Large Vertex Epidural Hematoma: Case Report and Review of Surgical Approaches

Vertex epidural hematomas (VEHs) are a special clinical entity due to their clinical presentation, vascular etiology and options of surgical approach. The clinical suspicion involves recognizing the mechanism of the injury and the correct visualization of the hematoma in computed tomography (CT) coronal sequences. In the present article, we describe a case of a very large (146 mL) VEH with central brain herniation, and provide a technical note on the surgical planning and treatment. A 34-year-old male patient was admitted to the hospital after an injury on the left superior parietal region. The Glasgow coma scale score was 6, and the left pupil of the patient was dilated. The CT scan showed a large epidural hematoma on the vertex between the coronal e lambdoid sutures, and a fracture over the sagittal suture. During the surgery, multiple burr holes were made laterally to the sagittal suture, and after inspection and no visualization of bleeding in the superior sagittal sinus (SSS), we performed a standard biparietal craniotomy. The patient was discharged three days after the surgery without any deficits. Currently, with the improvement in imaging modalities,more cases of VEH are being identified. Identifying the etiology prior to the craniotomy is challenging in severe cases. Tears in the SSS can bleed profusely, and they demand strategies during the craniotomy.With multiple burr holes parallel to the sagittal suture, we can visualize whether there is bleeding in the SSS and design a craniotomy with or without a central osseous bridge to anchor the dura. Neurosurgeons must be prepared to plan a surgical strategy in cases of large VEHs. Due to its rare frequency and bleeding risks, VEHs are considered challenging.

Spontaneous intracranial epidural hematoma during rivaroxaban treatment / Hematoma epidural intracraniano espontâneo durante tratamento com rivaroxaban

Summary According to our research, this is the first case described in the literature of spontaneous intracranial epidural hematoma secondary to the use of Xareltor. Spontaneous intracranial epidural hematomas are rarely described in the literature. They are associated with infectious diseases of the skull, coagulation disorders, vascular malformations of the dura mater and metastasis to the skull. Long-term post-marketing monitoring and independent reports will probably detect the full spectrum of hemorrhagic complications of the use of rivaroxaban.

Resumo Segundo nossa pesquisa, descrevemos o primeiro caso na literatura de hematoma epidural intracraniano espontâneo secundário ao uso de Xareltor. Hematomas epidurais intracranianos espontâneos raramente são descritos na literatura, sendo comumente associados a doenças infecciosas cranianas, distúrbios de coagulação, malformações vasculares da dura-máter e metástases cranianas. A elaboração de relatórios de monitoramento em longo prazo de pós-comercialização e relatórios independentes provavelmente irá detectar o espectro completo de complicações hemorrágicas do uso desse medicamento.

Extradural hematoma following double valve replacement under cardiopulmonary bypass: A rare complication.

The primary mechanisms responsible for acute neurological deterioration following cardiopulmonary bypass (CPB) include cerebral embolism, cerebral hypoperfusion and/or inflammatory process triggered by CPB. Extradural hematoma (EDH) following CPB is rare but associated with significant mortality and morbidity. We present a case of EDH following double valve replacement in an adolescent boy.

Análise epidemiológica de 210 casos de hematoma extradural traumático tratados cirurgicamente / Epidemiological analysis of 210 cases of surgically treated traumatic extradural hematoma

OBJETIVO: Analisar aspectos da epidemiologia, apresentação clínica e radiológica de pacientes com hematoma extradural traumático (HED) submetidos a procedimento neurocirúrgico. MÉTODOS: Foi realizada a revisão de prontuários de 210 pacientes admitidos no Serviço de Emergência com HED diagnosticados através de tomografia computadorizada, tratados cirurgicamente no período de agosto de 1998 a janeiro de 2008. Foram analisados: idade, sexo, apresentação clínica e radiológica, mecanismo de trauma e status neurológico no momento da alta hospitalar. RESULTADOS: Em 49,2% o mecanismo de trauma foi queda; 89,2% dos pacientes eram do gênero masculino; 49,7% dos casos tinham Escala de Coma de Glasgow (ECG) entre 13-15; 61% dos pacientes tinham idade entre 20-49 anos; A localização do HED em 26,5% e 19,6% dos casos foi têmporo-parietal e temporal, respectivamente; 32,8% tinham lesões intracranianas associadas, sendo a fratura craniana evidenciada em cerca de 45% dos casos; 76,2% dos pacientes tratados cirurgicamente tiveram alta com déficit mínimo ou ausência de déficit neurológico. CONCLUSÃO: Observamos que o HED, na população de estudo, apresenta-se mais frequentemente no gênero masculino, na quarta década de vida, mais relacionado às quedas. Na admissão, observamos uma ECG entre 13 e 15, sendo pertinente mencionar o envolvimento da região têmporo-parietal na maioria dos casos. Acreditamos que o conhecimento da epidemiologia do hematoma extradural traumático pode auxiliar na elaboração de medidas de saúde pública, visando à prevenção e identificação precoce desta doença em determinada população.

