Clinical Neurology and Neurosurgery 113 (2011) 496–498
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Case Report
Subdural haematoma after endoscopic skull base surgery: Case report and lesson learned I. Dallan a,∗ , R. Lenzi a , L. Muscatello a , M. Bignami b , P. Battaglia b , P. Castelnuovo b a b
ENT Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy Dept. of Otorhinolaryngology, University of Insubria, Varese, Azienda, Ospedaliero Universitaria Ospedale di Circolo e Fondazione Macchi, Varese, Italy
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Article history: Received 4 September 2009 Received in revised form 7 November 2010 Accepted 24 January 2011 Available online 2 March 2011 Keywords: Cerebrospinal fluid leak Subdural haematoma Endoscopic Multilayer Plasty Sinonasal malignancies
a b s t r a c t We report a case of a left fronto-temporo-parietal subdural haematoma that emerged as a complication of an endonasal endoscopic resection of a sinonasal adenocarcinoma of the left ethmoidal region. During the first surgical intervention, following oncological principles, the dura mater above the ethmoidal plate was removed and a skull base plasty was performed. In the post-operative phase a massive cerebrospinal fluid leak was observed and a revision duraplasty was performed the following day. Subsequently the patient was discharged on day 8 with no signs of CSF leakage. At the three month follow-up MR examination a subdural haematoma was observed and then treated by the neurosurgeon in a standard fashion. The collection was quite asymptomatic and discovered accidentally. We strongly advise the role of early post-op neuroimaging in every patient undergoing skull base procedures. We maintain that a massive CSF leak, that causes a significant reduction of intracranial pressure, should be managed as a surgical emergency, in order to reduce the risk of subdural haematoma. © 2011 Elsevier B.V. All rights reserved.
1. Introduction Endonasal skull base surgery can be associated with critical complications [1]. Of these, cerebrospinal fluid (CSF) leak is the commonest, being described in around 5% of cases after endonasal skull base surgery [2,3]. Acute subdural haematoma (SDH) is rare but potentially a fatal complication of CSF leaks. We document a case of SDH as a complication of endonasal endoscopic surgery for sinonasal malignancy, an entity that to our knowledge has not been previously reported yet, and we hereby discuss the pathogenesis and management aspects. 2. Illustrative case A 62 year-old male with an intestinal-type adenocarcinoma of the left ethmoid was admitted to the ENT unit of the University of Pisa. The tumor was classifiable as cT3N0M0 according to the 2002 tumor-node-metastases (TNM) UICC classification system. After a careful diagnostic work-up (CT scan, MRI, nasal endoscopy with biopsy), he underwent an endonasal endoscopic resection (EER) of the tumor following our codified surgical technique [4] with skull base reconstruction, performed with a multilayer fascia lata free
∗ Corresponding author at: ENT Unit, Azienda Ospedaliero Universitaria Pisana, via Paradisa, 3, 56124 PISA, Italy. Tel.: +39 050 997501; fax: +39 050 997514. E-mail address:
[email protected] (I. Dallan). 0303-8467/$ – see front matter © 2011 Elsevier B.V. All rights reserved. doi:10.1016/j.clineuro.2011.01.009
graft. After the surgical resection was completed the dural defect needed to be closed. Fascia lata was used to repair the defect: two layers were placed underlay (intracranial intradural) and a third layer was placed overlay (extracranial). Fibrin glue, Gelfoam (Pfizer, New York, NY) and nasal packing stabilized the plasty. As usual, postoperative antibiotics, antihistamine and laxative medications were prescribed. A few hours after surgery the patient had 2 episodes of vomiting and on the first day after surgery a massive CSF leak was observed. During revision surgery the grafts were found to be slightly displaced and a defect between the anterior dural margin of resection and the graft was visible. A second multilayer skull base plasty was performed following the same principles of the first reconstruction. The intradural layers (especially anteriorly) were carefully positioned in order to make possible a proper overlapping of the dural edge over the grafts. An antiemetic therapy was prescribed after surgery. The subsequent recovery was uneventful and the patient was discharged on the eighth postoperative day without signs of CSF leakage. During the follow-up phase the patient underwent serial endoscopic examinations with removal of crusting and cleaning of the nasal cavities. During the visits the patient complained of a vague and mild headache but no significant attention was given to this symptom. On the whole the patient was well and regained his normal living status. At the three-month followup MRI examination, a subdural haematoma was observed in the left fronto-temporo-parietal region (Fig. 1). No neurological signs were present. Since we believed that the subdural haematoma was causing the headache, the patient underwent a burr hole evacua-
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Fig. 1. A-endoscopic view of the dural window (GR-gyrus rectus, FPa-frontopolar artery, OT-olfactory tract); B-endoscopic appearance at one-month follow-up (rMT-right middle turbinate, RP-rhinopharynx); C-MR image at 3-month followup. The skull base plasty (arrow heads) and the subdural haematoma-higroma (*) are visible; D-MR image at 3-month follow-up. The subdural haematoma-higroma is clearly visible. No midline shift and mass effect are present.
