|Year : 2012 | Volume
| Issue : 3 | Page : 159-161
Chronic ossified extradural hematoma on the opposite side of the ventriculoperitoneal shunt procedure: A rare case report
Shashi Kant Jain, I Vijay Sundar, Vinod Sharma, Rajneesh Arora, KL Prasanna
Department of Neurosurgery, SMS Medical College and Hospital, Jaipur, Rajasthan, India
|Date of Web Publication||15-Jan-2013|
Shashi Kant Jain
Professor of Neurosurgery, 230, Himmat Nagar, Gopalpura Mode, Jaipur, PIN - 302018, Rajasthan
Source of Support: None, Conflict of Interest: None
Extradural hematoma (EDH) after ventriculoperitoneal shunt procedure is a rare, dangerous but easily manageable complication. It is more common in children and young adults presumably due to relatively lax adhesion of dura to calvarium. We report a case of a 20-year-old male with acqueductal stenosis who underwent ventriculoperitoneal shunt procedure and was discharged after 1 week. A follow-up computed tomographyscan 2 months later showed a chronic ossified EDH in the left frontal reigon. The ventricular catheter was in position and the ventricles were decompressed. Because the patient was asymptomatic, he was managed conservatively. A brief discussion of factors that lead to formation of EDH is included, with stress on techniques to prevent or minimize such complications.
Keywords: Adult, contralateral, extradural hematoma, ossified, ventriculoperitoneal shunt
|How to cite this article:|
Jain SK, Sundar I V, Sharma V, Arora R, Prasanna K L. Chronic ossified extradural hematoma on the opposite side of the ventriculoperitoneal shunt procedure: A rare case report. Saudi J Health Sci 2012;1:159-61
|How to cite this URL:|
Jain SK, Sundar I V, Sharma V, Arora R, Prasanna K L. Chronic ossified extradural hematoma on the opposite side of the ventriculoperitoneal shunt procedure: A rare case report. Saudi J Health Sci [serial online] 2012 [cited 2022 Jan 27];1:159-61. Available from: https://www.saudijhealthsci.org/text.asp?2012/1/3/159/106087
| Introduction|| |
Ventriculoperitoneal shunt procedures involve sudden decompression of the brain that can lead to subdural hematoma (SDH) or extradural hematoma (EDH) formation. Formation of EDH is relatively rare, more so on the side contralateral to the shunt procedure. Very few cases of EDH formation on the contralateral side to ventriculoperitoneal VP shunt have been reported in the literature. We report this case to spread awareness of this relatively rare complication of a very common neurosurgical procedure, which, in some cases, can be avoided, and, in all cases, can be diagnosed and managed easily before it turns into a catastrophic complication.
| Case Report|| |
A21-year-old male presented to us with long-standing headache. His neurological examination was normal. A computed tomography (CT) scan brain showed moderate obstructive hydrocephalus with triventricular dilatation due to acqueductal stenosis [Figure 1]. The patient underwent right-sided ventriculoperitoneal shunt procedure through right parietal burr hole using medium pressure Chabra slit and spring device. Right frontal burr hole was also made. Post-operatively, the patient improved symptomatically and was discharged after 5 days. The patient was in follow- up thereafter, and a routine follow-up CT scan brain done 2 months later revealed a chronic ossified left frontal EDH [Figure 2]. There was no mass effect or midline shift. A coagulation profile was done, which was normal. Because the patient was asymptomatic, he was managed conservatively and no further investigations for intracranial hypotension were done. He has been on regular follow-up for the past 4 months, and has no neurological deterioration.
|Figure 2: Post operative CT showing calcified EDH on the contralateral side to VP shunt|
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| Discussion|| |
EDHs are contact injuries resulting from blunt trauma to the skull and meninges. It is thought that the initial impact produces detachment of the dura directly beneath the site of the blow and injures blood vessels. Formation of acute SDH after ventricular decompression is well known in neurosurgical practice. As the brain slackens after decreasing ventricular pressure, the subdural bridging veins are stretched and may get torn, causing SDH. EDH however is a rare complication of ventriculoperitoneal shunt surgery, with most reported cases in children  and young adults. This is thought to be due to the firm attachment of the dura to the skull in older adults. It is reported to be more frequent in the frontal and parietal reigons and in patients withlong-standing hydrocephalus.
