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1.  Postoperative spinal epidural hematoma resulting in cauda equina syndrome: a case report and review of the literature 
Cases Journal  2009;2:8584.
Spinal epidural hematoma is a well known complication of spinal surgery. Clinically insignificant small epidural hematomas develop in most spinal surgeries following laminectomy. However, the incidence of clinically significant postoperative spinal epidural hematomas that result in neurological deficits is extremely rare. In this report, we present a 33-year-old female patient whose spinal surgery resulted in postoperative spinal epidural hematoma. She was diagnosed with lumbar disc disease and underwent hemipartial lumbar laminectomy and discectomy. After twelve hours postoperation, her neurologic status deteriorated and cauda equina syndrome with acute spinal epidural hematoma was identified. She was immediately treated with surgical decompression and evacuation of the hematoma. The incidence of epidural hematoma after spinal surgery is rare, but very serious complication. Spinal epidural hematomas can cause significant spinal cord and cauda equina compression, requiring surgical intervention. Once diagnosed, the patient should immediately undergo emergency surgical exploration and evacuation of the hematoma.
doi:10.4076/1757-1626-2-8584
PMCID: PMC2740261  PMID: 19830087
2.  Delayed Postoperative Epidural Hematoma Presenting Only with Vesicorectal Disturbance 
Case Reports in Orthopedics  2013;2013:861961.
We present a rare case of delayed onset of epidural hematoma after lumbar surgery whose only presenting symptom was vesicorectal disturbance. A 68-year-old man with degenerative spinal stenosis underwent lumbar decompression and instrumented posterolateral spine fusion. The day after his discharge following an unremarkable postoperative course, he presented to the emergency room complaining of difficulty in urination. An MRI revealed an epidural fluid collection causing compression of the thecal sac. The fluid was evacuated, revealing a postoperative hematoma. After removal of the hematoma, his symptoms disappeared immediately, and his urinary function completely recovered. Most reports have characterized postoperative epidural hematoma as occurring early after operation and accompanied with neurological deficits. But it can happen even two weeks after spinal surgery with no pain. Surgeons thus may need to follow up patients for at least a few weeks because some complications, such as epidural hematomas, could take that long to manifest themselves.
doi:10.1155/2013/861961
PMCID: PMC3773434  PMID: 24073350
3.  Contralateral delayed epidural hematoma following intracerebral hematoma surgery 
Background:
Delayed epidural hematoma (EDH) is an uncommon finding in patients after intracranial hematomas evacuation. It occurs in 6.7-7.4% of cases. A total of 29 reports were found in literature. Between them were no cases of delayed contralateral EDH after intracerebral hematoma evacuation.
Case Description:
This paper represents a clinical case of a 28-year-old male patient with opened penetrating head injury, who underwent left frontal lobe intracerebral hematoma evacuation and one day later a contralateral EDH was found and successfully surgically treated.
Conclusion:
Contralateral EDH is a life-threatening neurosurgical emergency case, which can occur during first 24 hours after decompressive craniectomy. Control CT scans must be performed next day after the operation to verify and treat contralateral EDH timely.
doi:10.4103/2152-7806.119234
PMCID: PMC3815043  PMID: 24233058
Decompressive craniectomy; epidural hematoma; head injury; postoperative hemorrhage
4.  Extensive Postoperative Epidural Hematoma After Full Anticoagulation: Case Report and Review of the Literature 
Background/Objective:
A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation.
Methods:
Case report.
Findings:
After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma.
Results:
Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy.
Conclusions:
Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.
PMCID: PMC2031966  PMID: 17684896
Spinal stenosis, lumbar; Spinal decompression; Anticoagulation; Epidural hematoma; Laminectomy
5.  Cervical Spinal Epidural Hematoma Following Cervical Posterior Laminoforaminotomy 
A 65-year-old man who had lateral cervical disc herniation underwent cervical posterior laminoforaminotomy at C5-6 and C6-7 level right side. During the operation, there was no serious surgical bleeding event. After operation, he complained persistent right shoulder pain and neck pain. Repeated magnetic resonance image (MRI) showed diffuse cervical epidural hematoma (EDH) extending from C5 to T1 level right side and spinal cord compression at C5-6-7 level. He underwent exploration. There was active bleeding at muscular layer. Muscular active bleeding was controlled and intramuscular hematoma was removed. The patient's symptom was reduced after second operation. Symptomatic postoperative spinal EDH requiring reoperation is rare. Meticulous bleeding control is important before wound closure. In addition, if patient presents persistent or aggravated pain after operation, rapid evaluation using MRI and second look operation is needed as soon as possible.
doi:10.3340/jkns.2013.53.2.125
PMCID: PMC3611058  PMID: 23560180
Cervical epidural hematoma; Posterior laminoforaminotomy; Cervical disc herniation; Postoperative bleeding; Reoperation
6.  Complete motor recovery after acute paraparesis caused by spontaneous spinal epidural hematoma: case report 
Background
Spontaneous spinal epidural hematoma is a relatively rare but potentially disabling disease. Prompt timely surgical management may promote recovery even in severe cases.
Case presentation
We report a 34-year-old man with a 2-hour history of sudden severe back pain, followed by weakness and numbness over the bilateral lower limbs, progressing to intense paraparesis and anesthesia. A spinal magnetic resonance imaging scan was performed and revealed an anterior epidural hematoma of the thoracic spine. He underwent an emergency decompression laminectomy of the thoracic spine and hematoma evacuation. Just after surgery, his lower extremity movements improved. After 1 week, there was no residual weakness and ambulation without assistance was resumed, with residual paresthesia on the plantar face of both feet. After 5 months, no residual symptoms persisted.
Conclusions
The diagnosis of spontaneous spinal epidural hematoma must be kept in mind in cases of sudden back pain with symptoms of spinal cord compression. Early recognition, accurate diagnosis and prompt surgical treatment may result in significant improvement even in severe cases.
doi:10.1186/1471-227X-11-10
PMCID: PMC3160384  PMID: 21794133
7.  Post-traumatic Lumbar Epidural Hematoma with Neurology: Report of 1 Case 
Asian Spine Journal  2011;5(2):130-132.
The purpose of this study was to report a case with post-traumatic spinal epidural hematomas with abnormal neurologic findings, which is uncommon. A 40-year-old man presented at our clinic after a blunt trauma caused by a traffic accident in which he was a pedestrian. After admission, abnormal neurologic symptoms developed including loss of sensation and motor function in his left lower extremity. Magnetic resonance imaging demonstrated a spinal epidural hematoma with 40% canal stenosis at the L5-S1 level. Decompression including hematoma evacuation was done. Symptoms started to be reduced 18 days after operation. He was treated conservatively with medications and all symptoms resolved completely during admission and there were no further neurologic sequelae. Post-traumatic lumbar spinal epidural hematoma with abnormal neurologic findings is an uncommon condition that may present belatedly after trauma with significant neurologic compromise.
doi:10.4184/asj.2011.5.2.130
PMCID: PMC3095803  PMID: 21629489
Lumbar spine; Epidural hematoma; Neurology
8.  Thoracic disc herniation causing transient paraplegia coincident with epidural anesthesia: a case report 
Cases Journal  2009;2:6228.
Neurological deficits following epidural or spinal anesthesia are extremely rare. Transient paraplegia following epidural anesthesia in a patient with thoracic disc herniation has been presented. A 44-year-old woman developed paraplegia during the operation for vascular surgery of her legs under epidural anesthesia. Epidural hematoma or spinal cord ischemia was ruled out by magnetic resonance imaging of the thoracic and lumbar spine in which protruded disc at T11-12 level compressing the spinal cord has been verified. Patient responded well to steroid treatment and rehabilitation interventions. Physicians should be aware of preceding disc protrusions, which may have detrimental effects on spinal cord perfusion, as a cause of persistent or transient paraplegia before epidural anesthesia procedure. MRI is a valuable imaging option to rule out epidural anesthesia complications and coexisting pathologies like disc herniations.
doi:10.4076/1757-1626-2-6228
PMCID: PMC2769273  PMID: 19918563
9.  Epidural Hematoma Presenting with Severe Neck Pain without Neurological Deficit - A Late Complication of Posterior Cervical Spine Surgery: Presentation of Three Unusual Cases 
Asian Spine Journal  2007;1(1):57-60.