tion under local anaesthesia and was dismissed 2 days later without any neurological deficit. At the last follow-up visit (13 months) the patient was well and without any sign of disease. 3. Discussion The ability to repair endoscopically surgical defects of the skull base has greatly improved over the last years, mostly due to a standardized multilayer technique [5] and the development of vascularised nasal flaps [6]; nevertheless, CSF leak remains an important concern after extended skull base procedures and is considered the most frequent major complication of this kind of surgery [2,3]. Frequently, in the case of ethmoidal malignancies, the nasal septum needs to be removed to perform an oncologically sound resection, therefore vascularised naso-septal flaps are not available to reconstruct the skull base. Indeed, autologous fascia lata is our preferred material to perform a skull base plasty in the majority of cases. In some cases, especially after transsphenoidal surgery, slight postoperative CSF leakage can be managed conservatively with success. In this sense lumbar draining with continuous drainage of CSF and bed rest are proposed as the preferred options. Nevertheless, the risk of pneumocephalus is always present and surgical revision should always be considered an important option in case of CSF leakage. In this sense a CT scan
allows an adequate evaluation of the condition of the patient. When pneumocephalus is present, the use of lumbar drain is contraindicated. Furthermore, it is well known that any CSF drainage procedure can result in SDH [7,8]. In such conditions it is the negative pressure caused by a CSF leak that results in subdural collection [9]. We report the case of a SDH that developed after endoscopic surgery of the anterior skull base. SDH has been previously reported for transsphenoidal surgery [10,11] but never in endoscopic anterior skull base surgery. We wish to underline the concept that skull base endosurgeons must be aware of this complication, as delays in detection can be fatal. In our patient we observed a SDH without significant symptoms and neurological signs. The discovery was accidental, during the 3 month follow-up MR examination. Two main lessons have been learned from the re-evaluation of our case: firstly, neuroimages should be obtained early after an anterior skull base procedure with a dural window. In our opinion a CT scan should be performed 24–48 h after the procedure and before the patient is discharged. Certainly a post-op CT scan could have helped us in recognizing this complication in our patient who fortunately developed no sequelae related to SDH; however, in other reported cases this did not happen [10]. Furthermore, SDH can be extremely difficult to recognize because it can be present even in the absence of symptoms. This is what happened in our case,
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where the patient did not manifest significant symptoms and had regained his normal life status. We underline that a high grade of clinical watchfulness is necessary. Secondly, the flow of CSF leaks is critical. Low flow leaks (csf “tears”) can be repaired with no hurry and can certainly be managed with a post-surgical care program, spine drainage and eventually revision duraplasty within 1 week. In contrast, massive high flow leaks should be repaired immediately. They produce a significant reduction of intracranial pressure, thus increasing the tension forces on the bridging veins which drain the underlying neural tissue and puncture the dura mater to empty into dural venous sinuses. In this sense, a severe intracranial hypotension can be suspected at surgery when the intracranial grafts are not pushing on the skull base but on the contrary are sucked into the cranial cavity. From a pathogenetic point of view different factors can predispose to the formation of a SDH. Atrophy of the brain certainly represents a potential cause, given the greater tension of the bridging veins. Furthermore, CSF leaking through the dural window may increase the negative intracranial pressure. This can increase the tension forces on these venous vessels thus resulting in their breaking and consequently in bleeding. Also the presence of a tension pneumocephalus, which can increase the tension on the bridging veins, can contribute to SDH [11]. In summary, we strongly stress the necessity to maintain a high degree of clinical watchfulness after every skull base procedure. Early post-op imaging is definitely advisable in every patient undergoing skull base procedures. The absence of neurological symptoms is definitely not sufficient to exclude such a diagnosis. 4. Conclusion SDH represents a rare but potentially fatal complication after endoscopic skull base procedures. Endosurgeons should be aware
of this. Postoperative high-flow CSF leak should be considered a surgical emergency and the patient should undergo revision surgery as soon as possible to prevent this occurrence. The role of early post-op neuroimaging is critical in detecting such complications. References [1] Carrau RL, Kassam AB, Snyderman CH, Mintz AH, Gardner P. Complications of endoscopic endonasal skull base surgery. In: Practical endoscopic skull base surgery. San Diego: Plural Publishing; 2007. p. 203–12. [2] Kassam A, Carrau RL, Snyderman CH, Gardner P, Mintz A. Evolution of reconstructive techniques following endoscopic expanded approaches. Neurosurg Focus 2005;19(1):E8. [3] Villaret AB, Yakirevitch A, Bizzoni A, Bosio R, Bignami M, Pistochini A, et al. Endoscopic transnasal craniectomy in the management of selected sinonasal malignancies. Am J Rhinol Allergy 2010;24(1):60–5. [4] Nicolai P, Battaglia P, Bignami M, Bolzoni Villaret A, Delù G, Khrais T, et al. Endoscopic surgery for malignant tumors of the sinonasal tract and adiacent skull base: a 10-year experience. Am J Rhinol Allergy 2008;22(3): 308–16. [5] Castelnuovo P, Delù G, Locatelli D, Padoan G, De Bernardi F, Pistochini A, et al. Endonasal endoscopic duraplasty: our experience. Skull Base 2006;16(1):19–24. [6] Hadad G, Bassagasteguy L, Carrau RL, Mataza JC, Kassam A, Snyderman CH, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope 2006;116(10):1882–6. [7] Gaucher jr DJ, Perez JAjr. Subdural hematoma following lumbar puncture. Arch Intern Med 2002;162:1904–5. [8] Mizuno J, Mummaneni PV, Rodts GE, Barrow DL. Recurrent subdural hematoma caused by cerebrospinal fluid leakage. J Neurosurg Spine 2006;4:183–5. [9] Poonnoose SI, Manjooran RP, Mathew J, Ramachandran P. Chronic subdural haematoma associated with nontraumatic CSF rhinorrhea: A management challenge. J Clin Neurosci 2007;14(3):281–3. [10] Menon G, Bahuleyan B, Nair S. Acute subdural hematoma after transsphenoidal surgery. J Clin Neurosci 2009;16:160–2. [11] Eloqayli H, Cappelen J, Vik A. Acute spontaneous subdural hematoma after transsphenoidal surgery. Acta Neurochir (Wien) 2006;148:587–90.
