1530 - Retained Gelfoam Resulting in Recurrent Epidural Hemorrhage: A Post-operative Complication During Traumatic Brain Injury Rehabilitation

Case Diagnosis: A 22-year-old male participating in traumatic brain injury rehabilitation was found to have a complex fluid collection in bilateral frontal lobes concerning for abscess; surgical intervention revealed a gelfoam matrix within the epidural space that resulted in recurrent hematoma.

Case Description: Patient was initially admitted following a 25- foot fall off a truck at work. He sustained multiple intracranial hemorrhages. Acute care management included a craniotomy for epidural hemorrhage evacuation. After medical stabilization he was transferred to an inpatient rehabilitation unit where his course had been unremarkable until he experienced a generalized seizure during therapy. He was unresponsive for 20 seconds with bilateral pupillary dilatation, left-ward head turn, and gaze deviation. MRI brain with/ without contrast demonstrated a complex fluid collection in the anterior right frontal lobe extending to the left lateral frontal lobe crossing midline with a rightward midline shift and mass effect. He transferred to acute care for definitive treatment with craniotomy for drainage of presumed epidural abscess. Intra-operatively he was found to have a retained gelfoam within the epidural space with overlying hematoma. He returned to inpatient rehabilitation and eventually discharged to a neurorehabilitative program without further complications.

Discussions: Resorbable (gelfoam, surgicel, cellulose) and nonresorbable chemical hemostatic agents are commonly used in craniotomies for effective hemostasis. However, inflammatory reactions are a known adverse effect, especially with nonresorbable agents, and can result in neurologic decline. For this reason, these agents require removal once hemostasis is achieved. Furthermore, gelfoam is difficult to visualize on CT imaging but can manifest on MRI with features concerning for abscess, tumor, or rebleeding.

Conclusions: This case highlights the importance of considering retained surgical products in the differential for neurologic decline in post-craniotomy patients, despite variable radiologic evidence.