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Delayed intracranial hemorrhage in children after suboccipital craniectomy
K T Nixon1, P A Hudgins, P C Davis
1Emory University School of Medicine, Department of Radiology, Atlanta, GA 30322.
Insights
Delayed extraaxial hemorrhages can occur in children years after posterior fossa surgery. These benign hematomas, often linked to dural substitutes, may arise from fragile vessels within neomembranes.
Area of Science:
- Pediatric Neurosurgery
- Neuroradiology
- Neuropathology
Background:
- Suboccipital craniectomy is a common procedure for posterior fossa tumors in children.
- Large dural defects often necessitate the use of dural substitutes, such as Silastic or human grafts.
- Neomembrane formation has been hypothesized as a potential cause of delayed complications after dural repair.
Purpose of the Study:
- To report clinical and imaging findings of delayed extraaxial intracranial hemorrhage in children post-craniotomy.
- To investigate the association between hemorrhage and neomembrane formation following dural substitute use.
- To differentiate these hemorrhages from recurrent tumor or other complications.
Main Methods:
- Retrospective review of clinical charts and imaging studies (CT, MRI, angiography) in seven pediatric patients.
- Analysis of surgical and pathological findings in four patients.
- Correlation of hemorrhage occurrence with prior suboccipital craniectomy for neoplasia and dural repair methods.
Main Results:
- Seven children developed acute extraaxial hemorrhages 3-12 years after suboccipital craniectomy.
- Hemorrhages occurred at the craniectomy site without evidence of tumor recurrence.
- Four hematomas were spontaneous, three followed minor head trauma; four patients had multiple episodes.
- Surgical exploration did not reveal a macroscopic bleeding source; pathology excluded recurrent tumor.
Conclusions:
- Delayed, benign extraaxial hematomas are a possible complication in children after posterior fossa tumor resection and dural repair with substitutes.
- Fragile vessels within neomembranes are a proposed source of these delayed hemorrhages.
- These findings highlight the importance of considering dural substitute-associated complications in the long-term follow-up of pediatric neurosurgery patients.
Objective:
The purpose of this study was to report the clinical and imaging findings of seven children who developed extraaxial, intracranial hemorrhage 3-12 years after suboccipital craniectomy for neoplasia. We attempt to explain the hemorrhages based on a previously reported hypothesis of neomembrane formation associated with dural substitutes used to repair large dural defects.
Materials And Methods:
Clinical charts (seven patients), surgical and pathologic findings (four patients), and imaging studies (CT scans and MR images in four; CT scans, MR images, and angiograms in one; and CT scans only in two patients) were reviewed retrospectively. Hemorrhage occurred 3-12 years after suboccipital craniectomy for tumor (ependymoma in two, medulloblastoma in three, astrocytoma in one, and ganglioglioma in one). Silastic dural substitute was used to repair the surgical wound in six cases and human dural graft in one case. Hematomas were spontaneous in four and occurred after minor head trauma in three. Four patients had multiple hemorrhagic episodes.
Results:
CT scans and MR images showed acute extraaxial hemorrhages at the craniectomy site without contiguous residual or recurrent neoplasia in all patients. No intraaxial or intratumoral hemorrhage was detected. Findings on cerebral angiograms in one patient were normal. Four patients underwent surgical exploration of the hematoma and craniectomy site; no macroscopic source of bleeding was detected. The hematomas were not associated with recurrent tumor pathologically.
Conclusion:
Delayed, benign extraaxial hematomas may occur in children who have undergone craniectomy for tumors of the posterior fossa and have had dural substitute used to repair large defects. Fragile vessels associated with nonmembranes have been proposed as the source of hemorrhage.