Acute traumatic vertex epidural haematomas surgically treated

Vertex epidural hematoma: Diagnosis, therapeutic consideration and outcome

OBJECTIVE

Vertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging.

MATERIALS AND METHODS

A retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome.

RESULTS

Patients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively (p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional "simple craniotomy". No patients undergoing "strip craniotomy" experienced massive bleeding. Thrombocytopenia (p = 0.008), headache (p = 0.015), consciousness disturbance (p = 0.043), pupil reactivity (p = 0.010), GCS score (p < 0.0001) and the relationship between skull fracture and the SSS (p = 0.037) were significant prognostic factors.

CONCLUSION

Our study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.

Acute epidural vertex hematoma with good hemostasis using delayed surgery after monitoring of coagulation and fibrinolytic parameters: A case report

Background

The appropriate timing and method of surgery for vertex epidural hematoma (VEDH) are uncertain due to the presentation and slow symptomatic exacerbation caused by bleeding from a venous origin involving the injured superior sagittal sinus (SSS). Coagulation and fibrinolytic disorders that occur after traumatic brain injury also worsen bleeding. For these reasons, it is challenging to decide the surgical procedure and timing of surgery.

Case Description

A 24-year-old man involved a car accident and was transported to our emergency department. He was unconscious but not lethargic. Computed tomography showed VEDH overlying the SSS, and hematoma increased temporarily. Due to abnormal coagulation and fibrinolysis at admission, he underwent intentionally delayed surgery after control of coagulation and fibrinolysis. Bilateral parasagittal craniotomy was chosen to ensure hemostasis from the torn SSS. The patient improved without complications and was discharged with no neurological deficit. This case indicates that this surgical strategy is favorable for VEDH with slow symptomatic progression.

Conclusion

VEDH is mostly caused by bleeding from the injured SSS secondary to diastatic fracture of sagittal suture. Intentionally delayed surgical intervention using bilateral parasagittal craniotomy after stabilization of coagulation and fibrinolysis is favorable for prevention of further hemorrhage and good hemostasis.

Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data

Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.

Management of Venous Sinus-Related Epidural Hematomas

BACKGROUND

Epidural hematomas (EDHs) involving the venous sinuses are uncommon and carry the risk of hemorrhage or venous infarction. We report the largest case series for superior sagittal sinus- and transverse sinus-related EDHs including surgical and nonsurgical management. We compare our findings to the relevant literature.

METHODS

A retrospective review of the EDH cases at our center was performed from 2013-2018. Patients were analyzed by surgical versus conservative management, outcomes, and complications.

RESULTS

Of the 268 EDH patients identified, 32 involved the venous sinuses (23 supratentorial and 9 infratentorial). Ten of the patients had surgery, and 22 were managed conservatively. No surgical complications occurred, and all had a Glasgow Outcome Scale score of 5 at follow-up. All of the nonsurgical patients had a Glasgow Outcome Scale score of 4 or 5 at follow-up except for 1 patient with prior disability. The literature search resulted in 39 infratentorial and 47 supratentorial EDHs involving venous sinuses.

CONCLUSIONS

Surgical and nonsurgical management of EDHs involving the venous sinuses are both viable options with good outcomes. Surgical intervention is based on location, size, neurologic examination, expansion on serial imaging, and vascular imaging findings. Surgery has the potential for significant complications, but all surgical patients in our series had good outcomes at follow-up. Similarly, nonsurgically managed patients had good outcomes and our overall series demonstrates better outcomes with fewer complications than other similar series in the literature.

Surgical Management of Vertex Epidural Hematoma: Technical Case Report and Literature Review

BACKGROUND

Vertex epidural hematoma (VEH) is an uncommon presentation of extra-axial hematomas. It can represent a surgical dilemma regarding when and how to operate, particularly considering the potential implication of the superior sagittal sinus (SSS).

OBJECTIVE

Here, we illustrate the surgical technique for VEH as well as a review of the existing literature.

METHODS

A 60-year-old man sustained a ground-level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bihemispheric convexities. Twenty-four hours later, the patient deteriorated, with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies, was performed. A central island of bone was left intact to spare the diastatic fracture from the craniotomies. This was done to ensure a stable anchor point for tacking-up the underlying displaced dura and SSS. The central bone prevents extensive bleeding from the diastatic fracture and eliminates the risk of further blood reaccumulation and tearing of a possible injured sinus during bone flap elevation.

RESULTS

The technique performed allowed us to evacuate completely the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation.

CONCLUSIONS

Because of its rare nature, VEH represents a surgical challenge. Because neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted.

Post-Traumatic Frontal and Parieto-Occipital Extradural Haematomas: a Retrospective Analysis of 41 Patients and Review of the Literature

The purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors.

