- Email: [email protected]
Bifrontal epidural haematomas following surgery for occipital falcine meningioma: an unusual complication of surgery in the prone position
582 Chandra et al. 5. 6.
7.
8. 9. 10.
11. 12. 13.
14. 15.
16. 17.
18.
19.
20. 21.
Curri D, Cervellini P, Zanusso M, Benedetti A. Isolated fracture of the occipital condyle. Case report. J Neurosurg Sci 1988; 32: 157±159. Deeb ZL, Rothful WE, Goldberg A, Daffner RH. Occult occipital condyle fractures presenting as tumors. J Comput Tomogra 1988; 12: 261±263. Desai SS, Coumas JM, Danylevich A, Hayes E, Dunn EJ. Fracture of the occipital condyle. Case report and review of the literature. J Trauma 1990; 30: 240±241. Goldstein SN, Woodring JH, Young AB. Occipital condyle fracture associated with cervical spine injury. Surg Neurol 1982; 17: 350±352. Harding-Smith, MacIntosh PK, Sherbon KJ. Fracture of the occipital condyle. J Bone Joint Surg (Am) 1981; 63A: 1170±1171. Leventhal MR, Boydston WR, Sebes JI, Pinstein ML, Watridge CB, Lowrey R. The diagnosis and treatment of fractures of the occipital condyle. Orthopedics 1992; 15: 944±947. Mody BS, Morris EW. Fracture of the occipital condyle: case report and review of the world literature. Injury 1992; 23: 350±352. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle. Neurosurgery 1984; 15: 101±103. Stroobants J, Fidlers L, Storms JL, Klaes R, Duag, Van Hoye M. High cervical pain and impairment of skull mobility as the only symptoms of an occipital condyle fracture. J Neurosurg 1994; 81: 137±138. Tuli S, Tator CH, Fehlings MG, Mackay M. Occipital condyle fractures. Neurosurgery 1997; 41: 368±377. Urculo E, Arrazola M, Arrazola M Jr, et al. Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. Case report. J Neurosurg 1996; 84: 522±525. Young W, Rosenwasser R, Getch C, Jallo J. Diagnosis and management of occipital condyle fractures. Neurosurgery 1994; 34: 257±261. Hashimoto T, Watanabe O, Takase M, Koniyama J, Kobota M. Collet-Sicard syndrome after minor head trauma. Neurosurgery 1988; 23: 367±370. Orbay T, Aykol S, Seckin Z, Ergun R. Late Hypoglossal nerve palsy following fracture of the occipital condyle. Surg Neurol 1989; 31: 402±404. Demisch S, Lindner A, Beck R, Zierz S. The forgotten condyle: delayed hypoglossal nerve palsy caused by fracture of the occipital condyle. Clin Neurol Neurosurg 1998; 100(1): 44±45. Bell C. Surgical observations. Middlesex Hospital 1816; 4: 469±470. (quoted in ref 18) Miltner E, Kallieris D, Schmidt G, Muller M. Injuries of the occipital condyles in fatal traffic accidents. J Leg Med 1990; 103: 523±528.
