Delayed detection versus delayed occurrence of contralateral hematoma.

Dear Sir,

Intraoperative or immediate development of contralateral hematoma, following decompressive craniectomy, with or without a coexisting fracture/hematoma, is a well documented entity in the literature.[1234] Having read the following article “Contralateral delayed epidural hematoma following intra cerebral hematoma surgery” by Solomiichuk and Drizhdov,[4] had few queries/doubts. This 28-year-old male, who had a traumatic left frontal contusion with a fracture of right temporal bone, was treated by the left sided hemicraniectomy and evacuation of intracerebral haematoma in left frontal lobe. The authors have mentioned an intraoperative event of acute brain swelling, a well documented entity due to loss of tamponade effect resulting in contralateral hematomas, which warrants imaging in the immediate postoperative period.[5] However, the imaging was delayed for reasons not mentioned. On contacting the authors through the editor, the authors contended that the patient was hemodynamically unstable and that was the reason for delay in obtaining the computed tomography (CT) scan. Had the patient been hemodynamically stable, the authors too would have obtained a control CT scan immediately. Development of anisocoria is a late event in the manifestation of transtentorial herniation with other features, especially the initial clouding of consciousness being masked by an already poor preoperative Glasgow Coma Scale (GCS; 5/15). In the absence of immediate postoperative scan, the clinical and operative findings are not consistent with the term “delayed” occurrence of contralateral hematoma, for it could have developed when there was a brain swelling and was detected at a later date when all the described signs of herniation had developed. In fact, this is a case best strengthening the classical teaching of obtaining an imaging in the immediate postoperative period with the backdrop of adverse events intraoperatively (acute brain swelling), to rule in or out surgically treatable causes.

However, circumstances may sometimes be unfavorable for shifting an hemodynamically unstable patient (as in the present case). This problem could possibly be avoided with widespread availability of mobile CT scanner in trauma care centers. The very aim of urgency in the setting of trauma is to have a relaxed brain at the earliest.

The debate might not end here but we should aim to develop protocols for improved care especially following an adverse event.