title: Subdural hematoma after thoracoabdominal aortic aneurysm repair: an underreported complication of spinal fluid drainage?
abstract: OBJECTIVE
  Cerebrospinal fluid (CSF) drainage is a commonly used adjunct to thoracoabdominal aortic aneurysm (TAAA) repair that improves perioperative spinal cord perfusion and thereby decreases the incidence of paraplegia. To date, little data exist on possible complications, such as subdural hematoma caused by stretching and tearing of dural veins, should CSF drainage be excessive. We reviewed our experience with patients in whom postoperative subdural hematomas were detected.
  
  
  METHODS
  The records of 230 patients who underwent TAAA repair at the Johns Hopkins Hospital between January 1992 and February 2001 were reviewed.
  
  
  RESULTS
  Eight patients had subdural hematomas (3.5%). The four men and four women had a mean age of 60.6 years; two of these patients had a connective tissue disorder. All patients had lumbar drains placed before surgery, including one patient who underwent an emergency operation for rupture. Drains were set to allow drainage for CSF pressure greater than 5 cm H(2)O in all but one patient set for 10 cm H(2)O; spinal cooling was not performed in any patient. All drains were removed on the third postoperative day. In patients in whom subdural hematomas developed, the mean amount of CSF removed after surgery was 690 +/- 79 mL, which was significantly greater than the amount drained from patients in whom subdural hematomas did not develop (359 +/- 24 mL; P =.0013, Mann-Whitney U test). Six patients had postoperative subdural hematomas detected during hospitalization (mean postoperative day, 9.3; range, 2 to 16), and two patients were seen in delayed fashion after discharge from the hospital at 1.5 and 5 months. Four patients died of the subdural hematoma (50%); only one of these patients had neurosurgical intervention. All four survivors responded to neurosurgical intervention and are neurologically healthy. Two patients, both of whom were seen in delayed fashion, needed a lumbar blood patch. Multivariate logistic regression identified the volume of CSF drained as the only variable predictive of occurrence of subdural hematoma (P =.01).
  
  
  CONCLUSIONS
  Subdural hematoma is an unusual and potentially catastrophic complication after TAAA repair. Prompt recognition and neurosurgical intervention is necessary for survival and recovery after acute presentation. Epidural placement of a blood patch is recommended if a chronic subdural hematoma is detected. Care should be taken to ensure that excessive CSF is not drained perioperatively, and higher (10 cm H(2)O) lumbar drain popoff pressures may be necessary together with meticulous monitoring of patient position and neurologic status.
authors.affiliation: Department of Vascular Surgery, Yale University School of Medicine, New Haven, CT 06520-8062, USA.
authors.forename: Alan
authors.initials: A
authors.lastname: Dardik
authors.forename: Bruce A
authors.initials: BA
authors.lastname: Perler
authors.forename: Glen S
authors.initials: GS
authors.lastname: Roseborough
authors.forename: G Melville
authors.initials: GM
authors.lastname: Williams
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000134:cerebrospinal fluid / Q000150:complications / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000134:cerebrospinal fluid / Q000150:complications / Q000601:surgery*; D001019:Aortic Rupture / Q000134:cerebrospinal fluid / Q000150:complications / Q000601:surgery*; D015142:Baltimore / Q000453:epidemiology; D003131:Combined Modality Therapy; D004322:Drainage; D017558:Elective Surgical Procedures; D005260:Female; D006408:Hematoma, Subdural / Q000209:etiology* / Q000401:mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology* / Q000401:mortality; D016019:Survival Analysis; D017211:Treatment Failure