Haemorrhagic shock as an early and late complication of abdominal bone flap storage following decompressive craniectomy: a multi-institutional case series.

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.