Bifrontal epidural haematomas following surgery for occipital falcine meningioma: an unusual complication of surgery in the prone position P. Sarat Chandra MCH, Avadhesh Jaiswal MBBS, A. K. Mahapatra MCH Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Summary A 25 year old lady underwent surgery for a left occipital falcine meningioma. The patient was positioned prone and following an occipital carniotomy, total excision of the tumour was performed. In the postoperative period, she developed bifrontal epidural haematomas, for which surgical evacuation was performed. Intracerebral haematomas distant from the site of craniotomies are uncommon and epidural haematomas are extremely rare. The literature is Journal of Clinical Neuroscience (2002) 9(5)
reviewed and the possible mechanisms causing this complication are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 582±584 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.1054, available online at http://www.idealibrary.com on
Keywords: bilateral frontal epidural haematomas, occipital meningioma, surgery in prone position Received 27 June 2001 Accepted 31 August 2001 Correspondence to: Dr. P. Sarat Chandra, Asst Professor, Department of Neurosurgery, Room no. 720, C.N. Center, AIIMS, Ansari Nagar, New Delhi, 110029, India. Tel.: 91 11 6593291 (office), 91 11 6190162 (residence); Fax: 91 11 6862663; E-mail: [email protected]
INTRODUCTION Haematomas developing remotely from the site of craniotomy or craniectomy are rare especially following posterior fossa surgery.1,2 Epidural haematomas are extremely rare.3±5 A case of bilateral frontal epidural haematomas following surgery for occipital meningioma in the prone position is presented. The patient did not have any other risks for developing bleeding like liver disease, hypertension, coagulopathy or was on anticoagulant therapy. We believe that this is a unique complication related to the prone position along with an obliterated superior saggital sinus by the occipital falcine meningioma. CASE REPORT A 25 year old female presented with symptoms of irregular headache for 1 year. She developed worsening of headache and progressive loss of vision in both eyes 4 months before admission. Clinical examination revealed markedly diminished visual acuity (perception of light only in the right eye and 6/12 in the left by Snellen's chart). Examination of fundi revealed bilateral secondary optic atrophy. Visual field examination showed a temporal field cut in the left eye. A complete blood profile showed no evidence of any coagulopathy or any other abnormality and the liver function tests were normal. CT scan (both plain and enhanced) showed a homogeneously enhancing mass in the occipital region on the left side of the falx, with a small amount of tumour also on the right side of the falx (Fig. 1). MRI showed an iso to mildly hyperintense mass on T1 sequence and becoming hyperintense on T2 sequence, the mass being extraaxial, located in the occipital region attached to the left side of the falx (Fig. 2). Some tumour was also seen arising from right of the falx. The superior saggital sinus was completely obliterated as seen by the absence of the flow void (Fig. 2) MR venography. For surgery, she was positioned prone on the horseshoe and a left occipital craniotomy was performed. During surgery, the tumour was found covered by a thin layer of cortex and was arising from the falx. A near total excision of the tumour was performed, and the tumour attached to the sinus and falx was excised and the dura was cauterized. The sinus was not opened. The falx was then cut and the tumour from the opposite was also excised. Complete haemostasis was achieved. However, at the end of the surgery the brain started to bulge. The brain swelling increased progressively, the surgery was terminated at this stage, the dura could not be closed and the bone flap was not replaced. Following the skin closure, the patient was shifted for a CT scan. The postoperative CT scan showed bilateral frontal symmetrical epidural haematomas (Figs 3 and 4). The patient was shifted to & 2002 Published by Elsevier Science Ltd.
Bifrontal epidural haematomas following surgery 583
the operation theatre immediately, and bilateral frontal trephine craniotomies and evacuation of the epidural haematomas was performed. During the surgery large frontal emissary veins were noticed and the frontal bone was very vascular. Following surgery the patient made satisfactory improvement. At discharge, she was conscious and had no focal neurological deficits. The patient was discharged on the eighth postoperative day. The occipital bone flap was replaced after six months.
Fig. 1 CT scan (contrast enhanced) axial section showing a left parieto-occipital parafalcine meningioma pushing the falx to the opposite side.
Fig. 2 MRI of the same patient on T1 weighted sequence. Note the amount of tumour on the opposite side of the falx and absence of the sinus flow void. MR venography showing obstruction of the posterior part of the superior saggital sinus by the tumour (arrow head).