OBJECTIVE: To assess the epidemiology, clinical and radiological presentation of patients with traumatic extradural hematoma (EDH) undergoing neurosurgical procedures. METHODS: We performed a chart review of 210 patients admitted to the emergency department with EDH diagnosed by CT scan and surgically treated between August 1998 and January 2008. Variables analyzed were: age, gender, clinical and radiological presentation, mechanism of injury and neurological status at discharge from hospital. RESULTS: In 49.2% trauma mechanism was fall; 89.2% of patients were male, 49.7% of cases had a Glasgow Coma Scale (GCS) between 13 and 15; 61% of patients had age between 20 and 49 years; the location of EDH was the temporo-parietal and temporal in 26.5% and 19.6% of the cases, respectively; 32.8% had associated intracranial lesions, with skull fractures seen in around 45% of cases; 76.2% of surgically treated patients were discharged with minimal or no neurologic deficit. CONCLUSION: We observed that, in the study population, EDH appears more often in males, in the fourth decade of life, and is more related to falls. On admission, GCS was observed between 13 and 15 and it is appropriate to mention the involvement of the temporo-parietal region in most cases. We believe that knowledge of the epidemiology of traumatic epidural hematoma can assist in developing public health measures aimed at prevention and early identification of this disease in the population.

Hematoma intradiploico: tratamento cirúrgico e relato de caso / Intradiploic hematoma: surgical treatment and case report

O hematoma intradiploico é uma lesão rara do crânio. Foi descrita inicialmente em 1934 e até hoje a sua patogênese não é conhecida. Trata-se de uma lesão rara e secundária a um processo reativo benigno após traumas cranianos leves ou coagulopatias. Paciente de 42 anos apresentava quadro progressivo de perda da marcha e alteração visual. Foi identificada massa na região occipital do paciente, de caráter progressivo. Os estudos radiológicos demonstravam lesão de aspecto heterogêneo, erosiva da calota craniana e com expansão intracraniana. Realizou angiografia digital que demonstrou trombose de seio sagital superior. Foi submetido à biópsia seguida de ressecção da lesão associada à cranioplastia. Houve melhora do padrão visual e do desempenho de marcha do paciente, em relação ao pré-operatório. Os autores relatam um caso raro de hematoma intradiploico, analisaram os diagnósticos diferenciais e discutem as opções cirúrgicas dessa rara doença.

Intradiploic hematoma: surgical treatment and case reportIntradiploic hematoma is a very rare lesion of the skull. It was first described in 1934 and until now his pathogenesis still unclear. It is a rare and benign reactive process that occurs after minor head trauma. This 42-year-old man presented with difficult to walk and visual loss. It was observed one growing mass at occipital bone. On computadorized tomography and magnetic resonance image one destructive lesion, heterogeneous and expansion. One angiographic study was performed and showed thrombosis of the superior sagital sinus. The patient was submitted to a biopsy and after the hematoma was radically resected with cranioplasty. The improved his walk condition and visual capacities. The authors reported one case of intradiploic hematoma, differential diagnosis were analyzed and discussed about the surgical options of this rare disease.

Tratamento das lesões focais intracranianas no traumatismo craniencefálico / Treatmento of focal intracranial lesions in cranioencephalic traumatism

O traumatismo craniencefálico pode resultar em lesões intracranianas difusas ou focais, representando afecções traumatoógicas graves, em parte necessitando de atendimento e conduta neurocirúrgica de emergência. As principais lesões focais de indicação cirúrgica são os hematomas epidurais, os hematomas subdurais agudos e as contusões cerebrais. Há ainda controvérsias sobre o tratamento em muitas situações. Os autores realizaram revisão da literatura descrevendo os princípios do tratamento cirúrgico de lesões focais secundárias ao trauma de crânio.

