title: Surgery for contralateral acute epidural hematoma following acute subdural hematoma evacuation: five new cases and a short literature review.
abstract: BACKGROUND
  The occurrence of a contralateral acute epidural hematoma (AEDH) following removal of an acute subdural hematoma (ASDH) is a rare but nearly devastating postoperative complication. Here, we describe a series of five patients with contralateral AEDH and provide a review of the literature to elucidate the characteristics and improve management of these patients.
  
  
  METHODS
  A total of 386 patients underwent ASDH evacuations in our hospital between August 2008 and July 2011. Five of these patients (1.3 %) developed AEDH that required surgery. Thirty-two additional patients were identified by a search of the PubMed database. Clinical features, surgical treatment, and outcomes (scored by Glasgow outcome scale, GOS) of the collective 37 AEDH cases were analyzed retrospectively.
  
  
  RESULTS
  Contralateral AEDH after ASDH evacuation occurred in 27 males (73 %) and 10 females (27 %) (mean age: 35.9 ± 14.2 years). Twenty-six patients (70 %) had unfavorable outcomes (GOS 1-3), and 11 patients (30 %) had favorable outcomes (GOS 4-5). Contralateral skull fractures and intraoperative acute brain swelling occurred in 30 (81 %) and 28 (76 %) patients, respectively. The preoperative Glasgow coma score (GCS) was significantly associated with outcome (p < 0.05).
  
  
  CONCLUSIONS
  Lower preoperative GCS score is an independent risk factor for prognosis of contralateral AEDH after ASDH. Postoperative management should include assessment of AEDH in patients treated for contralateral skull fractures and who experienced intraoperative acute brain swelling. We recommend early decompression with a burr-hole craniotomy, immediately followed by a decompressive craniectomy. This strategy provides gradual decompression, while advancing the initial surgical time and preventing the suddle decreased tamponade effect. As such, it may help decrease the risk of contralateral AEDH associated with decompression.
authors.affiliation: Department of Neurosurgery, First Affiliated Hospital, College of Medicine, Zhejiang University, No. 79 Qingchun Road, Hangzhou City, 310003, Zhejiang Province, People's Republic of China.
authors.forename: Jian
authors.initials: J
authors.lastname: Shen
authors.forename: Jian Wei
authors.initials: JW
authors.lastname: Pan
authors.forename: Zuo Xu
authors.initials: ZX
authors.lastname: Fan
authors.forename: Yong Qing
authors.initials: YQ
authors.lastname: Zhou
authors.forename: Zhe
authors.initials: Z
authors.lastname: Chen
authors.forename: Ren Ya
authors.initials: RY
authors.lastname: Zhan
mesh_terms: D000328:Adult; D056424:Decompressive Craniectomy; D005260:Female; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D006407:Hematoma, Epidural, Cranial / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D020199:Hematoma, Subdural, Acute / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis