Recurrent intracranial epidural seemingly responsible for such event as

elaborated from history. On examination,

hematoma following
there was no neurological deficit. Magnetic
ventriculoperitoneal shunt in a resonance imaging revealed obstructive
child hydrocephalus as well as cerebellar tonsil
herniation (Figure 1 A and B). Her blood
profile was within the normal range.
Abstract Immunological investigations were also
within normal limit. Patient underwent
Intracranial hematoma is commonly
right ventricular peritoneal shunting
observed in neurosurgical practice.
procedure. Post operative computed
However, recurrent intracranial epidural
tomography (CT) scan was performed as
hematoma following ventriculoperitoneal
her GCS was altered and showed right
(VP) shunt is more of an exception than the
fronto-parieto-temporal epidural
norm. It is a rare but serious cause of
hematoma (Figure 2A). Emergency fronto-
morbidity and mortality in patients with VP
parieto-temporal craniotomy was done and
shunt. However, treatment is very
dural tacked up sutures along the margin of
promising especially with surgical
craniotomy. 50 ml dark red blood clots,
intervention in time. Here we report a case
some of which was liquefied was found and
of a ten-year-old girl who presented with
evacuated. Patient was put under close
chronic headache for a couple of years
monitoring in ICU.
whose imaging features suggested a
Post operative CT scan of craniotomy
hydrocephalus with tonsillar herniation.
two days later showed just EDH (Figure 2B)
Initially, she developed right
but in a small amount so patient underwent
frontotemporal hematoma and then
strict observation. Patient complained of
bilateral frontal epidural hematoma
headache a week after craniotomy. CT scan
following a VP shunt. Emergency
showed bilateral frontal huge epidural
decompression was done.
hematoma (Figure 2C).
Keywords: Epidural hematoma,
Hydrocephalus, intracranial, Ventricular- Figure 2 (A) Non-contrast axial head CT after
peritoneal shunt VPS revealing right fronto- parietto-temporal
hypo- hyperdensity-epidural hematoma and a
portion of the shunting apparatus with mass effect.
Introduction
(B) Non- contrast head CT obtained after 2 days
Intracranial epidural hematomas of second operation, revealing hematoma frontal
(EDHs) accounts for approximately 2% of region (C)
patients following head trauma and 5-15% Head CT after 7 days of VPS, revealing huge
of patients with fatal head injuries. 65-90% bilateral frontal epidural hematoma.
(D)Head CT after third operation showing
cases are associated with skull fractures4.
normal ventricle with shunting apparatus
EDH following cerebrospinal fluid (CSF)
diversion for hydrocephalus is rare. We Bilateral frontal craniotomy was done
report our experience with EDH after and dura was tight sutured along site of
ventriculoperitoneal shunt (VPS), craniotomy. About 70 ml dark calcified
management aspects and review of
black blood, adhesion with dura was found
literature.
and evacuated. This time patient recovered
smoothly. Post operative CT scan showed
Case report normal shaped ventricle without EDH
(Figure 2D).
A ten-year-old female child presented with
intermittent headache for 2 years. She was Discussion
diagnosed with and treated for sinusitis at a
local hospital. However, it was severe with In 1902, Cushing H. introduced
repeated vomiting for a couple of months. ventricular drainage (VD) as a means of
She was referred to our hospital for reducing intracranial pressure. Since then,
further management. There was no VD procedure has been frequently
history of trauma, fever, any anticoagulation performed in neurosurgical practice.
drug intake, or any other co-morbid disease Several intracranial subdural hematomas
 (SDH) after VPS have been reported in the extradural pocket (7, 8). Once bleeding has
literature as a complication. To our begun, the blood fills the pocket.
knowledge, the first reported complication Experimental evidence indicates that
of VD was mentioned by Schorste in 1942 arterial bleeding into the resulting pocket
(9). There are only few published reports of creates a hydraulic water press effect,
intracranial EDH as a complication of VPS. progressively stripping away the dura from
Intracranial EDH following CSF diversion the skull and widening the perimeter of the
for hydrocephalus is an important cause of hematoma (2).
immediate deterioration and contributes to Post shunt EDH can be managed
morbidity and mortality. Their presentation surgically and conservatively. The choice
is according to the size and location of between a surgical or a nonsurgical
hematoma, elevated intracranial pressure treatment of post shunt EDH requires the
and midline shift. The computed evaluation of various factors: volume,
tomography scan has played a significant thickness, midline shift and amount of
role in the early detection and proper fresh blood present on CT scan (4), the age
treatment of post operative intracranial of the patient, and the clinical picture.
hematoma. Huge acute or subacute collections in adults
EDHs are contact injuries resulting from or in children with closed fontanelles
blunt trauma to the skull and meninges. usually require surgical treatment.
Fractures, most often linear, are present in However, in a series concerning a pediatric
30 to 91 per cent of patients with epidural population, it was stated that asymptomatic
hematomas (1). It is thought that the initial EDH may become symptomatic later on
impact, with deformation or fracturing of and that it is safer to treat all post shunt
the cranium, produces detachment of the EDH, whether symptomatic or not (1).
dura directly beneath the site of the blow Our case is quite unique where a patient
and injures blood vessels (most commonly had presented primarily with extradural
branches of the middle meningeal artery). hematoma after VPS and again gradually
Hemodynamic factors like vascular developed EDH within one week after
malformations of the dura mater and craniotomy. We performed craniotomy
preoperative administration of twice and evacuation of hematoma after
anticoagulation or disorders of blood dural tenting sutures along the margin to
coagulation (spontaneous or iatrogenic), help hemostasis (3). She did well post
hypertension, effect of operative position to operatively even after three consecutive
venous outflow are the mechanisms of operations and was discharged from the
EDH. J. F. Sanchis et al (1975) explained hospital in good condition.
that neighborhood infection is also one of Conclusion
the causative factors for EDH. In the VPS is a common neurosurgical
literature, authors mentioned that interventional procedure. Patients should
mechanical factors like bridging vein be monitored closely post shunt, so
tearing, dural detachment because of brain intervention can be done immediately if
parenchyma displacement induced by CSF any evidence of deterioration like SDH,
(5, 6, 7). Our case is interesting as EDH EDH and others. Neurosurgeons must
developed adjacent and distant to the VP keep in mind that ICP raised patients may
shunt in 24 hours and one week present with such potentially fatal
respectively. In our knowledge, the complication which can be successfully
duramater is firmly attached at the cranial treated if diagnosed in time.
sutures in infants. Sudden lowering of
intracranial pressure (ICP) or rapid
drainage of ventricular CSF or gravitation
flow of CSF result in brain shrinkage from
the skull. Ultimately, detaching the
collagenous fixations of the dura from the
inner table of the skull may initially cause
dural and diploic veins to bleed into the