Head trauma presents in some cases, intracranial lesions, diffuse and focal. The more important lesions are acute epidural hematoma, subdural hematoma and brain contusions. There is controversy about the surgical treatment. In this study, the authors describe a critical review of literature about principles for surgical management for focal lesions by head trauma.

Bilateral cortical atrophy after severe brain trauma and extradural homatoma

We report the case of a severe head injured 43-year old male patient with a large extradural hematoma, Glasgow Coma Scale 3 and dilated fixed pupils. Patient was promptly submitted to surgical evacuation of the lesion, but remained in persistent vegetative state in the post-operative time. Head computed tomography scans performed before surgery, and at early and late post-operative periods comparatively revealed extreme bilateral cortical atrophy. Late consequences of severe head trauma drastically affect the prognosis of patients, being its prevention, and neuroprotection against secondary injury still a therapeutical challenge for neurosurgeons.

Relatamos o caso de um paciente de 43 anos, com traumatismo cranioencefálico grave, com grande hematoma extradural, Escala de Coma de Glasgow 3 e pupilas fixas e dilatadas. O paciente foi prontamente submetido à evacuação cirúrgica da lesão mas permaneceu em estado vegetativo persistente no período pós-operatório. As TC de crânio realizadas antes da cirurgia e nos períodos pós-operatórios precoce e tardio revelaram comparativamente extrema atrofia cerebral bilateral. As conseqüências tardias do traumatismo craniano grave afetam drasticamente o prognóstico dos pacientes, sendo sua prevenção, e a neuroproteção contra a injúria secundária ainda um desafio terapêutico para os neurocirurgiões.

Hematoma epidural pós-traumático na junção crânio-cervical: relato de caso e revisão de literatura / Post-traumatic epidural hematoma in the craniocervical junction: case report and review of the literature

Os autores relatam um caso raro de hematoma epidural pós-traumático na região da junção crâniocervical.Paciente de 63 anos, após grave acidente automobilístico, evoluiu com dor cervical intensa,refratária ao tratamento clínico. A ressonância magnética demonstrou um hematoma epidural desde ajunção crânio-cervical até C1-C2, de localização póstero-lateral direita, sem alterações de partes ósseas.Optado pelo tratamento cirúrgico imediato, foi realizada laminectomia com retirada do hematoma. Houvedesaparecimento da dor e resolução completa do hematoma, comprovado pela ressonância magnética.É feita revisão da literatura sobre o tema.

The authors report a rare case of post-traumatic epidural hematoma in the craniocervical junction ina 63 y.o. male patient, following a car accident. He presented with intense cervical pain refractory tothe clinical treatment. The magnetic resonance imaging demonstrated an epidural hematoma fromthe craniocervical junction down to C1-C2 level, on the right posterior-lateral region, without any bonealterations. An immediate laminectomy for drainage of the hematoma was carried through. The patientpresented alleviation of the pain and complete resolution of the hematoma, as proven by the magneticresonance imaging. Revision of literature on the subject is made.

Hematoma extradural do vértex: relato de caso / Epidural hematoma at the vertex: case report

Relatamos caso incomum de um paciente de 37 anos com hematoma extradural traumático do vértex com sintomas de hipertensão intracraniana. O diagnóstico foi feito através da tomografia do crânio em cortes coronais e o paciente foi submetido a craniotomia com drenagem do hematoma.

Acute extradural haematoma: factors affecting the outcome

The objective of the present study was to determine the factors that affect the outcome in the management of acute extradural haematoma. Material and The study was carried out at the Department of Neurosurgery, PGMI Hayatabad Medical Complex Peshawar, from 1st January 2000 to 31st December 2001. The clinical record of patients who were operated for acute extradural haematoma in the Neurosurgical Unit was reviewed. Their clinical condition, Glasgow coma score [GCS], duration and mode of trauma at the time of presentation were noted. The CT Scan findings, and the surgical procedure done, were analyzed. The postoperative outcome was assessed on the basis of Glasgow coma score. In this study 108 patients operated for acute extradural haematoma were selected. The ages ranged from 8 months to 65 years with male to female ratio of 5:1. Out of these patients, 26 [24%] were less than 15 years, 38 [35.1%] were between 16 and 30 years, 32 [29.6%] between 31 and 45 years. A satisfactory out come was achieved in 74 [69%] cases that presented within 12 hours as compared to those who presented late. Patient's age less than 45 years had better outcome as compared to those with more than 45 years of age. Mortality rate was 8% [n=7]. Timely surgery in patients who are in younger age group has better out come. The size of the haematoma and mode of trauma are also important factors that affect the outcome

