British journal of neurosurgery · 2025
Haemorrhagic shock as an early and late complication of abdominal bone flap storage following decompressive craniectomy: a multi-institutional case series.
СтатьяКлинический случайМногоцентровое исследованиеНазвание и аннотация: Перевод в очереди
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Mcsweeney Daniel, Hayat Muhammad Khizar, Healy Vincent, Brosnan Conor, Horan Jack, Dablouk Mohamed O, Rodrigues Joao Marcos, Dablouk Lena, Roche Adam F, Moran Catherine, Kamel Mahmoud, O'Sullivan Michael G J
Аннотация
BACKGROUND: Decompressive craniectomy (DC) is a well-established intervention for refractory intracranial hypertension. Autologous bone flaps are commonly preserved by cryopreservation or subcutaneous abdominal storage.
OBJECTIVE: To report a novel, life-threatening complication of abdominal bone flap storage: haemorrhagic shock secondary to abdominal wall haematoma.
METHODS: We describe three cases (2 males, 1 female; ages 46-73) from two tertiary centres. Two patients underwent DC for traumatic brain injury, one for malignant MCA infarction. Each developed a large subcutaneous haematoma at the abdominal pocket site - analogous to a device pocket haematoma - precipitating haemorrhagic shock.
RESULTS: Haematomas developed between <6 hours and 14 days postoperatively. Anticoagulation varied: therapeutic heparin (n = 1), prophylactic LMWH (n = 1), none (n = 1). CT angiography and operative findings demonstrated focal arterial bleeding, likely from superficial rectus sheath branches of the superficial epigastric artery, attributed to abrasion by the bone flap edge. Despite moderate haematoma volumes (800-1000 mL), all patients developed ATLS class III-IV shock, reflecting physiological vulnerability after major surgery, trauma or advanced age. Urgent surgical exploration, flap removal, and electrocautery achieved haemodynamic stabilisation. This Clavien-Dindo grade IV complication appears rare - estimated incidence ∼0.5% (3/600 cases).
CONCLUSION: Abdominal bone flap storage, though considered safe, can cause focal vascular injury and life-threatening haemorrhage. Preventive measures - meticulous haemostasis, appropriate pocket sizing, and vigilant monitoring - are essential to enhance safety.
OBJECTIVE: To report a novel, life-threatening complication of abdominal bone flap storage: haemorrhagic shock secondary to abdominal wall haematoma.
METHODS: We describe three cases (2 males, 1 female; ages 46-73) from two tertiary centres. Two patients underwent DC for traumatic brain injury, one for malignant MCA infarction. Each developed a large subcutaneous haematoma at the abdominal pocket site - analogous to a device pocket haematoma - precipitating haemorrhagic shock.
RESULTS: Haematomas developed between <6 hours and 14 days postoperatively. Anticoagulation varied: therapeutic heparin (n = 1), prophylactic LMWH (n = 1), none (n = 1). CT angiography and operative findings demonstrated focal arterial bleeding, likely from superficial rectus sheath branches of the superficial epigastric artery, attributed to abrasion by the bone flap edge. Despite moderate haematoma volumes (800-1000 mL), all patients developed ATLS class III-IV shock, reflecting physiological vulnerability after major surgery, trauma or advanced age. Urgent surgical exploration, flap removal, and electrocautery achieved haemodynamic stabilisation. This Clavien-Dindo grade IV complication appears rare - estimated incidence ∼0.5% (3/600 cases).
CONCLUSION: Abdominal bone flap storage, though considered safe, can cause focal vascular injury and life-threatening haemorrhage. Preventive measures - meticulous haemostasis, appropriate pocket sizing, and vigilant monitoring - are essential to enhance safety.