Postoperative epidural hematoma (EDH) usually present with neurological deficit. Massive EDH presenting with only severe pain without neurological deficit are rare. Atypical presentations of postoperative EDHs may lead to delayed diagnosis and treatment. We present three such cases after posterior cervical spine surgery. Three patients presented with severe neck pain and spasms without motor deficits several days after posterior cervical decompressive procedures. Imaging studies identified compressive EDHs at the surgical site with severe compression of the spinal cord. All were treated with emergent decompression, with resulting improvement of symptoms and pain relief without further neurological sequelae. In conclusion, postoperative EDHs after posterior cervical spine surgery may result in minimal neurological deficit. Our report reminds surgeons to keep this possibility in mind when patients complain of unusually severe neck pain and spasms after posterior cervical spine surgery.
doi:10.4184/asj.2007.1.1.57
PMCID: PMC2857499  PMID: 20411155
Cervical spine; Epidural hematoma; Postoperative complication
10.  Hemiparesis Caused by Cervical Spontaneous Spinal Epidural Hematoma: A Report of 3 Cases 
Advances in Orthopedics  2011;2011:516382.
We report three cases of spontaneous spinal epidural hematoma (SSEH) with hemiparesis. The first patient was a 73-year-old woman who presented with left hemiparesis, neck pain, and left shoulder pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C3–C6 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The second patient was a 62-year-old man who presented with right hemiparesis and neck pain. A cervical MRI scan revealed a right posterolateral dominant epidural hematoma at the C6-T1 level. The condition of the patient improved after laminectomy and evacuation of the epidural hematoma. The third patient was a 60-year-old woman who presented with left hemiparesis and neck pain. A cervical MRI scan revealed a left posterolateral epidural hematoma at the C2–C4 level. The condition of the patient improved with conservative treatment. The classical clinical presentation of SSEH is acute onset of severe irradiating back pain followed by progression to paralysis, whereas SSEH with hemiparesis is less common. Our cases suggest that acute cervical spinal epidural hematoma should be considered as a differential diagnosis in patients presenting with clinical symptoms of sudden neck pain and radicular pain with progression to hemiparesis.
doi:10.4061/2011/516382
PMCID: PMC3170783  PMID: 21991415
11.  Postoperative Spinal Epidural Hematoma: Risk Factor and Clinical Outcome 
Yonsei Medical Journal  2006;47(3):326-332.
We report a series of epidural hematomas which cause neurologic deterioration after spinal surgery, and have taken risk factors and prognostic factors into consideration. We retrospectively reviewed the database of 3720 cases of spine operation in a single institute over 7 years (1998 April-2005 July). Nine patients who demonstrated neurologic deterioration after surgery and required surgical decompression were identified. Factors postulated to increase the postoperative epidural hematoma and to improve neurologic outcome were investigated. The incidence of postoperative epidural hematoma was 0.24%. Operation sites were cervical 3 cases, thoracic 2 cases, and lumbar 4 cases. Their original diagnoses were tumor 3 cases, cervical stenosis 2 cases, lumbar stenosis 3 cases and herniated lumbar disc 1case. The symptoms of epidural hematomas were neurologic deterioration and pain. After decompression, clinical outcome revealed complete recovery in 3 cases (33.3%), incomplete recovery in 5 cases (55.6%) and no change in 1 case (11.1%). Factors increasing the risk of postoperative epidural hematoma were coagulopathy from medical illness or anticoagulation therapy (4 cases, 44.4%) and highly vascularized tumor (3 cases, 33.3%). The time interval to evacuation of complete recovery group (29.3 hours) was shorter than incomplete recovery group (66.3 hours). Patients with coagulopathy and highly vascularized tumor were more vulnerable to spinal epidural hematoma. The postoperative outcome was related to the preoperative neurological deficit and the time interval to the decompression.
doi:10.3349/ymj.2006.47.3.326
PMCID: PMC2688151  PMID: 16807981
Clinical outcome; risk factor; postoperative; spinal epidural hematoma; spine surgery
12.  Intracranial Subdural Hematoma after Spinal Anesthesia for Cesarean Section 
Intracranial subdural hematoma following spinal anesthesia is an infrequent occurrence in the obstetric population. Nevertheless, it is a potentially life-threatening complication. In the majority of the cases, the first clinical symptom associated with intracranial subdural bleeding is severe headache, but the clinical course may have different presentations. In this report, we describe the case of a 38-year-old woman with an acute intracranial subdural hematoma shortly after spinal anesthesia for cesarean section. Early recognition of symptoms of neurologic impairment led to an emergency craniotomy for hematoma evacuation with good recovery of neurologic functions. The possibility of subdural hematoma should be considered in any patient complaining of severe persistent headache following regional anesthesia, unrelieved by conservative measures. Only early diagnosis and an appropriate treatment may avoid death or irreversible neurologic damage.
