Ann Thorac Surg 2003;76:614-615
© 2003 The Society of Thoracic Surgeons
Case report
Subdural hemorrhagic injury after open heart surgery
Masato Nakajima, MD*a,
Kouji Tsuchiya, MDa,
Kazuya Kanemaru, MDb,
Hiromichi Yamazaki, MDb,
Hidehito Koizumi, MDb,
Shin Nakano, MDb,
Hidenori Inoue, MDa,
Yuji Naito, MDa,
Eiki Mizutani, MDa
a Department of Cardiovascular Surgery , Yamanashi, Japan
b Department of Neurosurgery, Yamanashi Central Hospital, Yamanashi, Japan
Accepted for publication December 23, 2002.
* Address reprint requests to Dr Nakajima, Department of Cardiovascular Surgery, Yamanashi Central Hospital, 1-1-1 Fujimi, Kofu City, Yamanashi 400-0027, Japan
e-mail: m-nakajima2a{at}ych.pref.yamanashi.jp
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Abstract
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We report two cases of acute subdural hematoma after cardiac surgery using cardiopulmonary bypass. In both patients, emergency removal and drainage of a subdural hematoma was performed by neurosurgeons, and complete recovery followed. Subdural hemorrhagic brain injury after cardiac surgery is rare and devastating; however, we consider early diagnosis and proper treatment to be effective because organic brain damage did not occur.
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Introduction
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The management for strokes after open heart surgery is still controversial because of the difficulty for further examination and lack of effective treatment. Most strokes are embolic events, and hemorrhagic brain injury with acute subdural hematoma after cardiac surgery has been rarely reported. Most cases with acute subdural hemorrhage occur as a result of trauma, and the early surgical result depends on the degree of brain damage sustained. However, in situations involving nontraumatic subdural hemorrhage, prompt diagnosis and early surgical treatment are considered effective because brain damage is slight.
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Case reports
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Patient 1
A 70-year-old woman with acute type A aortic dissection underwent an emergency graft replacement of the ascending aorta under deep hypothermic circulatory arrest with cardiopulmonary bypass. The patient was weaned from cardiopulmonary bypass without difficulty, but a long time was required to obtain hemostasis due to coagulation disability with thrombocytopenia (platelet count of 37 x 102/mm3). The patient’s postoperative hemodynamic status was stable, and she recovered well, but her consciousness deteriorated rapidly on the postoperative day 4. Emergency brain computed tomographic scan revealed massive subdural hematoma in the left convexity space (Fig 1a),
and an emergency operation was indicated. In the operating room, the patient’s Glasgow Coma Scale score fell from 9 to 6. Drainage of subdural hematoma was performed under local anesthesia and the patient completely recovered.
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Fig 1. (a) Brain computed tomographic scan of patient 1 demonstrating subdural hematoma in left convexity space (arrows) and herniation. (b) Brain computed tomographic scan of patient 2 demonstrating subdural hematoma in posterior fossa (arrows), which compressed the 4th ventricle.
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Patient 2
A 49-year-old woman with congestive heart failure caused by severe mitral and aortic valve stenosis and moderate tricuspid regurgitation was admitted to our department for surgical treatment. The patient had undergone open mitral and aortic commissurotomy 22 years earlier and had been taking warfarin for atrial fibrillation combined with heart valve disease. She had suffered thromboembolic brain infarction 15 years previously and had right side hemiparesis. Because of the progression of the heart valve disease, she underwent aortic and mitral valve replacement with mechanical prostheses along with tricuspid annuloplasty (De Vega method). Her postoperative hemodynamic condition was stable and anticoagulation therapy (warfarin) was started from postoperative day 1. On the next day, she left the intensive care unit in good condition. However, her consciousness suddenly deteriorated, and she fell into a coma (Glasgow Coma Scale score of 4) in the emergency ward. Emergency brain computed tomographic scan revealed subdural hemorrhage in the posterior fossa, which compressed the 4th ventricle (Fig 1b) and indicated surgical treatment. An emergency operation for subdural hematoma removal and drainage was performed under general anesthesia 3 hours after the diagnosis, and complete recovery followed. Anticoagulation therapy was restarted 1 week after surgery, and a follow-up brain computed tomographic scan revealed no new lesions associated with subdural hemorrhage.
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Comment
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The occurrence of stroke after cardiac surgery is recognized as a devastating injury that increases early mortality [1]. Hemorrhagic brain injuries are rare compared with ischemic brain injuries. Most strokes are embolic events that occur after initial, uneventful neurologic recovery from surgery, and no effective treatment has been identified [2, 3].
Acute subdural hemorrhage often occurs as a result of trauma and is rarely reported after cardiac surgery. The early surgical result after subdural hematoma depends on the degree of brain damage sustained. Thus, various factors correlate to indicate surgical treatment including mechanism of injury, age, degree of coma (Glasgow Coma Scale), intracranial pressure, and time from injury. Furthermore, management of postoperative intracranial hypertension is important to decrease operative morbidity [4, 5].
In both cases, the patient was at risk for bleeding. In one patient a bleeding tendency continued from the onset of acute aortic dissection, whereas the other patient was on anticoagulation therapy after valve replacement with mechanical prostheses. The onset of subdural hemorrhage was unclear, because both patients had remained lucid until rapid deterioration of consciousness occurred, and neither patient had an episode of traumatic brain injury. Therefore, in situations involving nontraumatic subdural hemorrhage, brain damage is often slight. Prompt diagnosis by computed tomographic scan and early surgical treatment should be considered important for resolution of this catastrophic hemorrhagic brain injury after open heart surgery.
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References
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- Almassi G.H., Sommers T., Moritz T.E., et al. Stroke in cardiac surgical patients: determinants and outcome. Ann Thorac Surg 1999;68:391-398.[Abstract/Free Full Text]
- Hogue C.W., Jr, Murphy S.F., Schechtman K.B., et al. Risk factors for early or delayed stroke after cardiac surgery. Circulation 1999;100:642-647.[Abstract/Free Full Text]
- Salazar J.D., Wityk R.J., Grega M.A., et al. Stroke after cardiac surgery: short- and long-term outcomes. Ann Thorac Surg 2001;72:1195-1202.[Abstract/Free Full Text]
- Wilberger J.E., Jr, Harris M., Diamond D.L. Acute subdural hematoma: morbidity, mortality, and operative timing. J Neurosurg 1991;74:212-218.[Medline]
- Seelig J.M., Becker D.P., Miller J.D., et al. Traumatic acute subdural hematoma. Major mortality reduction in comatose patients treated within four hours. N Eng J Med 1981;304:1511-1518.[Abstract]
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Abstract
Introduction