Lumbar spontaneous spinal epidural haematoma

Spinal epidural haematoma can be secondary to congential acquired coagulation disorder or rupture of a vascular malformation. However, sometimes none of these aetilogies are present, as in the case of our patient. The authors report a case of lumbar spontaneous epidural haematoma causing complications of a malignant systemic arterial hypertension in a 48-year-old patient, who had not presented signs of arterial hypertension previously. In this study, we discuss the clinical aspects, pathogenesis and exploration methods of this rare disease. Its characteristics are that it appears suddenly and constitutes a therapeutic emergency

Acute cervical epidural hematoma: case report

A 74 year-old patient with a nocturnal onset of neck and chest pain was brought to an emergency clinic. Physical examination and cardiac assessment were normal. Three hours after the addmittance, a flaccid paralysis of the four limbs supervened. Suspecting of an unusual onset of central nervous system infection, a lumbar puncture was performed, yielding 20 ml of normal cerebrospinal fluid. Thirty oinutes after the puncture, the patient completely regained neurological funcion. He was then referred to a General Hospital where a computed tomography (CT) scan was done showing a large cervical epidural bleeding in the posterolateral region of C4/C5 extending to C7/Th1, along with a C6 vertebral body hemangioma. A magnetic resonance imaging revealed the same CT findings. A normal selective angiography of vertebral arteries, carotid arteries and thyreocervical trunk was carried out. Spontaneous spinal epidural hematoma (ASSEH) is a rare but dramatic cause of neurological impairment. In this article we report a fortunate case of complete recovery after an unusual spine cord decompression. We also review the current literature concerning diagnosis and treatment of ASSEH

El cerebro blindado controversia en su manejo / Armored brain-treatment

A la calcificación de un hematoma subdural crónico en el cráneo que cubre la mayor parte de la superficie cortical de uno o ambos hemisferios cerebrales se le ha dado el nombre de "cerebro blindado". El diagnóstico de esta entidad se sospecha por la clínica y se confirma con estudios de imagen. El tratamiento aún es controvertido. E presente caso describe un paciente de 26 años de edad con antecedente de traumatismo craneoencefálico y crisis convulsivas generalizadas recurrentes. Veintidós horas previas a su ingreso tuvo una crisis convulsiva tónico-clónica generalizada que ocasionó caida de su propia altura y traumatismo craneoencefálico. Fue encontrado inconsciente con pupilas midriáticas, postura de descerebración y respuesta plantar extensora bilateral por lo que fue trasladado al Hospital Español donde fue recibido con una calificación de 4 en la escala de Glasgow. La TAC mostró un hematoma epidural fronto-parietal izquierdo con gran efecto de masa con desplazamiento de estructuras de la línea media con herniación subfacial hemorragia subaracnoidea e intraventricular así como contusión hemorrágica temporoparietal derecha sin efecto de masa. Fue intervenido con drenaje de hematoma epidural y del hematoma subdural calcificado con exéresis de membranas calcificadas. Su evolución fue tórpida sin mejoría de condición preoperatoria falleció a la semana La cirugía está indicada cuando el déficit neurológico se instala en forma aguda. En cambio en el paciente asintomático la cirugía no necesariamente corrige la deformidad cerebral debido a la atrofia cerebral secundaria. Se realizó una revisión de la literatura.