A
DISCUSSION Intracranial haemorrhage occurring remote from the site of craniotomy is a rare postoperative complication. There are only a few reports of this entity in the literature, and most of the cases describe occurrence of intracerebral haemorrhage.1,2,6±14 The occurrences of epidural haematomas distant from the site of craniotomy are extremely rare.3±5 Remote postoperative intracranial haematomas should be distinguished from other types of intracranial haemorrhages. Post craniotomy haemorrhage most commonly occurs at the site of surgery and is attributed to various aspects of intraoperative haemostasis.6 Post craniotomy haemorrhages occurring at a remote location are most commonly intracerebral and various aetiologies like bleeding diathesis, hypertension, aggressive intraoperative brain dehydration, cerebro- spinal fluid drainage and mechanical shifts have been postulated.1,2 Rarely, they can occur in the subdural or the epidural space.3±5 Intracerebral haematomas, remote from the site of craniotomy have been described in supratentorial and infratentorial locations.1,2 Brisman et al.2 have reviewed the literature and have found about 37 cases of intracerebral haematomas reported in 12 different series and case reports including five cases of their own.2,6±14 Most of the remote haemorrhages presented within hours of surgery. At times haematomas may develop immediately suggesting that most of these haematomas develop during or soon after surgery. They felt that the possible causes could be because of disturbances of deep venous drainage or mechanical displacement of the brain. Possibly, aggressive intraoperative dehydration and cerebrospinal fluid drainage could also predispose to shift and contribute to intracerebral haemorrhage.2 Epidural haematomas remote from the site of craniotomy are extremely rare and only a few cases have been reported in the literature.3±5 In the present case, we propose the following mechanism. Our patient had an obliterated posterior part of the superior saggital sinus by the tumour. Hence, it is most likely that venous drainage from the superior saggital sinus had been rerouted through the anterior emissary veins into the veins of the scalp. Therefore, when the patient was positioned in the prone position on a horseshoe, this must have led to the compression of veins of the scalp leading to a retrograde venous stasis in the epidural space. The subsequent rupture of the veins into the epidural space would have led to stripping of the dura and an increasing epidural collection would have led to the formation of bifrontal large epidural haematomas. This
B
Fig. 3 (A) CT scan (plain) performed in the immediate postoperative period showing a right frontal epidural haematoma; (B) Schematic line diagram of axial section of CT scan at a higher level showing frontal epidural haematoma and the occipital craniotomy in diagonally opposite side. The bone flap was not replaced after the first surgery.
& 2002 Published by Elsevier Science Ltd.
Journal of Clinical Neuroscience (2002) 9(5)
584 Hyodo et al.
A
B
Fig. 4 (A) Same study as above at a lower axial section showing bifrontal epidural haematomas; (B) Schematic line diagram of axial section of CT scan imaging at the level of the third ventricle showing bilateral frontal epidural haematomas. The level of craniotomy is at a higher level. 11.
complication possibly could been averted if the patient was positioned with the aid of a three pin clamp, thus avoiding scalp compression. Hence we recommend three-pin fixation in patients with posterior saggital sinus thrombosis.
12.
CONCLUSIONS
14.
Postoperative intracranial haematomas occurring remote from the site of craniotomy are uncommon. Of these, epidural haematomas are extremely rare. In the present case, we feel that this complication occurred as a result of venous stasis due to compression by the horseshoe over the scalp (in the background of an obliterated superior saggital sinus) leading to rupture of the veins draining into the superior saggital sinus and subsequent formation of an epidural haematoma. This complication may have been avoided if a three-pin fixation was used. We feel that in cases where surgery has been performed in the prone position and in whom the superior saggital sinus has been obliterated due to the tumour, surgery in these patients should be performed using a pin fixation system rather than a horseshoe. Our case is unique and to our knowledge is the first of its kind in the literature.
13.
Seiler RW, Zurbrugg HR. Supratentorial intracerebral haemorrhage after posterior fossa operation. Neurosurgery 1986; 18: 472±474. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: A retrospective analysis of 488 cases. Neurosurgery 1984; 14: 649±658. Calenberg VF, Goffin J, Plets C. Cerebellar haemorrhage complicating supratentorial craniotomy. Report of two cases. Surg Neurol 1993; 40: 336±338. Waga S, Shimosaka S, Sakakura M. Intracerebral haemorhage remote from the site of the initial neurosurgical procedure. Neurosurgery 1983; 13: 662±665.
Coil migration during endovascular treatment in a patient with Galenic arteriovenous malformation Akio Hyodo MD PHD, Kiyoyuki Yanaka MD PHD, Noriyuki Kato MD, Tadao Nose MD PHD
REFERENCES 1. 2.
3.
4. 5. 6.
7.
8.
9. 10.
Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral haemorrhage following posterior surgery. J Neurosurg 1978; 49: 881±886. Brisman MH, Bederson JB, Sen CN et al. Intracerebral haemorrhage occurring remote from the craniotomy site. Neurosurg 1996; 39(6): 1114±1120. Fukamachi A, Koizumi H, Nagaseki Y et al. Postoperative extradural haematomas: Computed tomographic survey of 1105 intracranial operations. Neurosurgery 1986; 19: 589±593. Kalfas IH, Little JR. Postoperative haemorrhage: A survey of 4992 intracranial procedures. Neurosurgery 1988; 23: 343±347. Lourie H, Young RF. Posterior epidural haematoma following subfrontal tumour removal. J Neurosurg 1974; 40: 643±646. Fukamachi A, Koizumi H, Nukui H. Postoperative extradural haematomas: Computed tomographic findings after 1074 intracranial operations. Surg Neurol 1985; 23: 589±593. Harders A, Gilsbach J, Weigel K. Supratentorial space-occupying lesions following infratentorial surgery: Early diagnosis and treatment. Acta Neurochir (Wein) 1985; 74: 57±60. Koyabashi S, Sugita K, Gibo H et al. Contralateral pontine haemorrhage as a complication of acoustic neuroma surgery. Surg Neurol 1983; 35: 943±948. Konig A, Laas R, Hermann HD. Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir (Wein) 1987; 88: 104±108. Modesti LM, Hodge CJ, Barnwell ML. Intracerebral haematoma after evacuation of chronic extracerebral fluid collections. Neurosurg 1982; 10: 689±693.
Journal of Clinical Neuroscience (2002) 9(5)
Summary High flow arteriovenous malformations are commonly treated by using an endovascular approach with detachable coils. Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration of a coil mass comprised of several coils is uncommonly seen, and not recorded. We report a case of Galenic arteriovenous malformation in a 22-year-old male in which coil migration was observed during the endovascular procedure. Possible mechanisms are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 584±585 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.0974, available online at http://www.idealibrary.com on
Keywords: arteriovenous malformation, coil migration, detachable coil, vein of Galen Received 27 June 2001 Accepted 24 July 2001 Correspondence to: Kiyoyuki Yanaka MD, PhD, Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan. Tel.: 81-298-53-3220; Fax: 81-298-53-3214; E-mail: [email protected]
& 2002 Published by Elsevier Science Ltd.
7.
8. 9. 10.
11. 12. 13.
14. 15.
16. 17.
18.
19.
20. 21.
Curri D, Cervellini P, Zanusso M, Benedetti A. Isolated fracture of the occipital condyle. Case report. J Neurosurg Sci 1988; 32: 157±159. Deeb ZL, Rothful WE, Goldberg A, Daffner RH. Occult occipital condyle fractures presenting as tumors. J Comput Tomogra 1988; 12: 261±263. Desai SS, Coumas JM, Danylevich A, Hayes E, Dunn EJ. Fracture of the occipital condyle. Case report and review of the literature. J Trauma 1990; 30: 240±241. Goldstein SN, Woodring JH, Young AB. Occipital condyle fracture associated with cervical spine injury. Surg Neurol 1982; 17: 350±352. Harding-Smith, MacIntosh PK, Sherbon KJ. Fracture of the occipital condyle. J Bone Joint Surg (Am) 1981; 63A: 1170±1171. Leventhal MR, Boydston WR, Sebes JI, Pinstein ML, Watridge CB, Lowrey R. The diagnosis and treatment of fractures of the occipital condyle. Orthopedics 1992; 15: 944±947. Mody BS, Morris EW. Fracture of the occipital condyle: case report and review of the world literature. Injury 1992; 23: 350±352. Spencer JA, Yeakley JW, Kaufman HH. Fracture of the occipital condyle. Neurosurgery 1984; 15: 101±103. Stroobants J, Fidlers L, Storms JL, Klaes R, Duag, Van Hoye M. High cervical pain and impairment of skull mobility as the only symptoms of an occipital condyle fracture. J Neurosurg 1994; 81: 137±138. Tuli S, Tator CH, Fehlings MG, Mackay M. Occipital condyle fractures. Neurosurgery 1997; 41: 368±377. Urculo E, Arrazola M, Arrazola M Jr, et al. Delayed glossopharyngeal and vagus nerve paralysis following occipital condyle fracture. Case report. J Neurosurg 1996; 84: 522±525. Young W, Rosenwasser R, Getch C, Jallo J. Diagnosis and management of occipital condyle fractures. Neurosurgery 1994; 34: 257±261. Hashimoto T, Watanabe O, Takase M, Koniyama J, Kobota M. Collet-Sicard syndrome after minor head trauma. Neurosurgery 1988; 23: 367±370. Orbay T, Aykol S, Seckin Z, Ergun R. Late Hypoglossal nerve palsy following fracture of the occipital condyle. Surg Neurol 1989; 31: 402±404. Demisch S, Lindner A, Beck R, Zierz S. The forgotten condyle: delayed hypoglossal nerve palsy caused by fracture of the occipital condyle. Clin Neurol Neurosurg 1998; 100(1): 44±45. Bell C. Surgical observations. Middlesex Hospital 1816; 4: 469±470. (quoted in ref 18) Miltner E, Kallieris D, Schmidt G, Muller M. Injuries of the occipital condyles in fatal traffic accidents. J Leg Med 1990; 103: 523±528.
