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      Pseudohypoxic Brain Swelling after Unilateral Burr Hole Drainage: A Novel Case Report

      case-report

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          Abstract

          An 85-year-old man underwent emergency right trepanation and drainage for a symptomatic chronic subdural hematoma. Pseudohypoxic brain swelling (PHBS) was suspected because magnetic resonance imaging revealed diffuse brain swelling. Although cerebrospinal fluid (CSF) leakage was not obvious during or after surgery, most of the reported PHBS cases have leaked CSF during craniotomy or spine surgery. PHBS has not been previously reported in patients without obvious CSF leakage or after unilateral burr hole drainage. Herein, we report an extremely rare case with a literature review investigating its pathogenesis and clinical features.

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          The Monro-Kellie hypothesis: applications in CSF volume depletion.

          B Mokri (2001)
          More than two centuries ago, Alexander Monro applied some of the principles of physics to the intracranial contents and for the first time hypothesized that the blood circulating in the cranium was of constant volume at all times. This hypothesis was supported by experiments by Kellie. In its original form, the hypothesis had shortcomings that prompted modification by others. What finally came to be known as the Monro-Kellie doctrine, or hypothesis, is that the sum of volumes of brain, CSF, and intracranial blood is constant. An increase in one should cause a decrease in one or both of the remaining two. This hypothesis has substantial theoretical implications in increased intracranial pressure and in decreased CSF volume. Many of the MRI abnormalities seen in intracranial hypotension or CSF volume depletion can be explained by the Monro-Kellie hypothesis. These abnormalities include meningeal enhancement, subdural fluid collections, engorgement of cerebral venous sinuses, prominence of the spinal epidural venous plexus, and enlargement of the pituitary gland.
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            Pseudohypoxic brain swelling: a newly defined complication after uneventful brain surgery, probably related to suction drainage.

            Dirk Van Gansbeke, Christof Thees, Johannes Schramm … (2003)
            This is the first description of a severe and sometimes fatal complication after uneventful intracranial surgery. The clinical presentation and imaging features mimic those of global cerebral hypoxia. Extensive investigations were performed to discover the pathogenesis. Seventeen cases of pseudohypoxic brain swelling (PHBS) were collected from our institution and from various other neurosurgical departments and were studied for common features. PHBS can occur in a mild, moderate, or severe degree. It is characterized by a very early postoperative onset of clinical deterioration (clouded or lost consciousness and pupillary abnormalities), in association with typical bilateral computed tomographic or magnetic resonance imaging changes (hypodensities or altered intensities in the basal ganglia and/or thalamus). The following variables were considered: age, primary pathological lesion and intracranial location, previous cranial surgery, anesthetic risk, type of anesthesia, approach and duration of surgery, intraoperative observations, technical monitoring results, and blood gas analyses. The results of postoperative computed tomography and various other imaging studies, intracranial pressure measurements, transcranial Doppler sonography, toxicological analyses, brain and muscle biopsies, and autopsies were also considered in the investigation. Several countermeasures were instituted and evaluated. Anoxemic and ischemic hypoxia was excluded as a cause of PHBS. No evidence was found for inhibition of the respiratory chain, mitochondriopathy, poisoning, or adverse effects of drugs. Indications of intracranial hypotension, induced by suction drainage, being the main pathomechanism of PHBS are discussed. A serious warning is issued regarding the use of suction drainage after intracranial surgery.
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              Transient hyperemia immediately after rapid decompression of chronic subdural hematoma.

              K Koshu, A Ogawa, Annie Ogasawara … (1999)
              Intracerebral hemorrhage occurring after removal of a chronic subdural hematoma (CSH) is a rare but usually devastating postoperative complication. In patients with CSH, we determined cerebral blood flow immediately after surgical decompression to clarify the pathogenic mechanism of this complication. In 22 patients with unilateral CSH, a catheter was inserted into the hematoma cavity through a single burr hole without leakage of the contents. Cerebral blood flow was measured using single-photon emission computed tomography 1 day before surgery, immediately after rapid decompression by opening the catheter, and 3 days after surgery. Single-photon emission computed tomography imaging immediately after decompression demonstrated areas of hyperemia in nine patients (41%). In all nine patients, hyperemia was observed in the cortex beneath the CSH, and it disappeared on the 3rd postoperative day. The patients with hyperemia were significantly older than those without hyperemia. Other variables, including preoperative cerebral blood flow, intrahematoma pressure before decompression, and mean arterial blood pressure during decompression had no significant effect on the occurrence of hyperemia. In elderly patients, rapid decompression of CSH frequently results in transient hyperemia in the cerebral cortex beneath the hematoma.
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                Author and article information

                Journal
                Journal ID (nlm-ta): NMC Case Rep J
                Journal ID (iso-abbrev): NMC Case Rep J
                Title: NMC Case Report Journal
                Publisher: The Japan Neurosurgical Society
                ISSN (Electronic): 2188-4226
                Publication date Collection: 2022
                Publication date (Electronic): 31 May 2022
                Volume: 9
                Pages: 135-138
                Affiliations
                [1 ]Department of Neurosurgery, Nagasaki Prefecture Shimabara Hospital, Shimabara, Nagasaki, Japan
                [2 ]Department of Neurology, Nagasaki Prefecture Shimabara Hospital, Shimabara, Nagasaki, Japan
                Author notes

                Corresponding author: Hikaru Nakamura, MD

                Department of Neurosurgery, Nagasaki Prefecture Shimabara Hospital, 7895 Shimokawasiri, Shimabara, Nagasaki 855-0816, Japan.

                e-mail: hikaru.nakamura560@ 123456gmail.com

                Article
                DOI: 10.2176/jns-nmc.2021-0410
                PMC ID: 9217157
                SO-VID: c5e21c03-0230-4b66-8e96-3e808401fdd7
                Copyright © © 2022 The Japan Neurosurgical Society
                License:

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives International License.

                History
                Date received : 14 December 2021
                Date accepted : 31 March 2022
                Categories
                Subject: Case Report

                Keywords: pseudohypoxic brain swelling,chronic subdural hematoma,burr hole drainage,postoperative intracranial hypotension-associated venous congestion,cerebrospinal fluid leakage
                Data availability:
                Keywords: pseudohypoxic brain swelling, chronic subdural hematoma, burr hole drainage, postoperative intracranial hypotension-associated venous congestion, cerebrospinal fluid leakage

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