Acute extradural hematoma analysis-factors influencing the outcome of patients undergoinm surgery in coma

Mortality due to extradural hematoma is virtually restricted to patients who undergo surgery while in coma. We have analysed the factors influencing the outcome of 24 patients who underwent evacuation of extradural clot when brought in comatose state. The study was conducted at Sandeman Provincial Hospital, Quetta from December 1994 to October 1996. The study was conducted randomly. Out of 24 patients, 10 patients [42 percent] made a good functional recovery, 7 patients [29 percent] died while 7 were moderately/severely disabled [29 percent]. The factors which affected the overall results were mechanism of trauma, age of patient, interval between trauma and surgery, Glasgow coma score at operation, associated intracranial lesions and hematoma volume etc. The duration of postoperative coma also affected the final outcome. The mortality rate was significantly higher in patients who were operated later than 12 hours [43 percent] than in patients operated on within 6 hours of injury [10 percent]. This study attempts to indentify factors responsible for higher mortality and morbidity in patients with extradural hematoma

Hematoma epidural espontâneo. Relato de dois casos / Spontaneous epidural hematoma. Report of two cases

Os hematomas epidurais espontâneos sao raramente descritos na literatura. Estao associados a doenças infecciosas do crânio, distúrbios da coagulaçao, malformaçoes vasculares da dura-máter e metástases na calota craniana. Os autores relatam dois casos de hematomas epidurais espontâneos de diferentes etiologias e discutem aspectos relacionados à hemostasia.

La hemorragia extradural intracraneal aguda temporalmente contenida. El riesgo de la tomografía axial computada demasiado precoz / Temporarily contained acute intracraneal extradural hemorrhage. The risk of very early computed axial tomography

Una tomografía axial computada (TAC) de cráneo normal o mínimamente anormal obtenida ultratempranamente en el manejo de un paciente traumatizado, no siempre es garantía de una evolución clínica sin problemas. El caso a relatar epitomiza esta aseveración. Un hombre de 35 años de edad fue hospitalizado en la sala de emergencias, en coma, pero hemodinámicamente estable. Unos 30 minutos antes había sufrifo traumatismo mútiple al ser atropellado por automóvil en la vía pública, con inconciencia inmediata. En admisión, la calificación en la Escala de Coma Glasgow (ECG) fue de 7. Después de intubársele por vía orotraqueal e hiperventilado mecánicamente, una fractura expuesta de la tibia y el peroné de la pierna izquierda fue estabilizada en una férula posterior. Una TAC de cráneo, obtenida a unos 60 minutos del accidente, demostró contusión cerebral difusa, discreta hemorragia subaracnoide e intraventricular y una hemorragia insignificante extradural laminar temporal derecha de 3 mL de volumen, subyacente a una fractura lineal de la escama del hueso temporal. Las estructura de línea media y la cisterna ambiens estaban preservadas. Ocho horas más tarde sobrevino cuadro de choque sistémico, el que respondió prontamente a la administración parenteral de soluciones cristaloides. Un lavado peritoneal diagnóstico fue negativo. Dos horas después, la pupila derecha fue descubierta totalmente dilatada y fija y aparecieron en el paciente crisis mesencefálicas de extensión bilateral. La calificación en el ECG cayó a 4. Nueva TAC de urgencia reveló extenso hematoma extradural temporoparietal derecho de 105 mL de volumen, con rechazamiento de estructuras cerebrales y desaparición de la cisterna ambiens. Mediante una apremiante craniectomía, el hematoma fue removido y la arteria meníngea media activamente sangrante, electrofulgorada. Cuando fue dado de alta en el 17º día postoperatorio, el paciente estaba confuso y exhibía una hemiparesis flácida izquierda. A 18 meses de la operación el paciente está parcialmente incapacitado y confinado a una silla de ruedas

Hematoma epidural medular espontâneo: relato de um caso / Spontaneous epidural spinal hematoma: case report

Os autores apresentam um caso de hematoma epidural medular espontâneo acometendo uma mulher de 49 anos, hígida e sem antecedente de hipertensäo arterial ou uso de anticoagulantes, com resoluçäo cirúrgica e diagnóstico dado pelo exame anatomopatológico. A revisäo da literatura permite identificar algumas patologias associadas e possíveis fatores envolvidos na formaçäo do hematoma. Os autores concluem sugerindo que se aprofunde ao máximo a investigaçäo diagnóstica das causas dos hematomas epidurais medulares espontâneos.

Multiple ipsilateral extradural hematoma. a case report

A rare case of two extradural hematomas on the same side in relation to a linear fracture with two different sources of bleeding is reported and its pathogenesis and management discussed