Abstract
A case of epidural hematoma secondary to a ventriculoperitoneal shunt for hydrocephalus was described, and 42 cases of epidural hematoma as a complication of internal decompression were reviewed from the literature. Internal decompression in 42 cases consisted of ventricular puncture, ventricular drainage, ventriculography or shunt with or without suboccipital craniectomy in 35 cases, and supratentorial craniotomy without these procedures, but with certain other procedures such as suction of cerebrospinal fluid during surgery in 7 cases.
The authors' case was a 19 year-old female who had a left frontal arteriovenous malformation which caused an intracerebral hematoma and intraventricular hemorrhage. She was treated by evacuation of the intracerebral hematoma and total resection of the arteriovenous malformation. External drainage from the left lateral ventricle was performed for 2 days. Postoperative meningitis was followed by communicating hydrocephalus, and a right ventriculoperitoneal shunt was installed 2 months after the hemorrhage. After the operation the patient was awake, but became drowsy in one hour. A large right temporoparietal epidural hematoma was detected by CT scan. After immediate evacuation of the hematoma, the patient recovered with left hemiparesis which cleared in 3 months without deficit.
A review of the literature shows that epidural hematomas following internal decompression tend to arise in young and middle aged patients from 10 to 40, whereas subdural hematomas following shunt procedure tend to arise in infants and the elderly. Epidural hematoma is not always related to the operative site or side. One of explanations of the epidural hemorrhages is detachment of the dura as a result of dural contraction due to its elasticity under falling intracranial pressure. In 67.4% of a total of 43 cases including our case, onset of signs and symptoms appeared during the operation or in a few hours after the operation. In 25.6%, epidural hematoma was not disclosed before death and in 27%, it was found by exploratory burr holes, burr holes for shunts or decompressive craniotomy. Only 23.2% or 4.6% of all cases were adequately diagnosed preoperatively by angiography or CT scan, respectively. Prognosis of the epidural hematoma complicating internal decompression was quite poor and 44.2% of the cases died and 11.6% recovered with deficits.
It is necessary to keep the possibility of acute epidural hematoma in mind during or after internal decompression and to examine the patient immediately by CT scan for unexplainable postoperative or intraoperative events.