Bifrontal epidural haematomas following surgery for occipital falcine meningioma: an unusual complication of surgery in the prone position P. Sarat Chandra MCH, Avadhesh Jaiswal MBBS, A. K. Mahapatra MCH Department of Neurosurgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Summary A 25 year old lady underwent surgery for a left occipital falcine meningioma. The patient was positioned prone and following an occipital carniotomy, total excision of the tumour was performed. In the postoperative period, she developed bifrontal epidural haematomas, for which surgical evacuation was performed. Intracerebral haematomas distant from the site of craniotomies are uncommon and epidural haematomas are extremely rare. The literature is Journal of Clinical Neuroscience (2002) 9(5)
reviewed and the possible mechanisms causing this complication are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 582±584 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.1054, available online at http://www.idealibrary.com on
Keywords: bilateral frontal epidural haematomas, occipital meningioma, surgery in prone position Received 27 June 2001 Accepted 31 August 2001 Correspondence to: Dr. P. Sarat Chandra, Asst Professor, Department of Neurosurgery, Room no. 720, C.N. Center, AIIMS, Ansari Nagar, New Delhi, 110029, India. Tel.: 91 11 6593291 (office), 91 11 6190162 (residence); Fax: 91 11 6862663; E-mail: [email protected]
INTRODUCTION Haematomas developing remotely from the site of craniotomy or craniectomy are rare especially following posterior fossa surgery.1,2 Epidural haematomas are extremely rare.3±5 A case of bilateral frontal epidural haematomas following surgery for occipital meningioma in the prone position is presented. The patient did not have any other risks for developing bleeding like liver disease, hypertension, coagulopathy or was on anticoagulant therapy. We believe that this is a unique complication related to the prone position along with an obliterated superior saggital sinus by the occipital falcine meningioma. CASE REPORT A 25 year old female presented with symptoms of irregular headache for 1 year. She developed worsening of headache and progressive loss of vision in both eyes 4 months before admission. Clinical examination revealed markedly diminished visual acuity (perception of light only in the right eye and 6/12 in the left by Snellen's chart). Examination of fundi revealed bilateral secondary optic atrophy. Visual field examination showed a temporal field cut in the left eye. A complete blood profile showed no evidence of any coagulopathy or any other abnormality and the liver function tests were normal. CT scan (both plain and enhanced) showed a homogeneously enhancing mass in the occipital region on the left side of the falx, with a small amount of tumour also on the right side of the falx (Fig. 1). MRI showed an iso to mildly hyperintense mass on T1 sequence and becoming hyperintense on T2 sequence, the mass being extraaxial, located in the occipital region attached to the left side of the falx (Fig. 2). Some tumour was also seen arising from right of the falx. The superior saggital sinus was completely obliterated as seen by the absence of the flow void (Fig. 2) MR venography. For surgery, she was positioned prone on the horseshoe and a left occipital craniotomy was performed. During surgery, the tumour was found covered by a thin layer of cortex and was arising from the falx. A near total excision of the tumour was performed, and the tumour attached to the sinus and falx was excised and the dura was cauterized. The sinus was not opened. The falx was then cut and the tumour from the opposite was also excised. Complete haemostasis was achieved. However, at the end of the surgery the brain started to bulge. The brain swelling increased progressively, the surgery was terminated at this stage, the dura could not be closed and the bone flap was not replaced. Following the skin closure, the patient was shifted for a CT scan. The postoperative CT scan showed bilateral frontal symmetrical epidural haematomas (Figs 3 and 4). The patient was shifted to & 2002 Published by Elsevier Science Ltd.