doi:10.1155/2013/253408
PMCID: PMC3884612  PMID: 24455348
13.  Spontaneous Intracranial Epidural Hematoma Originating from Dural Metastasis of Hepatocellular Carcinoma 
Spontaneous intracranial epidural hematoma (EDH) due to dural metastasis of hepatocellular carcinoma is very rare. A 53-year-old male patient with hepatocellular carcinoma, who was admitted to the department of oncology, was referred to department of neurosurgery because of sudden mental deterioration to semicoma with papillary anisocoria and decerebrate rigidity after transarterial chemoembolization for hepatoma. Brain computed tomography (CT) revealed large amount of acute EDH with severe midline shifting. An emergent craniotomy and evacuation of EDH was performed. Active bleeding from middle cranial fossa floor was identified. There showed osteolytic change on the middle fossa floor with friable mass-like lesion spreading on the overlying dura suggesting metastasis. Pathological examination revealed anaplastic cells with sinusoidal arrangement which probably led to spontaneous hemorrhage and formation of EDH. As a rare cause of spontaneous EDH, dural metastasis from malignancy should be considered.
doi:10.3340/jkns.2010.48.2.166
PMCID: PMC2941862  PMID: 20856668
Spontaneous epidural hematoma; Hepatocellular carcinoma; Dural metastasis
14.  Epidural hematoma after thoracic epidural analgesia in a patient treated with ketorolac, mefenamic acid, and naftazone: a case report 
Korean Journal of Anesthesiology  2014;66(3):240-243.
A 26-year-old male undergoing thoracotomy and bleeding control received a preoperative thoracic epidural for postoperative analgesia. On the fifth postoperative day, paralysis of both lower limbs occurred and urgent magnetic resonance imaging showed massive anterior epidural hematoma. During laminectomy and decompression, platelet dysfunction was diagnosed and preoperative non-steroidal anti-inflammatory drugs medications were supposed to the cause of platelet dysfunction. After infusion of ten units of platelet concentrate, coagulopathy was improved. We should be more careful to drugs with antiplatelet effect when using regional analgesia.
doi:10.4097/kjae.2014.66.3.240
PMCID: PMC3983422
Epidural hematoma; Ketorolac; Mefenamic acid; Naftazone; Platelet function
15.  Is Closed-suction Drainage Necessary for Single-level Lumbar Decompression?: Review of 560 Cases 
Background
Closed-suction drainage is commonly used for prevention of postoperative hematoma and associated neurologic compromise after lumbar decompression, but it remains unclear whether suction drainage reduces postoperative complications.
Questions/purposes
We evaluated the efficacy of closed-suction drainage in single-level lumbar decompression surgery.
Patients and Methods
We retrospectively reviewed 560 patients who underwent single-level lumbar decompression or discectomy. We routinely used closed-suction drainage in all spinal surgeries until July 2003, and thereafter, we did not use drains in single-level lumbar decompression surgery. These two groups (298 patients in the group that received drains, 262 in the group that did not receive drains) were compared for rates of wound infection and epidural hematoma.
Results
Mean operating time (55 versus 56 minutes) and intraoperative blood loss (64 versus 57 mL) were not different between the two groups. None of 560 patients had a wound infection requiring surgical intervention. The rate of postoperative hematoma was 0.7% in the group that received drains (two of 298 patients) and 0% in the group that did not receive drains (zero of 262 patients).
Conclusions
In this study, the risk of wound infection and hematomas in single-level lumbar decompression surgery was not influenced by use of a drain. The use of postoperative wound drainage in patients with potential risk for epidural bleeding in situations such as multiple-level decompression, instrumentation surgery, anticoagulant therapy, trauma, and tumors or metastases needs additional study.
