible portion of the
hematoma was removed, and the foramen
spinosum plugged; the tumor was then
removed, and the wound closed. A parietal
flap was immediately turned; the remainder
of the extradural hematoma was removed
and hemostasis secured. The postoperative
course was complicated by high intraven-
tricular pressure necessitating ventricular
drainage and hospitalization until death 2
months later.
Case 3
This 34-year-old man had a right frontal
astrocytoma removed by a large lobectomy
(130 gm) on August 20, 1968. The
operation was complicated by troublesome

J. Neurosurg. / Volume 40 / June, 1974 783

 Henry Troupp
"swelling" of the frontal lobe from the start,
even before the lobectomy was started.
When eventually the dura had been closed, a
large extradural hematoma extending back-
ward over the whole parietal area was
found. The hematoma was removed through
the frontal craniotomy; on August 23, more
hematoma was removed and hemostasis
secured through an enlarged parietal burr
hole. The patient then recovered unevent-
fully.

Case 4
A 39-year-old man was operated on on FIG. 1. Case 4. Postoperative skull film
May 9, 1972, for a left occipital meningio- showing how far forward the extradural hematoma
ma of the falx. The operation was long and extended from the original occipital bone flap for
sanguinary; 22 pints of blood had to be the removal of a meningioma of the falx. The
metal clip above the sella marks the anterior limit
transfused. The tumor had been removed of the hematoma; the four burr holes are part of
and its attachment to the falx excised when the secondary bone flap turned for the hematoma;
it seemed the occipital lobe was swelling. An the burr holes of the primary bone flap are scarcely
extradural hematoma had developed anteri- visible in this projection.
orly extending along the base from the bone
flap. A second bone flap was turned
for such things as tumor, aneurysm, traumat-
anteriorly and the hematoma, which extend-
ic hematomas.
ed into the anterior temporal region, was
Subdural hematoma is a well-known
evacuated (Fig. 1 ). Recovery was compli-
complication after shunts for hydrocepha-
cated by meningitis, which subsided with
lus. ~,s,9 There have also been reports of
antibiotics.
extradural hematoma 2,~ complicating ven-
triculography. 1-4,1~ It is reasonable to
Case 5
assume that in most of these cases an
This 23-year-old man had a left posterior important cause was the abrupt lowering of
parietal parasagittal meningioma removed intracranial pressure in connection with
on February 27, 1973. Toward the end of
the procedure, as hemostasis was well under
way, an extradural hematoma was found
extending basally and forward from the
craniotomy. Since the hematoma was thin
and there was little extradural bleeding or
evidence of rising intracranial pressure,
nothing further was done. A left carotid
angiogram performed immediately after the
wound had been closed verified the presence
of a thin extradural hematoma (Fig. 2).
The patient recovered uneventfully without
specific therapy.

Discussion
Extradural hematomas that develop be-
yond the original bone flap during cranioto-
FI~. 2. Case 5. Immediate postoperative
my are rare. The five we have reported since angiogram showing that the extradural hematoma
1965 occurred among the approximately was reasonably thin. No operation was considered
400 formal craniotomies we do each year necessary for this hematoma.

784 J. Neurosurg. / Volume 40 / June, 1974

Extradural hematoma during craniotomy

ventricular puncture. However, only in Aeta Neuroehir (Wien) 20:31-35, 1969

Cases 1 and 2 is it possible that during the 4. Horwitz NH, Rizzoli HV: Postoperative
Complications in Neurosurgical Prac-
operation so much CSF had been sucked out tice: Recognition, Prevention, Manage-
that the dura fell away from the bone; in ment. Baltimore, Williams & Wilkins,
Case 3, the frontal lobe started protruding 1967
as soon as the first biopsy for a frozen 5. Illingsworth RD: Subdural haematoma after
the treatment of chronic hydrocephalus by
section had been taken, even before lobec- ventriculocaval shunts. J Neurol Neurosurg
tomy had been started. In Cases 4 and 5, Psychiat 33:95-99, 1970
there was little extra space during removal 6. Irsigler FJ: Allgemeine Operationslehre, in
of the tumor. Olivecrona H, T6nnis W (eds): Handbuch
der Neurochirurgie, Vol 4, Part 1.
Our routine operative policy includes the Berlin/GSttingen/Heidelberg, Springer-Ver-
placement of stay sutures in the dura all the lag, 1960, pp 1-121
way around the flap at the time of turning 7. Olivecrona H: The surgical treatment of
the dural flap. Also, after completion of the intracranial tumors, in Olivecrona H, TSnnis
intradural portion of the operation and W (eds): Handbuch der Neurochirurgie,
Vol 4, Part 4. Berlin/Heidelberg/New York,
closure of the dura, permanent tacking Springer-Verlag, 1967, pp 1-301
sutures are placed at intervals of 1 to 1 89 8. Peserico L, Benedetti A, Andrioli GC." Su
cm. The complications reported occurred due casi di ematoma sottodurale acuto
despite the fact that these precautions were insorto dopo intervento di derivazione ventri-
colo-venosa. Min Neurochir 15:118-120,
taken in all five cases. 1971
We suggest that during craniotomy if the 9. Portnoy HD, Schutte RR, Fox JL, et al"
brain appears to be swelling in spite of Anti-siphon and reversible occlusion valves
adequately controlled conditions, it is worth for shunting in hydrocephalus and preventing
examining the boundaries of the bone flap post-shunt subdural hematomas. J Neuro-
surg 38:729-738, 1973
carefully for the type of operative hematoma 10. Robertson JT, Denton IC: Surgical consider-
described in these five patients. ations of ventriculography, in Youmans JR
(ed): Neurological Surgery, Vol 1. Phila-
References delphia/London/Toronto, W B Saunders,
1973, pp 229-234
1. Arias BA, Voris HC: Extradural hemorrhage 11. Teng P, Papatheodorou C: Postoperative
after ventriculography. Am J Surg 116:109- massive epidural haematoma. Neuroehirur-
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2. Candia O: Doppio ematoma extradurale
conseguente a brusco abbassamento della
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9:124-126, 1965 Address reprint requests t o : Henry Troupp,
3. Frera C: Supratentorial extradural haemato- M.D., Neurosurgical Clinic, Topeliuksenkatu 5,
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