Bifrontal epidural haematomas following surgery 583
the operation theatre immediately, and bilateral frontal trephine craniotomies and evacuation of the epidural haematomas was performed. During the surgery large frontal emissary veins were noticed and the frontal bone was very vascular. Following surgery the patient made satisfactory improvement. At discharge, she was conscious and had no focal neurological deficits. The patient was discharged on the eighth postoperative day. The occipital bone flap was replaced after six months.
Fig. 1 CT scan (contrast enhanced) axial section showing a left parieto-occipital parafalcine meningioma pushing the falx to the opposite side.
Fig. 2 MRI of the same patient on T1 weighted sequence. Note the amount of tumour on the opposite side of the falx and absence of the sinus flow void. MR venography showing obstruction of the posterior part of the superior saggital sinus by the tumour (arrow head).
A
DISCUSSION Intracranial haemorrhage occurring remote from the site of craniotomy is a rare postoperative complication. There are only a few reports of this entity in the literature, and most of the cases describe occurrence of intracerebral haemorrhage.1,2,6±14 The occurrences of epidural haematomas distant from the site of craniotomy are extremely rare.3±5 Remote postoperative intracranial haematomas should be distinguished from other types of intracranial haemorrhages. Post craniotomy haemorrhage most commonly occurs at the site of surgery and is attributed to various aspects of intraoperative haemostasis.6 Post craniotomy haemorrhages occurring at a remote location are most commonly intracerebral and various aetiologies like bleeding diathesis, hypertension, aggressive intraoperative brain dehydration, cerebro- spinal fluid drainage and mechanical shifts have been postulated.1,2 Rarely, they can occur in the subdural or the epidural space.3±5 Intracerebral haematomas, remote from the site of craniotomy have been described in supratentorial and infratentorial locations.1,2 Brisman et al.2 have reviewed the literature and have found about 37 cases of intracerebral haematomas reported in 12 different series and case reports including five cases of their own.2,6±14 Most of the remote haemorrhages presented within hours of surgery. At times haematomas may develop immediately suggesting that most of these haematomas develop during or soon after surgery. They felt that the possible causes could be because of disturbances of deep venous drainage or mechanical displacement of the brain. Possibly, aggressive intraoperative dehydration and cerebrospinal fluid drainage could also predispose to shift and contribute to intracerebral haemorrhage.2 Epidural haematomas remote from the site of craniotomy are extremely rare and only a few cases have been reported in the literature.3±5 In the present case, we propose the following mechanism. Our patient had an obliterated posterior part of the superior saggital sinus by the tumour. Hence, it is most likely that venous drainage from the superior saggital sinus had been rerouted through the anterior emissary veins into the veins of the scalp. Therefore, when the patient was positioned in the prone position on a horseshoe, this must have led to the compression of veins of the scalp leading to a retrograde venous stasis in the epidural space. The subsequent rupture of the veins into the epidural space would have led to stripping of the dura and an increasing epidural collection would have led to the formation of bifrontal large epidural haematomas. This
B
Fig. 3 (A) CT scan (plain) performed in the immediate postoperative period showing a right frontal epidural haematoma; (B) Schematic line diagram of axial section of CT scan at a higher level showing frontal epidural haematoma and the occipital craniotomy in diagonally opposite side. The bone flap was not replaced after the first surgery.
& 2002 Published by Elsevier Science Ltd.
Journal of Clinical Neuroscience (2002) 9(5)
584 Hyodo et al.
A
B
Fig. 4 (A) Same study as above at a lower axial section showing bifrontal epidural haematomas; (B) Schematic line diagram of axial section of CT scan imaging at the level of the third ventricle showing bilateral frontal epidural haematomas. The level of craniotomy is at a higher level. 11.
complication possibly could been averted if the patient was positioned with the aid of a three pin clamp, thus avoiding scalp compression. Hence we recommend three-pin fixation in patients with posterior saggital sinus thrombosis.
12.
CONCLUSIONS
14.
