Delayed postoperative hemorrhage in 21 patients with intracranial epidermoid cysts

Clinical article

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Object

Intracranial epidermoid cysts are rare, potentially curable, benign lesions that are sometimes associated with severe postoperative complications, including hemorrhage. Delayed hemorrhage, defined as one that occurred after an initial unremarkable postoperative CT scan, contributed to most cases of postoperative hemorrhage in patients with epidermoid cyst. In this study, the authors focus on delayed hemorrhage as one of the severe postoperative complications in epidermoid cyst, report its incidence and its clinical features, and analyze related clinical parameters.

Methods

There were 428 cases of intracranial epidermoid cysts that were surgically treated between 2002 and 2008 in Beijing Tiantan Hospital, and these were retrospectively reviewed. Among them, the cases with delayed postoperative hemorrhage were chosen for analysis. Clinical parameters were recorded, including the patient's age and sex, the chief surgeon's experience in neurosurgery, the year in which the operation was performed, tumor size, adhesion to neurovascular structures, and degree of resection. These parameters were compared in patients with and without delayed postoperative hemorrhage to identify risk factors associated with this entity.

Results

The incidences of postoperative hemorrhage and delayed postoperative hemorrhage in patients with epidermoid cyst were 5.61% (24 of 428) and 4.91% (21 of 428), respectively, both of which were significantly higher than that of postoperative hemorrhage in all concurrently treated intracranial tumors, which was 0.91% (122 of 13,479). The onset of delayed postoperative hemorrhage ranged from the 5th to 23rd day after the operation; the median time of onset was the 8th day. The onset manifestation included signs of intracranial hypertension and/or meningeal irritation (71.4%), brain herniation (14.3%), seizures (9.5%), and syncope (4.8%). Neuroimages revealed hematoma in 11 cases and subarachnoid hemorrhage in 10 cases. The rehemorrhage rate was 38.1% (8 of 21). The mortality rate for delayed postoperative hemorrhage was 28.6% (6 of 21). None of the clinical parameters was correlated with delayed postoperative hemorrhage (p > 0.05), despite a relatively lower p value for adhesion to neurovascular structures (p = 0.096).

Conclusions

Delayed postoperative hemorrhage contributed to most of the postoperative hemorrhages in patients with intracranial epidermoid cysts and was a unique postoperative complication with unfavorable outcomes. Adhesion to neurovascular structures was possibly related to delayed postoperative hemorrhage (p = 0.096).

Abbreviations used in this paper: CPA = cerebellopontine angle; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Song Lin, M.D., Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Tiantan Xili No. 6, Beijing 100050, China. email: linsong2005@126.com.

Please include this information when citing this paper: published online January 28, 2011; DOI: 10.3171/2010.12.JNS10325.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Bar graph showing time from intracranial surgery to clinical deterioration in 24 patients who developed postoperative hemorrhage.

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    Case 1. A: Axial T2-weighted MR image demonstrating a lesion at the right frontal lobe. B: Postoperative CT scan showing no hemorrhage 6 hours after the operation. C: Axial CT scan demonstrating a large hematoma in the operative field on the 8th day after the operation D: Axial CT scan showing slight subdural effusion 24 days after removal of the hematoma.

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    Case 5. Axial T2-weighted (A), sagittal T1-weighted (B), and coronal T1-weighted (C) MR images showing a space-occupying lesion in the right CPA. D: Initial postoperative CT scan demonstrating no hemorrhage 1 day after removal of the lesion. E: Subsequent CT scan demonstrating hemorrhage on the 10th day after removal of the lesion. F: Follow-up CT scan showing absorption of the hematoma 9 days after hemorrhage.

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    Case 10. A and B: Axial T1- and T2-weighted MR images demonstrating a space-occupying lesion in the left parasellar region. C: Diffusion-weighted MR image showing diffusing disturbance. D: Axial CT scan demonstrating no hemorrhage 6 hours after removal of the lesion. E and F: Axial CT scans demonstrating SAH on the 9th day after removal of the lesion.

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    Case 15. A: Preoperative axial CT scan demonstrating a space-occupying lesion in the right CPA. B: Axial CT scan showing no hemorrhage 6 hours after tumor removal. C: Axial CT scan demonstrating hemorrhage on the 7th day after tumor removal. D: Axial CT scan demonstrating no hemorrhage 2 days after removal of the hematoma. E: Axial CT scan showing rehemorrhage on the 7th day after removal of the hematoma. F: Axial CT scan obtained 1 day after removal of the second hematoma.

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    Case 21. Axial T2-weighted (A) and sagittal T1-weighted (B) MR images demonstrating a space-occupying lesion in the right CPA. C: Axial CT scan showing no hemorrhage 6 hours after removal of the lesion. D: Axial CT scan demonstrating delayed postoperative hemorrhage on the 7th day after removal of the lesion. E: Axial CT scan obtained several hours after removal of the hematoma. F: Photomicrograph of tissue obtained for pathological examination showing epidermoid cyst consisting of keratin and epithelium. H & E, original magnification × 100.

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