Introduction: Decompressive craniectomy is is a surgical treatment for severe traumatic brain injuries that are refractory to medical management. Its most common surgical complications are surgical site herniation, post-operative infections, epilepsy...etc. Contralateral hematoma is a very rare but severe complication after decompressive surgery for traumatic brain injury. Development of this complication can lead to devastating consequences and bad outcome.
Case report: We report the case of a 29-year old man, with no medical background, who was brought to the emergency after a severe brain injury secondary to a car accident. Glasgow Coma Scale (GCS) upon arrival was 8 (V=2, M=4, E=2). CT scan upon arrival showed an acute hemispheric right subdural oedema, along with a large right temporal contusion with midline shift superior than 10mm. The surgical procedure was well explained to the family with the prognosis. Urgent decompressive craniectomy and evacuation of the hematoma along with temporal contusectomy were performed with wide duraplasty. The bone flap was sacrificed because of the brain swollen. Post-operatively, left anisocoria was noticed. CT scan showed a large contralateral parietal epidural hematoma with gross midline shift. The patient was reoperated on. An immediate evacuation of the hematoma. A linear fracture of the left parietal bone overlying the epidural hematoma was noticed. The post-operative follow-up was carried out in intensive care with strict neurological and hemodynamic monitoring, anisocoria regressed after surgery and the patient was extubated two weeks postoperatively. Despite right hemiparesis, the patient is able to walk independently.
Conclusion: Epidural hematoma after decompressive craniectomy surgery is a rare but dangerous complication. Severe head injury, a skull fracture contralateral to first surgery and intraoperative brain protrusion are typical clinical findings. In patients operated on for decompressive craniectomy with a contralateral skull fracture, immediate postoperative CT scan is indicated to evaluate this rare but lethal complication.