Brainstem Hemorrhage After Extradural Hematoma Evacuation: Myth or Truth?

Brainstem hemorrhage can occur as a primary or secondary event in traumatic brain injury (TBI). Duret hemorrhage is a type of brainstem hemorrhage caused by a secondary increase in intracranial pressure and transtentorial herniation. Duret hemorrhage following TBI has been considered an irreversible and terminal event. We report a young adult patient with bifrontal extradural hematoma who presented with a low Glasgow Coma Scale score and advanced signs of cerebral herniation. The patient underwent an urgent craniotomy for evacuation of an acute epidural hematoma and remained in a poor neurological state post-surgery. A postoperative scan was done within 24 hours, which showed a newly developed Duret hemorrhage. The patient was nursed postoperatively with aggressive neurocritical and neurorehabilitation maneuvers; however, continued to have a poor neurological score. Although Duret hemorrhage has been reported in neurosurgical literature owing to various other etiologies, interestingly only four cases till now have been reported post craniotomy for extradural hematoma evacuation. Duret hemorrhage in the setting of cerebral herniation after a severe TBI has been considered a terminal brainstem event with a high incidence of death or persistent vegetative outcome.