|LETTER TO EDITOR
|Year : 2021 | Volume
| Issue : 1 | Page : 25-26
Acute subdural hematoma after spinal surgery
Varun Aggarwal1, Amit Narang1, Chandani Maheshwari2, Paramdeep Singh3
1 Department of Neurosurgery, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
2 Department of Anaesthesia, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
3 Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab, India
|Date of Submission||13-Jul-2020|
|Date of Acceptance||21-Jul-2020|
|Date of Web Publication||04-Jan-2021|
Dr. Paramdeep Singh
Department of Radiology, Guru Gobind Singh Medical College and Hospital, Baba Farid University of Health Sciences, Faridkot, Punjab
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Aggarwal V, Narang A, Maheshwari C, Singh P. Acute subdural hematoma after spinal surgery. Vasc Invest Ther 2021;4:25-6
Intracranial hematoma is an uncommon complication of the spinal cord surgery that may present as extradural hematoma (EDH), acute subdural hematoma (SDH), chronic SDH, intracerebral hematoma (ICH). We report a case of acute SDH after the surgery of intradural extramedullary tumor. A 76-year-old male presented with a history of lower back pain for 6 months, which was radiating to the right lower limb till knee. No history of bladder bowel involvement was seen. On neurologic examination, the patient has no sensory motor deficit with normal deep tendon reflex. Romberg's test was positive. On magnetic resonance imaging, a 1.2 cm × 1.03 cm × 2.2 cm, intradural extramedullary lesion was found at L2-L3 level. Lesion was solid cystic, the cystic area was hypointense on T1-weighted images and hyperintense on T2-weighted images. The solid lesion was isointense on T1-weighted and heterogenous on T2-weighted image. It was abutting and pushing the cauda equina to the left side. These features were suggestive of the intradural extramedullary lesion with the possibility of a schwannoma/neurofibroma [Figure 1]. The patient underwent L2-L3 laminectomy with total excision of tumor. Intraoperatively, lesion was found to arise from one of the cauda equina root intradurally, and histopathology was suggestive of a Schwannoma. On the 5th postoperative day, the patient developed a severe headache, altered sensorium, left hemiparesis, and slurring of speech. There was neither any history of any fall, trauma or seizure nor did the patient had any history of anticoagulant intake. On examination, there was no discharge from the lumber wound. Computed tomography head showed right fronto-temporo-parietal acute SDH with a thickness of 1.5 cm and midline shift of 12 mm toward the contralateral side [Figure 2]. This patient then underwent emergency frontotemporoparietal craniotomy and evacuation of the hematoma. Postoperatively, patient showed clinical improvement and was discharged after 5 days.
|Figure 1: Magnetic resonance imaging showing intradural extramedullary tumor|
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|Figure 2: Computed tomography images showing right Subdural hematoma that was operated upon|
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Spine surgery is linked with a wide range of intraoperative and postoperative complications, also comprising dural tear that not uncommon, with reported incidence rates of 1%–17%. The most common causes of the dural tear are thin dura, adhesion of dura, and surgical technique. The dural tear may cause postural headache, nerve root or brainstem herniation, cerebellar dysfunction, or intracranial hemorrhage.,,,, Intraoperative cerebrospinal fluid (CSF) loss following dural tear may occur unexpectedly due to reasons such as spine surgery, myelography, ventriculoperitoneal shunt placement, epidural anesthesia, spine trauma, etc., The subsequent development of intracranial and/or intraspinal hypotension may result in postural headache usually lasting for 5 days, nerve root or brainstem herniation, cerebellar dysfunction, photophobia, mental status alteration, and seizure in affected patients. One of the rare fatal complications following CSF leak is the formation of intracranial hematoma in different locations comprising acute SDH, extradural hematoma (EDH), and remote cerebellar hemorrhage.,,,,
Intracranial hemorrhage after CSF leakage may occur due to the rupture of the vessels as CSF leak results in a drop in intracranial pressure followed by subdural space expansion and stretching of bridging veins., This can further lead to caudal descent of the brain and creating tension on the dura and fragile subdural veins, making them prone to rupture, with ensuing SDH formation. The inferior displacement of the cerebellum may cause entrapment of venous sinuses between the cerebellum and skull base, lead to acute occlusion of the intracranial bridging veins. Therefore, the venous infarction of the brain parenchyma may also occur.,,, To conclude, massive loss of CSF has been considered a risk factor for intracranial hemorrhage and cerebral infarction.
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.
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Conflicts of interest
There are no conflicts of interest
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[Figure 1], [Figure 2]