Learning from errors

Chronic subdural haematoma management: an iatrogenic
complication. Case report and literature review
Pavlov Vladislav, George Bernard, Salvatore Chibbaro
Neurosurgery Department, Lariboisiere University Hospital, Paris, France
Correspondence to Ms Salvatore Chibbaro, schibbaro@hotmail.com

Summary
The authors report the case of a 45-year-old woman who presented to our institution with 10 days history of confusion and signs of progressive
raised intracranial pressure as a result of a minor head injury occurred 4 weeks before. A brain CT-scan showed a large right hemispheric
chronic subdural haematoma which was, as routinely, treated by burr-hole craniostomy and closed-drainage. Although the procedure was
uneventful, the next day the patient developed a mild left hemiparesis associated to a slight global status worsening. A brain CT scan
showed an intracerebral position of the drain with diffuse brain oedema and midline shift. Following drain removal the patient developed a
serious neurological deterioration dropping the Glasgow coma scale to 8/15 as the result of an intracerebral and intraventricular haemorrhage
along the removed drain trajectory. The clinical features of this iatrogenic complication are reported analysing also globally chronic subdural
haematoma management and discussing pertinent literature.

BACKGROUND
Evacuation of chronic subdural haematoma (CSDH) represents one of the most frequently performed neurosurgical procedure. Surgery is usually realised by twist-drill
craniostomy and spontaneous haematoma evacuation1 2
and/or catheter drainage,3–5 larger craniotomy evacuation
and membranectomy,6–9 and burr-hole craniostomy with
or without continuous closed drainage.10–19 The optimal
surgical management is still a matter of debate. The complications related to CSDH treatment may be divided in
surgical and medical related (peri- and postoperative).
The most common surgical complications are seizures,
subdural empyema, intracerebral haemorrhage, epidural
haematoma, pneumocephalus, intracerebral abscess.20
Haematoma recurrence and/or incomplete evacuation
with persisting or recurrent symptoms needed repeated
surgery or craniotomy were observed in 31.6% of patient

Figure 1

by Rohde et al.20 A recurrence rate of approximately 10%
has been reported in another study.21 Other complications
such as, meningitis,22 polymicrobial skull osteomyelitis,23
cerebral aspergillosis,24 cerebellar haemorrhage,23 acute
carotid arterial occlusion,24 brain stem haemorrhage25
combination of epidural and intracerebral haematoma26
have also been described. Overall mortality after surgical
treatment of CSDH has been reported to be 0–8%.27 At
our institution, burr-hole craniostomy and closed drainage
(BCD) is the operative technique of choice. In the present
paper, the authors describe an iatrogenic and life-threatening complication of CSDH management with its clinical
features reviewing also pertinent literature.

CASE PRESENTATION
We report the case of a 45-years old woman presenting to
our institution as an emergency with 10 days history of

Preoperative axial CT scan showing a right chronic subdural collection.

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progressive headache, episodic mental confusion with disorientation in time and space (grade II according to Bender
grading).28 The patient suffered a minor head injury 3
weeks prior admission.
An urgent brain CT scan (figure 1) showed a large right
subdural hyperdense collection with sign of recent bleeding causing a midline shift of 10 mm. At this stage, after
completing all the preoperative screening, surgery was
proposed to the patient who gave formal consent. Surgery
was performed under local anaesthesia with the patient in
supine position and the head turned contralaterally.
A right parietal burr-hole was preformed using an air
power drill which was enlarged by kerrison rongeur. Dura
was opened in a cruciate fashion; the parietal haematoma
membrane was identified and once incised the haematoma was evacuated (coming out under high pressure).
A jackson-pratt type drain was inserted in the subdural

cavity and connected to a closed reservoir. The skin was
finally closed in anatomical layers and the drain fixed to the
skin. The procedure was uneventful and in the immediate
postoperative stage the patient was conscious; cooperative
without any motor or sensory deficits. The next morning the patient started to be very confused and drowsy,
droping the GCS to 12/15 with a slight left hemiparisis.
Immediately a brain CT (figures 2 and 3) and angio CT scan
(figure 4a, b) was performed showing a deep intracerabral
position of the drain with diffuse hemispheric oedema and
important midline shift.
Nevertheless, the drain was removed followed by
further progressive neurological deterioration down to
a Glasgow coma scale of 8/15. An emergent brain CT
scan reveals an intraparenchymal haematoma along the
removed drain trajectory (figure 5a,b). The patient was
thus transferred to the intensive care unit (ICU), where

Figure 2 Postoperative axial CT scan showing the intracerabral
catheter trajectory going from right parietal area to controlateral
temporal area through the callosal body.

Figure 3 Postoperative coronal CT scan showing the
intracerabral catheter trajectory and its relationship with brain
structures.

