A Case of Myotonic Dystrophy misdiagnosed as Higher Brain Dysfunction after Acute Epidural Hematoma / The Japanese Journal of Rehabilitation Medicine

A 43-year-old man was admitted to our hospital for rehabilitation of higher brain dysfunction caused by traumatic brain injury. He had undergone an emergency operation for acute epidural hematoma after a fall. He had impaired cognitive function with regard to memory, attention, and executive function. However, he also exhibited facial features such as frontal baldness and hatched face. Neurological examination showed mild distal muscle weakness in the extremities, gait disturbance, and grip and percussion myotonia. Needle electromyography showed myotonic discharges. Brain magnetic resonance imaging did not show any intra-axial abnormalities. Myotonic dystrophy (DM) was therefore diagnosed. Rehabilitation resulted in improved gait stability, but the patient's cognitive function did not improve. Severity of illness in DM patients varies from a floppy infant to a lack of awareness of the disease throughout one's lifetime. Therefore, DM patients might not be properly diagnosed because of the mildness of their clinical symptoms. It is important for non-neurologists to be aware of the possible occurrence of this disease.

Postoperative Contralateral Supra- and Infratentorial Acute Epidural Hematoma after Decompressive Surgery for an Acute Subdural Hematoma: A Case Report

A postoperative contralateral supra- and infratentorial epidural hematoma after decompressive surgery is an extremely rare event. We describe a 38-year-old male with a contralateral supra- and infratentorial acute epidural hematoma just after decompressive surgery for an acute subdural hematoma. A contralateral skull fracture involving a lambdoidal suture and an intraoperative brain protrusion may be warning signs. The mechanisms, along with relevant literature, are discussed.

Rapid Spontaneous Redistribution of Acute Epidural Hematoma : Case Report and Literature Review

Acute epidural hematoma (AEDH) occurring as a result of traumatic head injury constitutes one of the most critical emergencies in neurosurgery. However, there are only several reports that show the rapid disappearance of AEDH without surgical intervention. We suggest redistribution of hematoma through the overlying skull fractures as the mechanism of rapid disappearance of AEDH. A 13-year-old female fell from a height of about 2 m and presented with mild headache. A computed tomography (CT) scan performed 4 hours after the injury revealed an AEDH with an overlying fracture in the right temporal region and acute small hemorrhagic contusion in the left frontal region. A repeat CT scan 16 hours after injury revealed that the AEDH had almost completely disappeared and showed an increase in the epicranial hematoma. The patient was discharged 10 days after injury with no neurological deficits. This case is characterized by the rapid disappearance of an AEDH associated with an overlying skull fracture. We believe that the rapid disappearance of the AEDH is due to the redistribution of the hematoma, rather than its resolution or absorption, and fracture plays a key role in this process.

The Operation of Acute Epidural Hematoma Through Small Craniotomy: Technical Note

We introduce a new operative method for acute epidural hematoma(AEDH) through small craniotomy. Between January 1999 and December 2001, 63 patients underwent craniotomy in our hospital to evacuate an acute posttraumatic epidural hematoma. Among these, we operated 18 patients with linear scalp incision and about 4 X 4cm sized small craniotomy. After operation, neurological symptoms were improved and there were no significant postoperative complications in all patients. This operative method is simple and less time consuming. It can be done under the local anesthesia and may be useful to all AEDH without severe brain swelling, subdural hematoma and intracerebral hematoma.

Clinical Analysis of Acute Epidural Hematoma

The authors have analyzed the factors influencing the outcome of the 168 patients with acute epidural hematoma who had been managed in our hospital for 3 years from July 1986 to June 1989. 1) Sex incidence showed that male patients were 4.8 times more commonly affected than females, and the most commonly affected age group was the 3rd decade. 2) The most common cause of injury was motor vehicle accidents. The patients with unknown cause of injury which probably suggested significant delay in starting the clinical managements had a higher mortality rate. 3) The most common site of hematoma was the FTP convexity(63.6%). The patients with diffuse hematoma in the fronto-temporo-parietal region had a high mortality and deteriorated level of consciousness. 4) Skull fractures were not seen only in 9.5% of the patients with acute epidural hematoma. 5) The main factors associated with the higher mortality rate were rapid development of hematoma, pupillary dilatation, low score in Glasgow Coma Scale on arrival, and more midline shifting on brain CT. 6) The patients with concomitant intracranial lesions had a high mortality rate(25.8%), and the patients with acute epidural hematoma alone had a low rate(2%), and the overall mortality rate of the patients with acute epidural hematoma was 11.3%.

Clinical Study of Conservative Management of the Acute Epidural Hematoma

The authors present 31 patient with acute epidural hematoma who had been admitted from January, 1987 to June. 1989 managed by consevative treatment. The results were as follows ; 1) The age of patients was distributed evenly, most patients were male (26 cases) and the most common mechanism of injury was traffic accidents(14 cases). 2) Sites of hematoma were mostly the temporal and parietal area and the maximum thickness of hematoma was not different from each site. 3) On admission, all patients presented GCS score above 13 except 2 cases. 4) All patients did not undergo delayed up, due to the enlargement of the hematoma or neurological deterioration. 5) The maximum thickness of hematoma was under 20 mm in all patients. 6) The hematoma was resolved within 30 days in all cases. This was confirmed with brain CT scan.