Elsevier

Injury

Volume 43, Issue 5, May 2012, Pages 594-597
Injury

Contralateral subdural effusion related to decompressive craniectomy performed in patients with severe traumatic brain injury

https://doi.org/10.1016/j.injury.2010.06.004Get rights and content

Abstract

Background

Contralateral subdural effusion caused by decompressive craniectomy (DC) is not uncommon. However, it has rarely been reported.

Method

From 2004 to 2008, 123 severe traumatic brain injury (TBI) patients were identified as having undergone DC for increased intracranial pressure (IICP) with or without removal of a blood clot or contused brain. Of these 123 patients, nine developed delayed contralateral subdural effusion. Demographics, clinical presentations, treatment and outcome were reported.

Results

The overall incidence of contralateral subdural effusion was 7.3%. On average, this complication was found 23 days after DC. Of the nine patients, six had neurological deterioration and received drainage through a burr hole. One patient needed a subsequent subduro-peritoneal shunting because of recurrent subdural effusion.

Conclusion

Contralateral subdural effusions may be not uncommon and need more aggressive treatment because of their tendency to cause midline shift. Surgical intervention may be warranted if the patients develop deteriorating clinical manifestations or if the subdural effusion has an apparent mass effect.

Section snippets

Patients and methods

From 2004 to 2008, 123 patients, 18 years of age or older, were retrospectively identified as having undergone DC for refractory IICP with or without removal of a blood clot or contused brain after severe TBI at E-Da Hospital (Kaohsiung, Taiwan).

All patients were admitted to intensive care unit (ICU) and managed according to a protocol that was consistent with the international guidelines for severe TBI.14 Severe TBI was defined as a Glasgow Coma Scale (GCS) score of 8 or less following

Results

All the nine patients were male with an age of 41 ± 13 years (mean ± SD) (range, 28–63 years). The injury mechanism was a motor vehicle accident (MVA) in six and a fall in three patients. The time interval from DC to contralateral subdural effusion was 23 ± 11 days (mean ± SD) (range, 8–39 days).

The clinical manifestations of contralateral subdural effusion were deterioration of consciousness, pupil dilation, muscle power weakness, headache and IICP. The average midline shift on CT scan of these

Illustrative case report

A 29-year-old man was brought to the emergency department of E-Da Hospital because he was a victim of an MVA. On arrival, he was in a deep coma (GCS 4), and his left pupil was dilated and not reactive to light. The initial brain CT scan revealed acute subdural haematoma and contusion haemorrhage in the left fronto-temporo-parietal region, with midline structures deviating to the right (Fig. 1). Emergency left fronto-temporo-parietal decompressive craniectomy and evacuation of the subdural

Discussion

Several possible mechanisms could be responsible for the development of contralateral subdural effusions. Rapid reduction in intracranial pressure as well as outward herniation after decompression may incite a pressure gradient between the two hemispheres and lead to the enlargement of the contralateral subdural space and the accumulation of effusion, especially when, initially, there is a possible rupture in the arachnoid layer after head trauma.12, 13, 16 Rupture of the arachnoid layer

References (16)

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