and Left Infratentorial - Case Report
Emad EH H Mohamed1, Sallah I Tantawy2
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INTRODUCTION
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We report this case as we
failed to find a similar one in the available literature and also because
of the unexpected transient post-operative deterioration.
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CASE
REPORT
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A 68-year-old fisherman was evaluated because of increasing headache, confusion, gait disturbance and urinary incontinence, which began approximately one month prior to admission. There had been no visual, motor or sensory complaints. He was not on any medication, had no other medical illnesses and had suffered no recent trauma. On examination, Glasgow Coma Score (GCS) was E3 V2 M4 = 9, he was lethargic, pupils were equal and reactive and both fundi showed early papilloedema. He demonstrated generalised hyperreflexia and bilateral extensor planters. The remainder of his neurological examination was unremarkable. The laboratory tests including bleeding, coagulation and prothrombine times, full blood picture, main liver and kidney function tests were normal. Skull and chest x-ray did not reveal any abnormalities but plain computed tomography of the brain (Fig. 1) showed a bilateral hypodense frontoparietal and a left posterior fossa chronic subdural haematoma (CSDH). There was no supratentorial midline shift but the fourth ventricle was distorted.
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Surgery and operative findings: The patient was
given 8 mg dexamethasone and under general anaesthesia large burr
hole “small craniectomy” drainage was carried out starting with the
right side, then left side and lastly the posterior fossa. The haematoma
were watery in consistency, amber to brown in colour with no solid
elements and under moderate tension. The posterior fossa one was lighter
and under higher pressure. A soft catheter was left in each cavity
connected to a closed non-suction drainage system. Post-operative course: Over the first 24 hours GCS was E1 V1 M4 = 6 compared to 9 pre-operatively with sluggish equal pupils and slow deep respiration. There were no electrolyte imbalance but arterial blood gases showed hypoxia, which was treated with oxygen nasal cannular at 4 litres per minute. The improvement was slow but progressive and on the fourth post-operative day GCS was E4 V3 M6 = 13. Three months later he was able to resume his work as before. |
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DISCUSSION
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Bilateral CSDH is well known but posterior fossa CSDH is very rare and
having both together has not been previously reported. CT scan may fail
in direct demonstration of CSDH but the failure rate can be minimised
by using a contrast enhancement, patient’s sedation or general anaesthesia,
xenon inhalation and the improved resolving power of newer CT scans.(3)
Magnetic resonance imaging is superior in detecting CSDH especially when
in a subtemporal or subfrontal position or when related to the tentorium.(2)
The cause of the transient post-operation deterioration is not definite
but could be due to the sudden massive decompression at multiple sites.
If so, would the twist-drill craniotomy under local anaesthesia with slow
continuous catheter drainage have been more helpful?(4 )
In bilateral CSDH it is recommended for the larger to be evacuated first
but both sides should be done in a single operative session.(1) The timing
of evacuation of an associated posterior fossa haematoma has not, so far,
been settled.
In conclusion, having infratentorial and supratentorial CSDH together
should be given more attention and the treatment must be carefully planned.
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REFERENCES
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| 1. | Douglas Miller J: Surgical management of acute and chronic subdural haematoma. In Schmideh HH, Sweet WH (Eds), Operative neurosurgical techniques, indications, methods and results. WB Saunders, Philadelphia 1988 (1): 33-36 |
| 2. | Hadley DM: Magnetic resonance imaging – how has it helped the neurosurgeon? In: Teasdale GM, Douglas Miller J (Eds). Current Neurosurgery. Churchill Livingstone 1992, 157-184 |
| 3. | Lanksch W, Frumme TH, Kazner E: Computed tomography in head injuries. Translated by Dougherty FC, Springer-Verglag, Berlin Heidelberg, New York 1979, 48-64 |
| 4. | Camel M, Grubb RL Jr: Treatment of chronic subdural haematoma by twist-drill crainotomy with continuous catheter drainage. J Neurosurg 1986, 65: 183-187 |
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