Postoperative epidural hematoma as a rare complication after intracranial tumor resection: a case series report and causes analysis

Abstract

Background: To review the treatment and the causes of postoperative epidural hematoma (PEDH) after intracranial tumor resection.

Method: A retrospective case study was conducted to examine a series of patients who developed PEDH as a complication following intracranial tumor resection between January 2016 and June 2021. The study collected data from hospital charts, including clinical status at admission, imaging results, histopathologic findings, surgical management, complications, and outcomes. Causes of PEDH were evaluated through a review of operative notes and discussions with the surgical team.

Results: Twenty-five patients (10 males, 15 females; median age 42 years, range 11-61 years; median medical history 27 months, range 1-96 months) were enrolled in the study. Regarding tumor location, 16 cases exhibited supratentorial brain tumors, 4 cases had infratentorial brain tumors, 2 cases of tumors occurred in the petroclival region, 2 cases in the peritorcular region, and 1 case in the pineal region. Four of these cases were complicated with supratentorial hydrocephalus. The 25 cases in this study were classified into four types based on location. Type 1 refers to EDHs that occur at the adjacent site of the operative field without involvement of the surgical area. Type 2 includes hematomas that occur at the adjacent site of the surgical area and the surgical area. Type 3 includes EDHs that occur in distant areas, and type 4 involves EDHs in the surgical field. The numbers of cases of types 1, 2, 3, and 4 PEDHs were 16, 2, 3, and 4 cases, respectively. Most PEDHs were associated with reduced ICP after craniotomy due to intracranial tumor resection and substantial loss of CSF. All patients achieved satisfactory outcomes after hematoma evacuation.

Conclusion: The decrease in ICP resulting from intracranial tumor resection and CSF loss might lead to PEDHs. By employing optimized surgical techniques and meticulous patient management to prevent rapid decreases in ICP and dural detachment, we can potentially lower the incidence of PEDHs. Additionally, prompt evacuation of hematomas can contribute to positive outcomes.

Keywords: Brain tumor; Craniotomy; Epidural hematoma; Postoperative complication.

Fig. 1

Schematic representation of the four types of PEDH based on the location. Type 1 PEDH: hematoma formation adjacent to the surgical site, without involvement of the surgical area (A, E). Type 2 PEDH: hematoma at both the adjacent site and within the surgical area (B, F). Type 3 PEDH: EDH occurring in remote areas or on the contralateral side of the surgical area (C, G). Type 4 PEDH: hematoma within the surgical field (D, H). The black arrows in A, B, C, and D indicate bone flaps. The white arrows in E, F, G, and H demarcate bone flaps. The asterisk in H highlights the epidural drainage tube

Fig. 2

MRI with contrast enhancement revealing a giant parasagittal meningioma (A and B). CT scan showing a type 1 PEDH on the left frontal-parietal lobe (C). CT scan demonstrating the liquefaction of the EDH 2 weeks later (D). After the EDH evacuation via burr hole and drainage procedure, a CT scan was obtained (E). CT scan obtained 3 months later (F)

Fig. 3

MRI with contrast enhancement revealing a right peritorcular meningioma (A and B). A type 2 PEDH on the bilateral occipital lobe (C). The causes of PEDH were attributed to the failure of dura suspension and bleeding in the sagittal sinus, according to the operative note. The CT bone window showed that the bone flap reached the midline, possibly leading to incomplete suspension due to the sagittal sinus (D). The EDH was evacuated (E). MRI with contrast enhancement obtained 3 months after surgery (F)

Fig. 4

The enhanced MRI showed a tumor in the right ventricle (A, B). The postoperative CT showed PEDH on the contralateral (left) temporal-parietal-occipital region (C). CT of the patient following acute extradural hematoma evacuation surgery (D). And enhanced MRI (E, F) 3 months post-surgery was obtained for a follow-up examination

Fig. 5

SWI revealing multiple cavernous angiomas (A, B, and C). CT scan demonstrating a type 4 PEDH-epidural hematoma located under the surgical field following tumor resection (D). CT scan showing that the hematoma had been successfully evacuated (E). CT scan obtained 3 months postoperatively (F)

Fig. 6

Different reasons lead to dural stripping. There are two distinct methods of separating the dura from the inner table of the skull. The relative displacement between the inner skull plate (red dot a) and the dura (red dot b) may result in dural detachment, which can cause extradural vessel hemorrhage. The vertical and parallel direction relative displacement is caused by forces in different directions (A). The use of a milling cutter can cause dural stripping (B). Downward pressure is produced by the lever principle when using the Penfield dissector to remove the bone flap (C). When exposing a giant meningioma, due to the large bone window and intracranial hypertension, intracranial content bulges through the opening, leading to the displacement of the dura and bone window margin in a parallel direction (D). Falling intracranial pressure causes the cortex to collapse and result in dural detachment (E)

Fig. 7

It can be difficult to place close subdural stay sutures when the dural suspension involves the sagittal sinus (A). Fully exposing the sagittal sinus makes it easier to place stay sutures (B)