Figure 4 a) Axial and b) coronal angio CT scan showing the deep intracerabral position of the drain and its relation/contiguity to brain vessels.
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BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5397

she was deeply sedated, intubated and ventilated; intracranial pressure (ICP) was monitored showing a mean
value of 20 mm Hg with a good brain circulatory profile
demonstrated by transcranial Doppler. The patient was
managed conservatively during 7 days in the ICU during which she first developed epilepsy and any attempt
of weaning sedation resulted in raised ICP up to 35 mm
Hg. Two repeated check CT scan showed diffused brain
oedema as well as the evolution towards resorption of the
haematoma. After a week the sedation could be weaned
off with a mean of ICP value of 12–15 mm Hg and the
patient waking up progressively and extubated at day 8
showing a residual hemipareis more important on the
left upper limb. The patient received a course of physical
therapy and promptly improved her left-sided motor deficit within 10 days being able to return at home. Physical
therapy was carried out for 4 weeks with complete recovery. At 2 months follow-up the patient was neurologically
intact reporting a generalised well being and a check brain
CT scan revealed a complete resorbtion of the known
haematoma (figure 6a,b).

DISCUSSION
Spontaneous resolution of the CSDH has been described
sporadically,28 29 most of the CSDH require surgical management. Studies have shown that medical therapy of
CSDH is inferior to surgical evacuation and therefore it
was abandoned in patients with symptoms with spaceoccupying lesions.30 In the pre-CT era, craniotomy or
craniectomy, often with membranectomy, was predominantly used until the 80s, when CT scanning became
available allowing a closer radiological follow-up of the
patients, leaving place to less invasive techniques such as
burr-hole and twist-drill trephination with and without
closed-system drainage.1–5 10–19 The former techniques
significantly lowered the mortality and morbidity rates of
such disease, although the optimal surgical management is
still a matter of debate and medical and surgical complications still remain a real management problem.
Regarding surgical management of CSDH the authors
have performed an internal audit (unpublished data) on
800 CSDH managed during 20 years (from January 1991
to December 2010) analysing the operative technique as

Figure 5

a) Axial and b) coronal CT scan showing the intraparenchymal and intraventricular haematoma following the drain removal.

Figure 6

a) Coronal and b) axial check CT scan at 3-month follow-up showing a complete resorbtion of the haematoma.

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follow: twist-drill single versus double, extended burr hole,
trephine craniotomy and/or larger craniotomy with membranectomy, which has shown pretty similar outcome
results except for the larger craniotomy technique having
an higher morbidity rate; furthermore the type of drainage
was analysed as follow: open subdural drain versus closed
system, subgaleal, or no drain at all; complete evacuation,
recurrence and pneumoencephalus rate were similar except
for the use of the closed subdural system drainage showing
a higher complete evacuation rate with a lower recurrence
and pneumoencephalus rate.
Rapid decompression of the haematoma results in focal
cortical hyperaemia, which is believed to be the cause of
intracerebral haemorrhagic complications in combination
with cofactors such as labile hypertension and cerebral
amyloid angiopathy.27 31 32 In the present paper, the intracerebral complication was iatrogenic by a traumatic placement of the subdural drain. This very rare complication we
do think could be avoided by a careful placement of the
subdural drain under visual control and by further irrigation of the subdural compartment to verify if any bridging
or cortical vessel has been injured or as in our case if the
drain even penetrated into brain parenchyma. Furthermore
for this purpose an important feature would be the correct
fixation of the drain to the skin as also a mobile drain may
easily come out or inadvertently migrate further deeply
inside. The authors are aware that this complication has
already probably happened elsewhere but never reported.
We also do believe that the present case may constitute an
important and unique report and demonstration of a dangerous complication in treating a frequent disease which
could be a very useful example for trainees.

Learning points
CSDH represents one of the most frequent
neurosurgical diseases and upto date its best
management remains still controversial. Many
complications may occur in treating such pathology;
their knowledge could essentially contribute to improve
the daily standard level of care and outcome results.
▶ To avoid such complication: a subdural drain should
carefully placed as much as possible under visual
control with the aid of a rigid curved instrument to
hold it against dura, during the drain introduction the
subdural compartment should be abundantly irrigated
to verify if any bridging or cortical vessel has been
injured or as in the present case if the drain has
even penetrated the brain parenchyma and finally
an important feature is the drain correct fixation to
the skin as a mobile drain may easily come out or
inadvertently migrate further deeply inside.
▶

Competing interests None.
Patient consent Obtained.

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BMJ Case Reports 2012; doi:10.1136/bcr.12.2011.5397

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Vladislav P, Bernard G, Chibbaro S. Chronic subdural haematoma management: an iatrogenic complication. Case report and literature review.
BMJ Case Reports 2012;10.1136/bcr.12.2011.5397, Published XXX
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