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Postoperative organised subdural haematoma that involved bridging veins treated by craniotomy
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  1. Kosuke Karatsu,
  2. Tokunori Kanazawa,
  3. Takumi Kuramae and
  4. Masayuki Ishihara
  1. Department of Neurosurgery, National Hospital Organisation Tochigi Medical Center, Utsunomiya, Japan
  1. Correspondence to Dr Tokunori Kanazawa; norinori0128jp{at}yahoo.co.jp

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Description

A man in his 70s underwent burr hole drainage for bilateral chronic subdural haematomas (CSDH) 4 years ago (figure 1A). Three years after the surgery, a similar round mass was observed in the left frontal intracranial region, which increased in size after 1 year (figure 1B–E). His medical history included thoracic aortic dissection, abdominal aortic aneurysm and colon cancer. Routine blood tests showed no abnormal findings, including no elevation of white blood cell count and serum C reactive protein. Contrast-enhanced CT was performed and revealed no obvious feeder or contrast effect (figure 1F). The mass had increased in size, thus a craniotomy was decided to differentiate between subdural haematoma, abscess and tumour. We performed a unilateral frontal craniotomy. After a dural incision, a thick outer membrane of the mass was found. Considering the possibility of an abscess, we detached it from the dura and cortical surface without leaking the contents. The inner membrane was not so adherent to the arachnoid surface. During the process, bridging veins were found to be involved in the mass on the anterior cerebral longitudinal fissure side (figure 2A,B). The veins were detached from the mass by dissecting the capsule along the vessel wall (figure 2C). When the capsule was cut open, a brown, muddy organised haematoma was found (figure 2D). Pathological examination revealed a relatively new haematoma surrounded by thick fibrous tissue with a thin layer of granulation-like tissue on the luminal surface (figure 2E). Postoperative brain CT showed complete capsule removal, without acute haemorrhage. The patient was discharged on the 12th postoperative day without neurological deficits. Six months after the surgery, CT showed no recurrent lesions (figure 2F).

Figure 1

Head CT before burr hole drainage (A) showed bilateral chronic subdural haematomas. Fluid attenuated inversion recovery (FLAIR) image 3 years after burr hole drainage (B). Diffusion-weighted image (C), FLAIR image (D) and T2-star weighted image (E) 4 years after burr hole drainage showed the increasing round mass in the left frontal intracranial region. Contrast-enhanced CT (F) revealed no obvious feeder or contrast effect.

Figure 2

Intraoperative photographs showed that bridging veins (arrowheads) were involved in an organised subdural haematoma (OSDH) (A and B). We detached the veins (arrowhead) by incising the haematoma capsule along the vein wall (C). A brown, muddy organised haematoma was found inside the capsule (D). Pathological examination revealed a new haematoma surrounded by thick fibrous tissue (E). Head CT 6 months after surgery showed no recurrent lesions (F).

Organised SDH (OSDH) is rare among CSDH (0.5%–2%).1 OSDH can be suspected when CT images show mixed density haematomas, calcification or a multiseptated structure. Magnetic resonance images of OSDH often show a heterogeneous web-net-like structure within the haematoma cavity.1 2 However, no such findings were observed in this case, and the mass was round and localised, thus we could not rule out the possibility of subdural abscess or tumour.

OSDH does not usually improve by burr hole drainage and is treated by craniotomy with membranectomy.3 Previous literature does not recommend an inner membrane removal by traction. The inner membrane is often adherent arachnoid surface; therefore, it can damage the cortical surface and is considered to cause postoperative seizures.3 4 Additionally, partial haematoma excision is associated with the risk of postoperative rehaemorrhage from the residual outer membrane of the haematoma and dura.5 6 Herein, detaching the inner membrane was easy, but the penetration of bridging veins made the haematoma removal difficult. We detached the veins by incising the haematoma capsule along the vein wall, but if it is difficult, some haematoma around the veins could be left behind. However, as mentioned previously, partial OSDH removal is considered a risk for postoperative rehaemorrhage and should be kept to a minimum.

Patient’s perspective

Son: ‘We were informed and agreed that my father had an intracranial mass lesion and underwent a small craniotomy. We were relieved with the confirmation of a hematoma and its removal while it was still small. After discharge, he experienced no deficit and was fine’.

Learning points

  • We treated a case of organised subdural haematoma (OSDH) that involved bridging veins by dissecting along the vein wall.

  • In OSDH treatment, the organised haematoma should not be partially removed because of the risk of rehaemorrhage.

  • With a difficulty in detaching the OSDH from the veins, a minimum haematoma should be left behind.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors Study concept or design: KK and TK. Data collection: KK. Data analysis or interpretation: KK. Writing the paper: KK. Management of this patient: KK and TK. Supervisor: TK and MI. All authors have critically reviewed the manuscript and approved the final version of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.