EDH is much rarer after ventricular drainage because the dura is generally adherent to the inner surface of the skull.  The principal mechanism for hematoma formation after ventricular decompression is sudden lowering of intra-cranial pressure, which results in a suction force on structures between the cortex and the inner table of the skull.  Tearing of cortical bridging or meningeal vessels may lead to the formation of SDH or EDH, respectively. In case of the latter, detaching the collagenous fixation of the dura from the inner table of the skull may initially cause the dural and diploic veins to bleed into the epidural space. As the hematoma enlarges and the distance between the dura and the bony arterial channels increases, the dural arteries may also tear.
Many authors thought that the traction exerted on the duramater by the many vessels attached to the brain cause a displacement and make the vessels between the membrane and the skull to be torn. This is supported by the fact that most reported cases occur in children, in whom the dura is less tightly adhered to the skull than in adults. Craniocerebral disproportion may be responsible in some patients.  Other mechanical factors mentioned include bridging vein tearing and dural detachment because of brain parenchyma displacement induced by cerebrospinal fluid (CSF) drainage. A sudden lowering of intracranial pressure, due to cortex collapse, helps hematomas, increasing up to a catastrophic complication if not recognized and treated in time.
In case of EDH directly adjoining the burr hole site of VP shunt, excessive coagulation of dura of the burr hole before dural incision may, in some cases, cause enough shrinkage to result in dural separation from the skull and EDH formation. This dural separation is further aided by rapid lowering of intracranial pressure.
Once bleeding has begun by any mechanism, arterial bleeding into the resulting pocket creates a hydraulic "water press" effect, progressively stripping away the dura from the skull and widening the perimeter of the hematoma.
Usage of valve-regulated shunt systems has lowered the incidence of SDH and EDH after ventricular drainage. There are only 18 cases of epidural hematomas after valve-regulated shunt placement in the literature.  Most of these cases had acute hematomas, and only five of them had chronic calcified/ossified hematomas.  These patients were 15-35 years old. In all epidural hematomas, the incidence of chronic EDH is between 3.9% and 30%. Chronic EDH occurs more commonly in younger ages.
A postoperative epidural hematoma usually causes symptoms during or immediately after surgery. However, the diagnosis may be delayed in a case with VP shunt insertion because of a reduction in CSF volume in the ventricles via a properly functioning shunt. 
The most common initial symptom is a headache, and there may be seizures in delayed cases.  The hematomas were unrelated to the burr-hole sites in most of the EDH cases due to a ventriculoperitoneal shunt.
Post-shunt EDH can be managed surgically and conservatively. The choice between a surgical or a nonsurgical treatment of post-shunt EDH requires the evaluation of various factors: volume, thickness, midline shift and amount of fresh blood present on CT scan, the age of the patient and the clinical picture. Huge acute or subacute collections in adults or in children with closed fontanelles usually require surgical treatment.
Because the formation of EDH after VP shunt indicates possible intracranial hypotension, investigations may be done to evaluate the same, such as contrast-enhanced magnetic resonance imaging. In our case, because the patient was asymptomatic, no further investigations were done and the patient was kept on a close follow-up for any neurological deterioration.
Some precautions are recommended to minimize the bleeding complications after ventriculoperitoneal shunting: minimal CSF spillage at the time of ventricular catheter insertion, meticulous surgical technique, use of high- or medium-pressure valves or differential pressure valves, slow return to upright position and close follow-up even including a postoperative CT scan.  An antisiphon device or a flow rate-limiting system may also decrease the chances of the occurrence of this complication.
| Conclusion|| |
Formation of EDH after VP shunt surgery is a rare but potentially dangerous complication. Although many theories exist, the common initial event seems to be separation of dura from the inner table of the skull, which may be facilitated by lax adhesions between the two. Careful clinical monitoring in the postoperative period helps in early recognition and treatment of this complication. Minimal intraoperative CSF spillage, good surgical technique and pressure-regulated shunt systems help reduce the incidence of this potentially life-threatening complication.
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[Figure 1], [Figure 2]