In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a “good” or “favourable outcome”, whereas severe disability, a vegetative state or death was a “poor outcome”.

In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had “good outcomes” than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.

Clinical features of temporal tip epidural hematomas

OBJECT

The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs).

METHODS

A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury.

RESULTS

A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score.

CONCLUSIONS

A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.

[Epidural hematoma at the vertex: case report]

We report the unusual case of a 37 years old man with an epidural traumatic hematoma at the vertex with intracranial hypertension symptoms. The diagnostic was achieved with coronal cranial tomographic scans and a craniotomy was performed for hematoma removal.

Chronic epidural hematoma of the vertex

Epidural hematomas of the cranial vertex can be rarely found in patients victims of head trauma. The diagnosis of the vertex hematoma may be delayed by the odd location of the bleeding site and the absence of a clear localization symptomatology. The current method of choice for investigation of head trauma patients, the computed tomography (CT) scans, may also give misleading diagnostic clues. Epidural hematomas of the vertex can be also encountered in a chronic form, and re-bleeding is possibly the underlying mechanism for the long term permanence of the hematoma. We report a case of a patient with a chronic epidural hematoma of the cranial vertex with a long interval between the trauma and the symptoms onset. We review the current literature focusing on the diagnostic pitfalls and forms of treatment of the chronic epidural hematoma of the vertex.

Spontaneous vertex extradural hematoma: considerations about causes. Case report and review of the literature

A 36-year-old woman with an uneventful medical history was admitted to the emergency department following an initial generalized seizure. Neuroimaging workup disclosed a homogeneous mass at the vertex, which first was diagnosed as vertex meningioma. Anticonvulsant drug therapy was administered and the patient was discharged. Two months later the patient was examined in our neurosurgery department for additional therapeutic recommendations. A repeated neuroimaging examination showed considerable regression of the lesion. The findings on magnetic resonance imaging were consistent with those of a regressing extradural hematoma (EDH). A complete blood-coagulation study displayed no evidence of abnormality. Thorough questioning of the patient revealed no history of pericranial infection or head trauma occurring within the last 2 years. The final diagnosis was spontaneously occurring vertex EDH. In this report the authors describe the clinical and neuroimaging features of the case as well as the management strategy, and discuss etiological aspects within the context of a careful review of the literature.

Vertex epidural hematomas: imaging findings and diagnostic pitfalls

PURPOSE

Our purpose was to show the computed tomography (CT) and magnetic resonance (MR) imaging features of vertex epidural hematomas (EDHs) and emphasize pitfalls in the diagnosis of this entity.

SUBJECTS AND METHODS

The neuroradiologic studies of four patients (CT in four, MR imaging and MR venography in one) were evaluated for EDH shape, size and appearance.

RESULTS

EDHs were biconvex in three patients and crescentic in one patient. CT appearances included a collection that was hyperdense (two patients), generally isodense with a few regions of hyperdensity (one patient) and mixed hyperdense and hypodense (one patient). MR imaging findings in one patient consisted of hyperintense signal on T1-weighted images and hypointense signal on T2-weighted images. Inferior displacement of the superior sagittal sinus was seen in two patients. Diagnosis of a small vertex EDH was difficult on routine axial CT in one patient, but apparent on MR imaging and MR venography.

CONCLUSIONS

Small vertex EDHs can be difficult to diagnose on routine CT. MR imaging or thin section CT should be performed to exclude the diagnosis in patients with trauma to the skull vertex.

Vertex epidural hematoma: surgical versus conservative management: two case reports and review of the literature

OBJECTIVE AND IMPORTANCE

Vertex epidural hematomas may be underestimated or overlooked altogether when computed tomographic scans alone are used for diagnosis. Such hematomas can be resolved with active intervention and sometimes with conservative treatment.

CLINICAL PRESENTATION

Two cases of successfully treated vertex epidural hematomas, in a 33-year-old man who presented with seizures and an 11-year-old girl who presented with headache and vomiting, are described. Both hematomas were traumatic in origin and were associated with cranial fractures. In each, coronal images (computed tomographic or magnetic resonance imaging scans) showed the extent of the hematoma much more clearly than did axial images.

INTERVENTION

One case was treated surgically and the other conservatively.

CONCLUSION

Magnetic resonance imaging is not usually indicated for trauma patients, but it is an appropriate diagnostic modality for these rare lesions, to supplement standard axial computed tomographic scans. Because vertex epidural hematomas may resolve spontaneously with time, conservative treatment should be considered on a case-by-case basis.

Vertex epidural hematoma: a diagnostic challenge

We present the case of a 27-year-old man who sustained a minor head injury and presented with complaints of headache and vomiting. The diagnosis of vertex epidural hematoma is discussed.