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LETTER TO EDITOR
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1255-1256

Postcraniotomy Spontaneous Extradural Hematoma Due to Superficial Temporal Artery Rupture


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Rajesh Kumar Meena
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi - 110 049
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.299167

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How to cite this article:
Das AR, Meena RK, Doddamani RS, Mishra S, Agrawal D. Postcraniotomy Spontaneous Extradural Hematoma Due to Superficial Temporal Artery Rupture. Neurol India 2020;68:1255-6

How to cite this URL:
Das AR, Meena RK, Doddamani RS, Mishra S, Agrawal D. Postcraniotomy Spontaneous Extradural Hematoma Due to Superficial Temporal Artery Rupture. Neurol India [serial online] 2020 [cited 2020 Nov 30];68:1255-6. Available from: https://www.neurologyindia.com/text.asp?2020/68/5/1255/299167




Sir,

A 40-year-old male patient, previously operated for left anterior 1/3 parasagittal atypical meningioma in 2008 [Figure 1]a, presented with a large recurrent lesion, opposite to the previously operated side [Figure 1]b. Patient then underwent bifrontal craniotomy and complete excision of the tumor [Figure 1]c.
Figure 1: Radiology of the patient. (a) Contrast magnetic resonance imaging (MRI) brain showing left anterior 1/3 parasagittal meningioma for which he was operated in 2008. (b) Contrast-enhanced computed tomography (CT) head showing large recurrent right anterior 1/3 parasagittal meningioma (c) CT head after excision of the meningioma. (d) Contrast CT head on 10th postoperative day (POD) showing contrast enhancement (arrow) in the right temporal region suggestive of infection. (e) NCCT head on 12th POD. (f) NCCT head on 20th POD. (g) NCCT head on 22nd POD. (h) NCCT head on 25th POD

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On the 10th postoperative day (POD), patient developed mild grade fever and pus discharge from the suture line. Contrast imaging showed subgaleal collection with exudates (suggestive of infection) [Figure 1]d. Re-exploration of the wound, thorough lavage of the subgaleal space, and bone flap removal was done [Figure 1]e. Pus culture and sensitivity report were sterile. The patient continued to receive broad-spectrum antibiotics.

On 20th POD after the first surgery, the patient developed sudden massive scalp swelling with bleeding from the incision site, which was arterial in nature and difficult to control. Temporary control of bleeding achieved with tamponade. Imaging showed large bifrontal extra dural hematoma (EDH) [Figure 1]f. Intraoperatively, the bleeding was from the superficial temporal artery (STA). The vessel was friable and inflamed, which was coagulated and then ligated with suture. Evacuation of EDH was done.

On 25th POD after the first surgery, i.e., five days after evacuation of EDH, patient continued to have high-grade fever with neck rigidity [Figure 1]g. Diagnostic lumbar puncture was suggestive of meningitis. Lumbar drain was inserted, and patient was started on intravenous as well as intrathecal colistin. After intrathecal instillation of colistin, the lumbar drain was clamped and released after 30 min, following which patient scalp flap started bulging and there was sudden fall in patient Glasgow Coma Scale. Imaging showed large bifrontal EDH with uncal herniation [Figure 1]h. The patient was immediately taken up for surgical evacuation of EDH. Intraoperatively, the source of bleeding was STA at the ligature site, which was coagulated. Despite rapid evacuation of EDH, patient had cardiac arrest intraoperatively, and he could not be revived.

Spontaneous EDH (SEDH) due to nontraumatic causes are of rare occurrence, majority of them were due to bleeding from middle meningeal artery.[1],[2],[3] SEDH as seen in our case from the STA has rarely been reported. Only one such case report exists in the English literature. Madhusudan et al. reported a case of pseudoaneurysm of the STA presenting with EDH.[4] In our case also, STA was found to be friable and inflamed (probably due to bacterial infection and vasculitis) that increased its susceptibility for rupture and EDH formation. Recurrence of EDH for the second time can be attributed to the sudden reduction in ICP following unclamping of the lumbar drain, that stressed already compromised STA vessel and lead to hematoma formation. Although STA biopsy was not sent in our case, we recommend that biopsy from the vessel wall should be sent for histopathological examination to further understand the disease process.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zheng FX, Chao Y. Spontaneous intracranial extradural hematoma: Case report and literature review. Neurol India 2009;57:324.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Yadav P, Verma A, Chatterjee A, Srivastava D, Riaz MR, Kannaujia A. Spontaneous Extradural Hemorrhage in a Patient with Chronic Kidney Disease: A Case Report and Review of Literature. World Neurosurg 2016;90:707.e13-16.  Back to cited text no. 2
    
3.
Chandra PS, Jaiswal A, Mahapatra AK. Bifrontal epidural haematomas following surgery for occipital falcine meningioma: An unusual complication of surgery in the prone position. J Clin Neurosci 2002;9:582-4.  Back to cited text no. 3
    
4.
Madhusudan HV, Krishnamoorthy N, Suresh PK, Subramaniam V. Superficial temporal artery pseudoaneurysm presenting as extradural hematoma: A case report and review of literature. Asian J Neurosurg 2015;10:63-5.  Back to cited text no. 4
[PUBMED]  [Full text]  


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