Level of Evidence
Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
doi:10.1007/s11999-010-1235-6
PMCID: PMC3049608  PMID: 20091386
16.  Epidural bleeding after ACL reconstruction under regional anaesthesia: a case report 
Cases Journal  2009;2:6732.
Introduction
Epidural bleeding as a complication of catheterization or epidural catheter removal is often associated with perioperative thromboprophylaxis especially in adult reconstructive surgery.
Case presentation
We report on a case of a 19 years old male athlete that underwent anterior cruciate ligament reconstruction, receiving low molecular weight heparin for thromboprophylaxis and developed an epidural hematoma and subsequent cauda equina syndrome two days after removal of the epidural catheter. An urgent magnetic resonance imaging scan revealed an epidural hematoma from the level of L3 to L4. Emergent decompression and hematoma evacuation resulted in patient's significant neurological improvement immediately postoperatively.
Conclusion
A high index of clinical suspicion and surgical intervention are necessary to prevent such potentially disabling complications especially after procedures on a day-case basis and early patient's discharge.
doi:10.1186/1757-1626-2-6732
PMCID: PMC2740288  PMID: 19829853
17.  Early postoperative MRI in detecting hematoma and dural compression after lumbar spinal decompression: prospective study of asymptomatic patients in comparison to patients requiring surgical revision 
European Spine Journal  2010;19(12):2216-2222.
Early postoperative MRI after spinal surgery is difficult to interpret because of confounding postoperative mass effects and frequent occurrence of epidural hematomas. Purpose of this prospective study is to evaluate prevalence, extent and significance of hematoma in the first postoperative week in asymptomatic patients after decompression for lumbar stenosis and to determine the degree of clinically significant dura compression by comparing with the patients with postoperative symptoms. MRI was performed in 30 asymptomatic patients (47 levels) in the first week after lumbar spine decompression for degenerative stenosis. Eleven patients requiring surgical revision (16 levels) for symptomatic early postoperative hematoma were used for comparison. In both groups the cross-sectional area of the maximum dural compression (bony stenosis and dural sac expansion) was measured preoperatively and postoperatively by an experienced radiologist. Epidural hematoma was seen in 42.5% in asymptomatic patients (20/47 levels). The median area of postoperative hematoma at the operated level was 176 mm2 in asymptomatic patients and 365 mm2 in symptomatic patients. The median cross-sectional area of the dural sac at the operated level was 128.5 and 0 mm2 in asymptomatic and symptomatic patients, respectively, at the site of maximal compression. In the symptomatic group 75% of the patients had a maximal postoperative dural sac area of 58.5 mm2 or less, whereas in the asymptomatic group 75% of patients with epidural hematoma had an area of 75 mm2 or more. The size of hematoma and the degree of dural sac compression were significantly larger in patients with symptoms needing surgical revision. Dural sac area of less than 75 mm2 in early postoperative MRI was found to be the threshold for clinical significance.
doi:10.1007/s00586-010-1483-x
PMCID: PMC2997206  PMID: 20556438
Epidural hematoma; Early postoperative MRI; Spinal stenosis; Neural compression
18.  Bilateral asynchronous acute epidural hematoma : a case report 
Background
Bilateral extradural hematomas have only rarely been reported in the literature. Even rarer are cases where the hematomas develop sequentially, one after removal of the other. Among 187 cases of operated epidural hematomas during past 4 years in our hospital, we found one case of sequentially developed bilateral epidural hematoma.
Case Presentation
An 18-year-old conscious male worker was admitted to our hospital after a fall. After deterioration of his consciousness, an emergency brain CT scan showed a right temporoparietal epidural hematoma. The hematoma was evacuated, but the patient did not improve afterwards. Another CT scan showed contralateral epidural hematoma and the patient was reoperated. Postoperatively, the patient recovered completely.
Conclusions
This case underlines the need for monitoring after an operation for an epidural hematoma and the need for repeat brain CT scans if the patient does not recover quickly after removal of the hematoma, especially if the first CT scan has been done less than 6 hours after the trauma. Intraoperative brain swelling can be considered as a clue for the development of contralateral hematoma.
doi:10.1186/1471-227X-3-1
PMCID: PMC317469  PMID: 14697100
bialteral; epidual; hematoma
19.  Sudden onset of paraplegia caused by hemorrhagic spinal epidural angiolipoma. A case report 
European Spine Journal  2008;17(Suppl 2):296-298.
