Venous infarction following surgery for chronic subdural hematoma: A lesson for us.

Dear Sir,

A 30-year-old male presented after 2 months of head injury with complaints of disorientation and poor feeding for last 4 days. He was initially treated at a local hospital. Computed tomography (CT) scan was done for the above complaint (after 55 days of head injury) in a private local diagnostic center, which was reported by a radiologist as lt hemispheric chronic subdural hematoma with mass effect. He was referred to our hospital as neurosurgery facility was not available there. On initial evaluation, he was responding to verbal commands but was not fully oriented to time, place, and person. He did not have any focal motor or sensory deficit. His pupils were bilaterally equal and reacting well to light. Neurological examination of his cranial nerves showed it to be within normal limits. We admitted the case after evaluating the patient and seeing the CT scan plate with report. He was planned for burr hole and evacuation under general anesthesia (GA). Burr hole was done over lt posterior parietal area, and dura was cauterized in a cruciate manner and nicked in the center. Profuse fresh bleeding occurred as dura was nicked. Suction over cotton piece reveled that brain matter was tightly attached to dura, with bleeding from a cortical vein, which was controlled by cauterizing the bleeding vein. When we rechecked the CT scan plate, to our surprise, we found that we had done a mistake by operating on the lt side whereas the lesion was on the rt side. Although chronic subdural hematoma was on the lt side of CT scan, the technician had marked that side as “r” [Figure 1]. Conventionally, rt side of CT scan is marked as “r,” but in this case, lt side of scan was marked as “r,” which confused us all, and the radiologist had reported it as lt side chronic subdural hematoma. Ultimately, another burr hole was done over rt posterior parietal area and the chronic subdural hematoma was evacuated.

Figure 1

Technician had marked lt side of photo as “r.” According to the technician, it is rt side chronic subdural hematoma, but going by convention, the radiologist and surgeon thought it as lt side chronic subdural hematoma

On the 2nd postoperative day, we did check scan. Underlying the first burr hole, there was an area of hypodensity suggesting associated venous infarct [Figure 2]. This infarction in post-op scan, which was absent in pre-op scan, might have appeared due to accidental injury to cortical vain due to our wrong decision of operating in the opposite side of lesion. Chronic subdural hematoma in the rt side had pushed the brain mater to the opposite side, thereby making it more vulnerable for injury. We had taken strong action not to repeat such an incident in the future. The diagnostic center and radiologist had been informed regarding such an incident and advised to take necessary steps.

Figure 2

Underlying the first burr hole, there was an area of hypodensity suggesting associated venous infarct

The case of wrong side being operated is a nightmare for surgeons. Such incidents happen so frequently that it is a significant risk for many surgeons during their professional career. Such types of cases are always underreported, the reason being obvious. Wrong-site surgery results from misinformation or misperception of the patient's orientation.[12] Some surgeons believe marking patient's operative site before surgery reduces such incidences, whereas others believe that marking is a limited method of preventing wrong-site surgery and may even increase the risk of wrong-site surgery. Discrepancies between history, clinical finding, and radiological finding should be analyzed and resolved prior to surgery. In cases like ours, where there was no localizing sign, we have to decide the side of lesion depending upon the scan finding. The reason behind reporting such an incident is that with widespread use of CT scan and the scan being done by untrained persons, such an incident is likely to occur with anyone. We have to be vigilant and not operate blindly by going through the radiologist's reports as they may be wrong. Whenever confusion arises between the reports and scan findings, it is better to discuss with the radiologist and get it cleared. The key to preventing wrong-site surgery is to have multiple independent checks of critical information before putting the knife over the scalp. We hope that our experience will be definitely helpful to others.