14AgrawalAmit_DelayedDeterioration 120 Agrawal et al Delayed deterioration following the evacuation of posterior fossa extradural hematoma Delayed deterioration following the evacuation of posterior fossa extradural hematoma Amit Agrawal1, S. Satish Kumar2, Umamaheswara Reddy V.3 1Professor of Neurosurgery, Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 2Associate Professor of Emergency Medicine, Department of Emergency Medicine, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) 3Assistant Professor of Radiology, Department of Radiology, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh (India) Abstract: A missed or delayed detection of intracranial injuries can lead to progressive neuronal damage and secondary brain damage. We present a case of 45 year female presented 8 after the road traffic accident and had a large posterior extradural hematoma on left side with mass effect. In addition there was a small speck of right frontal contusion with localized cerebral edema. The patient initially improved after evacuation of the hematoma. However on 3rd post-operative day she was complaining of headache and became progressively drowsy. A follow up CT scan showed increase in peri-lesional edema around the right frontal contusion with squashing of the lateral ventricles suggestive of diffuse cerebral edema. The patient was shifted back to intensive care unit and responded well to further conservative management. In our patient the events could be collaborated well with existing evidence (presence of contrecoup contusion and on clinical deterioration at day 3). Key words: Delayed deterioration, intracranial hematoma, clinical deterioration, epidural hematoma, posterior fossa. Introduction Posttraumatic posterior fossa extradural hematoma is complicates about 0.3% of all traumatic brain injuries and represents 4% to 12.9% of all extradural hematomas. (1-6) It is well known that a missed or delayed detection of intracranial injuries can lead to progressive neuronal damage and secondary brain damage that can have a negative impact on the clinical outcome. (7) We describe a case of delayed deterioration following evacuation a large posterior fossa extradural hematoma and discuss the possible underlying for this delayed deterioration. Romanian Neurosurgery (2015) XXIX (XXII) 1: 120 - 123 121 Case report A 45 year female presented 8 after the road traffic accident. She was in altered sensorium since the time of injury. She had multiple episodes of vomiting. There was no history of ENT bleed or seizures. Her general and systemic examination was unremarkable. She was in altered sensorium (GCS-E2, V2, and M5). Pupils were bilateral equal and reacting to light. She was moving all four limbs equally. Computed tomography (CT) scan brain plain showed a large posterior extradural hematoma on left side with mass effect and distortion of the 4th ventricle (Figure 1). Figure 1 - Pre-operative CT scan brain plain showing a large posterior fossa extradural hematoma with mass effect and small speck of right frontal contusion (please note the small size and distortion of the fourth ventricle) Figure 2 - Follow up CT scan performed day 3 after surgery showing good evacuation of extradural hematoma, 4th ventricle is opened, however there is increase in peri-lesional edema around frontal contusion and squashing of the lateral ventricles suggesting increase in cerebral edema It also showed a small speck of right frontal contusion with localized cerebral edema. The patient was taken for emergency evacuation of the extradural hematoma. Following surgery she became conscious by next day morning. Her GCS was E4V5 and M6. There were no focal neurological deficits. In view of small speck of cerebral contusion she was started on anti-convulsants, however no anti-edema medications were given. She was apparently alright for two days after surgery and on day 3 she was complaining of headache and became progressively drowsy. There was no vomiting or fever. Her GCS was E1, V1 and M3. Pupils were bilateral equal and reacting. A follow CT 122 Agrawal et al Delayed deterioration following the evacuation of posterior fossa extradural hematoma scan performed day 3 after surgery showing good evacuation of extradural hematoma, 4th ventricle is opened, however there was increase in peri-lesional edema around the right frontal contusion with squashing of the lateral ventricles suggestive of diffuse cerebral edema (Figure 2). The patient was shifted back to intensive care unit, in view of low GCS and respiratory distress endotracheal intubation was performed and she was kept on elective ventilation. She was started on anti-edema measures (injection Mannitol 100 ml intravenous 8 hourly). She responded well to this conservative management, could be weaned off from ventilator and recovered without any neurological deficits. Discussion It has been suggested that concurrent intracranial traumatic lesions which lead to increase in intracranial pressure provide a "protective mechanism" and as soon as this mechanism is withdrawn (either by the use of anti-edema measures or by evacuation of supratentorial mass lesions) it can result in delayed onset of EDH. (8-10) In contrast to this in present case the patient developed increase in the size of supratentorial lesions and there was increase in cerebral edema which resulted in clinical deterioration. Those patients who have associated intracranial injuries (i.e. a contrecoup injuries including subdural hemorrhage or traumatic subarachnoid hemorrhage) had a poor outcome. (11) Formation of cerebral edema is recognized as one of the major factors which can lead to high mortality following traumatic brain injury. (12) It has been shown that delayed deterioration after EDH can result from progressive cerebral edema and ischemia. (13) There is considerable evidence that brain water content is maximal at 2-3 days after traumatic brain injury and it is also the point at which intracranial pressure is also usually at peak. (12, 14) In our patient the events can collaborated well with existing evidence (presence of contrecoup contusion and on clinical deterioration at day 3). It can be recommended patients showing multiple lesions should be carefully observed until their condition is stabilized. (15) Correspondence Dr. Amit Agrawal Professor of Neurosurgery Department of Neurosurgery Narayana Medical College Hospital Chinthareddypalem Nellore-524003 Andhra Pradesh (India) Email- dramitagrawal@gmail.com dramit_in@yahoo.com Mobile- +91-8096410032 References 1.Garza-Mercado R. Extradural hematoma of the posterior cranial fossa. Report of seven cases with survival. Journal of neurosurgery 1983;59:664-672. 2.Campbell E, Whitfield RD, Greenwood R. Extradural hematomas of the posterior fossa. Annals of surgery 1953;138:509-520. 3.Ammirati M, Tomita T. Posterior fossa epidural hematoma during childhood. Neurosurgery 1984;14:541- 544. 4.Bozbuğa M, Izgi N, Polat G, Gürel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurgical review 1999;22:34-40. 5.Malik NK, Makhdoomi R, Indira B, Shankar S, Sastry K. Posterior fossa extradural hematoma: our experience and review of the literature. 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