PMC3514531_01
Above: Graph showing serum concentration of S-100B (mug/l) over time (days). Arrows indicating neurosurgical interventions. (A) Evacuation of subdural mass (NCSP code AAD10). (B) Re-evacuation of subdural mass and placement of ICP-monitoring device (Codman ; AAD05, AAA20). (C) Insertion of external ventricular drain (AAF00). (D) Hemicraniectomy left side (AAK99). Numbers indicating performed radiological examinations [Computerized Tomography (CT) of the head if not otherwise stated]. (1) 15 mm midline shift to the right because of left side subdural mass. Old ischemic lesion in left side internal capsule (Figure 2). (2) Post-op evacuation, midline shift 12 mm, still compressed sulci. (3) Midline shift 11 mm, small frontal left-sided hematoma. Diffuse ischemic lesions left side occipital lobe. (4) Midline shift 15 mm, infarction in posterior cerebral artery left side and partially on the right side. (5) Post-op evacuation, middle shift 10 mm, unchanged ischemic lesions. (6) Midline shift 10 mm, better general conditions regarding intra-cranial mass effect, unchanged ischemic lesions. (7) CT-angiography: no signs of cerebral artery stenosis, dissection, or vasospasm. (8) Midline shift 10 mm, unchanged ischemic lesions. (9) CT-Thorax/Upper abdominal: 4.5 cm wide tumor in the lung, right upper lobe with growth to the mediastinum. Smaller cancerogenic lumps in the lung parenchyma. Multiple metastasis to the liver. (10) Magnetic resonance imaging (MRI): Midline shift 14 mm, compression of the brain stem. Infarctions in right side thalamus, internal capsule, pons, mesencephalon. Cortical infarctions left occipital lobe and right occipital lobe. Cerebellar infarctions (Figure 3). (11) Post-op hemicraniectomy. Thin line of blood beneath synthetic dura. Twelve millimeters midline shift. Unchanged ischemic areas. (12) (On day 8) Midline shift 16 mm, epidural hematoma with local mass effect. Brain stem herniation, compressed basal cisternae (Figure 4). Below: Graph showing the temporal profile of serum concentration of NSE (mug/l) over time (days). Two data points are missing due to hemolysis contaminating the sample.
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F1
S-100B was not acquired on admission (Figure 1). S-100B sample was obtained post-operatively 4 h and 22 min after the paramedics were alerted. S-100B was elevated (1.9 mug/l; Figure 1). The S-100B levels were followed twice a day and showed an unusual peak of 22 mug/l (normal range <0.11 mug/l) on day 5 (Figure 1). Later day 5, a decompressive left-sided hemicraniectomy was performed (Figure 1, point E).
Computerized tomography of the head (CT) on admission showing a left-sided sudural mass and a gross midline-shift of 15 mm.
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F2
A CT scan showed a left-sided chronic subdural hemorrhage (SDH), resulting in a midline shift of 15 mm (Figure 2).
Diffusion weighted magnetic resonance imaging (DWI MRI) of the brain on day 5. The white arrows highlight the ischemic regions in the left and right occipital lobes.
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F3
An EEG did not show any epileptic activity, MRI confirmed multiple infarcts, more than previously detected (Figure 3) yet no other information regarding the dura.
CT on day 11, 4 days post a left-sided hemicraniectomy. An EVD catheter in situ in the right hemisphere. There is a left-sided epidural expansive mass adjacent to the duraplasty (artificial membrane) causing a severe midline-shift.
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F4
While the S-100B declined post-operatively, the patient's ICP was still refractory unstable and the midline-shift remained 15-16 mm (Figure 4).