Spinal epidural angiolipoma is a rare benign tumor containing vascular and mature adipose elements. A slow progressive clinical course was mostly presented and rarely a fluctuating course during pregnancy. The authors report the original case of spontaneous spinal epidural bleeding resulting from thoracic epidural angiolipoma who presented with hyperacute onset of paraplegia, simulating an extradural hematoma. The patient was admitted with sudden non-traumatic hyperacute paraplegia during a prolonged walk. Neurologic examination showed sensory loss below T6 and bladder disturbances. Spinal MRI revealed a non-enhanced heterogeneous thoracic epidural lesion, extending from T2 to T3. A bilateral T2–T4 laminectomy was performed to achieve resection of a lipomatous tumor containing area of spontaneous hemorrhage. The postoperative course was uneventful with complete neurologic recovery. Histologic examination revealed the tumor as an angiolipoma. Because the prognosis after rapid surgical management of this lesion is favorable, the diagnosis of spinal angiolipoma with bleeding should be considered in the differential diagnosis of hyperacute spinal cord compression.
doi:10.1007/s00586-008-0591-3
PMCID: PMC2525899  PMID: 18228054
Angiolipoma; Epidural spinal tumor; Spinal cord compression; Spinal epidural hematoma
20.  Spontaneous Spinal Epidural Hematomas Associated With Acute Myocardial Infarction Treatment 
Korean Circulation Journal  2011;41(12):759-762.
Many studies have reported spontaneous spinal epidural hematoma (SSEH). Although most cases are idiopathic, several are associated with thrombolytic therapy or anticoagulants. We report a case of SSEH coincident with acute myocardial infarction (AMI), which caused serious neurological deficits. A 56 year old man presented with chest pain accompanied with back and neck pain, which was regarded as an atypical symptom of AMI. He was treated with nitroglycerin, aspirin, low molecular weight heparin, and clopidogrel. A spinal magnetic resonance image taken after paraplegia developed 3 days after the initial symptoms revealed an epidural hematoma at the cervical and thoracolumbar spine. Despite emergent decompressive surgery, paraplegia has not improved 7 months after surgery. A SSEH should be considered when patients complain of abrupt, strong, and non-traumatic back and neck pain, particularly if they have no spinal pain history.
doi:10.4070/kcj.2011.41.12.759
PMCID: PMC3257462  PMID: 22259609
Acute myocardial infarction; Hematoma, epidural, spinal; Paraplegia; Thrombolytic therapy; Anticoagulants
21.  A life threatening problem in infants: supratentorial epidural hematoma 
Journal of Medicine and Life  2009;2(2):191-195.
Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants.Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific.Authors present a study on 30 infants with epidural hematoma (EDH) admitted in the Pediatric Department of Neurosurgery of the ‘Bagdasar–Arseni’ Clinical Hospital in the period of 1990–2007 (17 years).The most common symptom was irritability, which occurred in 16 cases (53.3%), of our patients. Pallor in all cases (100%) and subgaleal hematoma in 20/30 (66.6%) of the patients. These were the most common clinical signs that occurred upon admission; both of them represent signs of significant clinical importance. Surgical evacuation via craniotomy was required in 26/30 (86.6%) of our patients, while 4/30 (13.3%) of the patients were managed conservatively. The mortality rate was 6.6% in our series, whilst the long–term morbidity rate was 3.3%.
EDH in infants represents a life–threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient's clinical condition, the size of EDH, and the presence of a midline structure shift on the head's CT scan.
PMCID: PMC3018979  PMID: 20108539
Epidural hematoma; Infant; Pallor; Children Coma Scale(CGS); Traumatic Infant Neurological Score(TINS); Outcome
22.  Posteriorly migrated thoracic disc herniation: a case report 
Introduction
Posterior epidural migration of thoracic disc herniation is extremely rare but may occur in the same manner as in the lumbar spine.
Case presentation
A 53-year-old Japanese man experienced sudden onset of incomplete paraplegia after lifting a heavy object. Magnetic resonance imaging revealed a posterior epidural mass compressing the spinal cord at the T9-T10 level. The patient underwent emergency surgery consisting of laminectomy at T9-T10 with right medial facetectomy, removal of the mass lesion, and posterior instrumented fusion. Histological examination of the mass lesion yielded findings consistent with sequestered disc material. His symptoms resolved, and he was able to resume walking without a cane 4 weeks after surgery.
Conclusions
Pre-operative diagnosis of posterior epidural migration of herniated thoracic disc based on magnetic resonance imaging alone may be overlooked, given the rarity of this pathology. However, this entity should be considered among the differential diagnoses for an enhancing posterior thoracic extradural mass.
doi:10.1186/1752-1947-7-41
PMCID: PMC3582544  PMID: 23402642
Intervertebral disc herniation; Posterior migration; Thoracic spine
23.  Rotational thromboelastometry and multiple electrode platelet aggregometry in four patients with abnormal routine coagulation studies before removal of epidural catheters after major surgery: a case series and research study 
Introduction
Routine coagulation tests have a low predictability for perioperative bleeding complications, and spinal hematoma after removal of epidural catheters is very infrequent. Thromboelastometry and point-of-care platelet aggregometry may improve hemostatic monitoring but have not been studied in the context of safety around epidural removal.
Methods
Twenty patients who received an epidural catheter for major thoracoabdominal and abdominal surgery were included prospectively. In addition to routine coagulation tests, rotational thromboelastometry and multiple electrode platelet aggregometry were carried out.
Results
A coagulation deficit was suggested by routine coagulation tests on the intended day of epidural catheter removal in four out of 20 patients. Prothrombin time-international normalized ratio was elevated to 1.5 in one patient (normal range: 0.9 to 1.2) while rotational thromboelastometry and multiple electrode platelet aggregometry parameters were within normal limits. Activated partial thromboplastin time was elevated to 47 to 50 seconds in the remaining three patients (normal range 28 to 45 seconds). Rotational thromboelastometry showed that one of the patients’ results was due to heparin effect: the clotting time with the HEPTEM® activator was 154 seconds as compared to 261 seconds with INTEM. The three remaining patients with prolonged routine coagulation test results had all received over 1L of hydroxyethyl starch (Venofundin®) and thrombosis prophylaxis with low-molecular-weight heparin (enoxaparin). Rotational thromboelastometry and multiple electrode platelet aggregometrygave normal or hypercoagulative signals in most patients.
Conclusions
This case series is new in that it examines rotational thromboelastometry and multiple electrode platelet aggregometry postoperatively in the context of epidural analgesia and shows that they may be clinically useful. These methods should be validated before they can be used for standard patient care.
doi:10.1186/1752-1947-7-282
PMCID: PMC3892080  PMID: 24377397
aPTT; Epidural anesthesia; Epidural hematoma; Hydroxyethyl starch; Multiplate®; Platelet aggregometry; PT-INR; ROTEM®; Thromboelastography
24.  Vaccum drainage system application in the management of operation-related non-regional epidural hematoma 
Background
Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique.
Methods
Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system.
Results
The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed.
Conclusions
Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis.
doi:10.1186/1750-1164-7-7
PMCID: PMC3751531  PMID: 23842198
Intracranial tumor; Operation-related epidural hematoma; Non-regional epidural hematoma; Epidural drainage; Vaccum drainage system
25.  Calcified epidural hematoma in pediatric age group: A report of two cases 
The authors present a rare case of calcified (ossified) chronic epidural hematoma developed in a six-and-a-half-year-old female patient who was operated for cerebellar astrocytoma 6 months earlier. There was no history of trauma. Ossified epidural hematoma was seen as an incidental finding in the follow-up in computed tomography scan after 6 months of primary glioma surgery. Ossified chronic epidural hematoma with thick collagenous wall and newly formed bone on dura was excised. The development of calcified chronic subdural hematoma after decompressive intracranial surgery is a well-known occurrence, but the fact that a calcified epidural hematoma, which is rare and which can also develop after decompressive surgery, and the occurrence of calcified (ossified) epidural hematoma after postfossa a glioma surgery is not yet reported. The second case is a 9-year-old male anemic child with a history of fall while playing 5 months earlier who presented with headache of 3 months duration. He had bifrontal calcified epidural hematoma operated by craniotomy and excision of calcified dural edge.
doi:10.4103/0976-3147.71716
PMCID: PMC3139356  PMID: 21808510
Epidural hematoma; pediatric epidural hematoma; calcified

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