Postoperative intracranial haematomas occurring remote from the site of craniotomy are uncommon. Of these, epidural haematomas are extremely rare. In the present case, we feel that this complication occurred as a result of venous stasis due to compression by the horseshoe over the scalp (in the background of an obliterated superior saggital sinus) leading to rupture of the veins draining into the superior saggital sinus and subsequent formation of an epidural haematoma. This complication may have been avoided if a three-pin fixation was used. We feel that in cases where surgery has been performed in the prone position and in whom the superior saggital sinus has been obliterated due to the tumour, surgery in these patients should be performed using a pin fixation system rather than a horseshoe. Our case is unique and to our knowledge is the first of its kind in the literature.
13.
Seiler RW, Zurbrugg HR. Supratentorial intracerebral haemorrhage after posterior fossa operation. Neurosurgery 1986; 18: 472±474. Standefer M, Bay JW, Trusso R. The sitting position in neurosurgery: A retrospective analysis of 488 cases. Neurosurgery 1984; 14: 649±658. Calenberg VF, Goffin J, Plets C. Cerebellar haemorrhage complicating supratentorial craniotomy. Report of two cases. Surg Neurol 1993; 40: 336±338. Waga S, Shimosaka S, Sakakura M. Intracerebral haemorhage remote from the site of the initial neurosurgical procedure. Neurosurgery 1983; 13: 662±665.
Coil migration during endovascular treatment in a patient with Galenic arteriovenous malformation Akio Hyodo MD PHD, Kiyoyuki Yanaka MD PHD, Noriyuki Kato MD, Tadao Nose MD PHD
REFERENCES 1. 2.
3.
4. 5. 6.
7.
8.
9. 10.
Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral haemorrhage following posterior surgery. J Neurosurg 1978; 49: 881±886. Brisman MH, Bederson JB, Sen CN et al. Intracerebral haemorrhage occurring remote from the craniotomy site. Neurosurg 1996; 39(6): 1114±1120. Fukamachi A, Koizumi H, Nagaseki Y et al. Postoperative extradural haematomas: Computed tomographic survey of 1105 intracranial operations. Neurosurgery 1986; 19: 589±593. Kalfas IH, Little JR. Postoperative haemorrhage: A survey of 4992 intracranial procedures. Neurosurgery 1988; 23: 343±347. Lourie H, Young RF. Posterior epidural haematoma following subfrontal tumour removal. J Neurosurg 1974; 40: 643±646. Fukamachi A, Koizumi H, Nukui H. Postoperative extradural haematomas: Computed tomographic findings after 1074 intracranial operations. Surg Neurol 1985; 23: 589±593. Harders A, Gilsbach J, Weigel K. Supratentorial space-occupying lesions following infratentorial surgery: Early diagnosis and treatment. Acta Neurochir (Wein) 1985; 74: 57±60. Koyabashi S, Sugita K, Gibo H et al. Contralateral pontine haemorrhage as a complication of acoustic neuroma surgery. Surg Neurol 1983; 35: 943±948. Konig A, Laas R, Hermann HD. Cerebellar haemorrhage as a complication after supratentorial craniotomy. Acta Neurochir (Wein) 1987; 88: 104±108. Modesti LM, Hodge CJ, Barnwell ML. Intracerebral haematoma after evacuation of chronic extracerebral fluid collections. Neurosurg 1982; 10: 689±693.
Journal of Clinical Neuroscience (2002) 9(5)
Summary High flow arteriovenous malformations are commonly treated by using an endovascular approach with detachable coils. Although the risk of coil migration or distal embolisation into the venous system is almost always a consideration when treating these lesions, coil migration of a coil mass comprised of several coils is uncommonly seen, and not recorded. We report a case of Galenic arteriovenous malformation in a 22-year-old male in which coil migration was observed during the endovascular procedure. Possible mechanisms are discussed. & 2002 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2002) 9(5), 584±585 & 2002 Published by Elsevier Science Ltd. DOI: 10.1054/jocn.2001.0974, available online at http://www.idealibrary.com on
Keywords: arteriovenous malformation, coil migration, detachable coil, vein of Galen Received 27 June 2001 Accepted 24 July 2001 Correspondence to: Kiyoyuki Yanaka MD, PhD, Department of Neurosurgery, Institute of Clinical Medicine, University of Tsukuba, Tsukuba, Ibaraki 305-8575, Japan. Tel.: 81-298-53-3220; Fax: 81-298-53-3214; E-mail: [email protected]
& 2002 Published by Elsevier Science Ltd.