CASE REPORT
Neurol Med Chir (Tokyo) 52, 646¿648, 2012

Bilateral Supratentorial Epidural Hematomas:
a Rare Complication in Adolescent Spine Surgery
—Case Report—
Zhao-Jian LI,1 Peng SUN,1 Yi-He DOU,1 Xiao-Lei LAN,1
Jian XU,1 Chun-Yong ZHANG,2 and Jian-Peng WANG1
1Department of Neurosurgery, the Affiliated Hospital of Medical College,

Qingdao University, Qingdao, Shandong Province, China;
2Department of Neurosurgery, the 8th People's Hospital of Qingdao City,

Qingdao, Shandong Province, China

Abstract
A 14-year-old girl presented with a rare case of spontaneous bilateral supratentorial epidural hematomas which developed rapidly following cervical surgery. The hematomas presumably resulted from
dural dynamics changes secondary to cerebrospinal fluid loss and intracranial hypotension. Intracranial epidural hemorrhage after spinal surgery is extremely uncommon with only one previous case report.
Spontaneous intracranial epidural hematoma is an extremely rare complication, but should be considered as a possible complication of spine surgery, especially in adolescents complicated by delayed consciousness and breathing restoration from anesthesia. This case report expands the presently known
clinical spectrum of this uncommon complication.
Key words: cerebrospinal fluid loss,
spine surgery, adolescent

intracranial epidural hematoma,

Introduction

intracranial hypotension,

clinically observed. Laboratory results including platelet
count, prothrombin time, and partial thromboplastin time
found no abnormalities. Initial magnetic resonance imaging showed a 1.5 × 1.5 × 1.8 cm intradural space-occupying lesion with degenerative cyst at the C4 level, which
had clearly compressed and displaced the cervical spinal
cord (Fig. 1). Lesion resection was performed via a
posterior cervical midline approach in the prone position
without rigid pin fixation of the head. After cerebrospinal
fluid (CSF) release for local decompression, the tumor was
identified within the arachnoid layer, and adherent laterally and interiorly to the dorsal nerve roots of C3 and C4,
and was totally removed in a piecemeal manner. The oper-

Intracranial epidural hematoma generally occurs following head trauma or cranial surgery. In contrast, spontaneous intracranial epidural hematoma has been infrequently
reported in association with cranial decompression,10)
coagulopathy,13) sphenoid sinusitis,12) ruptured middle
meningeal artery psudoaneurysm,4) or cranial metastasis.6)
However, spontaneous intracranial epidural hematoma as
a complication of spine surgery is extremely unusual, with
only one such case described in an adolescent,11) who underwent resection of a thoracic spine lesion and developed acute supratentorial epidural hematoma postoperatively. Here we describe the occurrence of supratentorial
bilateral epidural hematomas after cervical schwannoma
surgery in a teenager, analyze the pathogenesis in detail,
and emphasize early identification and treatment of this
hazardous complication to avoid or minimize permanent
neurological injury.

Case Report
A 14-year-old girl was referred for neurosurgical evaluation with a complaint of 3-month chest and back pain on
the right radiating to the ipsilateral shoulder. No remarkable medical history was noted, no anticoagulant agents
had been administered, and no bleeding tendency was
Received

October 24, 2011;

Accepted

Fig. 1 T2-weighted magnetic resonance images revealing an
intradural well-circumscribed mass displacing the cervical spinal cord dorsally and laterally at the C4 segment.

March 7, 2012

646

Intracranial Epidural Hematoma Complicating Spine Surgery

Fig. 2 Emergent brain computed tomography scans disclosing
symmetric epidural hematomas with a total volume of 80 ml
and brain herniation with disappearance of the ventricles and
cisterns.

Fig. 3 Postoperative brain computed tomography scans showing multiple cerebellar hypodensity areas, extensive decreased
density in the white matter and cerebral cortex, and cerebral
atrophy.

ation was completed uneventfully, the dura was repaired,
and epidural drainage with normal pressure was located
10 cm under the incision. During the whole operation, systolic blood pressure was well controlled and never exceeded 140 mmHg, CSF loss was about 100 ml, blood loss was
only 300 ml, and no blood infusion was required. The
tumor pathology was consistent with schwannoma.
The light reflex of the pupils was normal at the time of
leaving the operation room. Two hours following surgery,
delayed emergence from general anesthesia and bilateral
dilated pupils with positive Babinski reflex were noted,
and the amount of CSF drainage was 60 ml. Emergent
computed tomography (CT) revealed bilateral parietal
epidural hematomas with obliteration of the cerebral ventricles and cisterns (Fig. 2), and the drainage was closed
immediately and extubated. Her postoperative blood clot-

Neurol Med Chir (Tokyo) 52, September, 2012

647

ting and platelet parameters were reexamined and found
to be normal. Bilateral craniotomies was then performed
for removal of the hematomas, and scattered small blood
oozes along the branches of the middle meningeal artery
on the outer surface of dura mater were found without evident fracture, middle meningeal artery injury, or pseudoaneurysm, and were easily controlled by gelatin sponge
compression or mild electric coagulation hemostasis. The
patient regained spontaneous breathing at 6 hours and
complete consciousness at 82 hours following hematoma
removal. After final cessation of 85-hour mechanical ventilation, repeat CT demonstrated bilateral cerebellar infarctions and supratentorial hypoxic encephalopathy (Fig.
3). Hyperbaric oxygen therapy was then performed at 2.5
atmospheres absolute twice daily for 2 weeks. The 6month follow-up examination found her upper limb
hemiparesis had resolved leaving severe residual gait
ataxia and amnestic disorder.

Discussion
Three distinct forms of hemorrhage associated with spinal
surgery have been classified according to bleeding location: supratentorial subdural hematoma,2,3) cerebellar
hematoma,5,7) and supratentorial epidural hematoma.11) Intracranial epidural hematoma is most uncommon with
only one case report.11) Similar to our case, a 15-year-old
girl developed bilateral acute supratentorial epidural
hematomas after spinal metastasis resection via a T4-T5
laminotomy.11) Both cases share several common traits:
young age, simultaneously bilateral convex hematomas
with acute progression, delayed emergence from surgical
anesthesia, and durotomy performed during surgery.
The common etiology of postoperative intracranial
epidural hematomas may involve use of anticoagulants,
blood clotting dysfunction, incomplete hemostasis of the
dura mater or diploe, poorly controlled high arterial blood
pressure, and the misuse of rigid pins for head fixation.
However, all these hemorrhagic risk factors can be ruled
out in both cases. Due to the extremely low frequency of
occurrence, there is still no satisfactory explanation for
the mechanism of this unpredictable complication, but
presumably large CSF loss during surgery may be important in the pathogenesis of such hemorrhage.11) In the
present case, CSF release following durotomy and
postoperative epidural drainage may have contributed to
CSF depletion. CSF hypovolemia reduced intracranial
buoyant support and displaced the whole brain caudally,
resulting in secondary intracranial hypotension or even
negative pressure. However, decreased intracranial pressure may just be the essential factor for epidural hematoma formation rather than a sufficient factor since intracranial epidural hematoma has never been reported in
patients with spontaneous intracranial hypotension syndrome.
Both patients were aged 14 or 15 years, and epidural
hematoma following spine surgery has an evident
predilection for adolescents. Cranium growth is more active in children than in adults, and the adhesion between
the dura mater and the internal table of the cranial vault

648

Z.-J. Li et al.

bones is less tight than in adults or the elderly.8) Therefore,
teenagers are more liable to suffer mechanical separation
of the dura from the cranium. Further, the separating
forces might come from two different origins. Firstly,
acute vascular caliber enlargement in the middle meningeal artery and vein, secondary to CSF loss and decreased
intracranial pressure, may generate a dissecting force to
loosen the dura-cranium adhesion by constantly fluctuating dilation. Based on the Monro-Kellie hypothesis, which
states that the sum of the volumes of intracranial blood,
CSF, and brain tissue must remain constant in an intact
cranium, dural vascular engorgement and vasodilation
has been confirmed to compensate for reduced CSF
volume in patients with spontaneous intracranial hypotension.8) Secondly, negative intracranial pressure has been
identified in CSF leakage patients,1,9) so rapid and large
CSF loss could result in negative intracranial pressure and
produce inner suction, which will facilitate dura separation from the internal table of the cranium. Therefore, we
speculate that multiple factors contribute to the formation
of intracranial epidural hematoma following spine surgery, but rapid CSF depletion is an important precondition or initiating agent, which induces two categories of
dura-separating forces and ultimately results in dura splitting-hemorrhage collection and enlargement. In contrast,
cerebellar or subdural hemorrhage related to spine surgery is of venous origin, and results from stretching of
supratentorial bridge veins or cerebellar superior veins
that cross the subdural space.2,3,5,7) Compared with adolescents, the elderly or adults have larger subdural spaces,
and so these veins are more vulnerable to stretching injury
by intracranial hypotension in the elderly or adults than in
adolescents.2,3,5,7) Therefore, cerebellar or subdural hemorrhage mainly occurs in old or adult patients with no
predilection for adolescents.
Bilateral intracranial epidural hematomas following
spine surgery is a life-threatening complication, which
can rapidly cause central brain herniation and subsequent
cerebellar tonsillar herniation (Fig. 2). Early detection and
correct management could result in full recovery as in the
previous case.11) However, delayed hematoma removal
will cause irreversible brain ischemic injury or even brain
death. In our case, repeat CT revealed cerebellar infarction involving the territory of the bilateral posterior inferior cerebellar arteries (PICAs) and cerebrum anoxic encephalopathy in spite of the short 2-hour interval between
spine surgery and craniotomy (Fig. 2). The cerebellar infarction in our case may have resulted from tonsillar herniation that stretched the hemispheric branches of the
bilateral PICAs down to the edge of the foramen magnum,
and the branches were directly compressed by the herniated tissue. Therefore, postoperative vigilance and early
management are the most important factors for avoiding
adverse outcomes. On the other hand, avoiding unnecessary CSF loss via minimally invasive spine surgery may be
an effective procedure to decrease the incidence of such
complications if intracranial hypotension by excessive
CSF depletion is the cause.
Spontaneous intracranial epidural hematoma is an extremely rare condition, but should be considered a possi-

ble complication of spine surgery, especially in adolescents complicated by delayed consciousness and breathing restoration from general anesthesia.

Acknowledgments
This work was funded by the National Natural Science
Foundation of China (No. 11004114) and the Natural
Science Foundation of Shandong Province (No.
Z2008C06).

Conflict of Interest Notification
There is no potential conflict for this study.

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Address reprint requests to: Zhaojian Li, MD, Department of
Neurosurgery, the Affiliated Hospital of Medical College,
Qingdao University, Qingdao, Shandong Province 266003,
China.
e-mail: lzj0532＠yahoo.com.cn

Neurol Med Chir (Tokyo) 52, September, 2012