Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review

Surgical management of supratentorial and infratentorial epidural hematoma in Korea: three case reports

Supratentorial and infratentorial epidural hematoma (SIEDH) is a rare but life-threatening complication following traumatic brain injury. However, the literature on SIEDH is sparse, consisting only of a few small series. Prompt diagnosis and the application of appropriate surgical techniques are crucial for the rapid and safe management of SIEDH. Herein, we present three cases of SIEDH treated at our institution, employing a range of surgical approaches.

Exploring Rare Traumatic Injuries: A Miniseries of 4 Cases Discussing Epidural Hematomas Bridging the Infratentorial and Supratentorial Regions

Supratentorial-infratentorial epidural hematomas (SIEH) are a rare occurrence following traumatic head injuries, representing only 2% of traumatic epidural hematomas. Given the unique anatomical characteristics of the infratentorial region, mainly its small size, surgical intervention is commonly undertaken to alleviate the pressure on the posterior fossa components. Consequently, there is ongoing debate surrounding the optimal surgical approaches.In this report, we present four cases of SIEH that were treated surgically. Furthermore, we conduct a comprehensive review of existing literature, encompassing clinical, radiological, and therapeutic aspects associated with this condition.SIEH are uncommon post-traumatic lesions that require urgent and individualized management on a case-by-case basis, as guided by multiplanar cerebral computed tomography scan findings. Preoperative planning is essential; however, intraoperative exploration and identification of transverse sinus and torcula lesions are crucial for optimal patient care. The surgical approach may be modified intraoperatively based on the nature and extent of these lesions. In all cases, prompt hematoma evacuation and meticulous hemostasis are the two primary objectives of this surgery.

Head Trauma Associated with Supra- and Infratentorial Epidural Hematoma: Diagnostic and Surgical Considerations

BACKGROUND

Supra- and infratentorial epidural hematoma (SIEDH) is a rare type of intracranial epidural hematoma. Due to the potential of vigorous hemorrhage from the injured transverse sinus (TS), it poses a challenge for neurosurgeons to evacuate the SIEDH.

METHODS

The medical records and radiographic studies were retrospectively reviewed to investigate the clinical and radiographic characteristics, clinical course, surgical findings and outcome in 34 patients with head trauma associated with SIEDH.

RESULTS

Patients treated surgically had a lower Glasgow Coma Scale score than those treated conservatively (P = 0.005). The surgical group had statistically larger thickness and volume of the SIEDH than those in the conservative group (P < 0.0001 and P < 0.0001, respectively). Six patients experienced significant intraoperative blood loss, and copious bleeding from the injured TS was noted in 5 (83.3%) of these patients. Five (50%) of 10 patients undergoing simple craniotomy experienced significant blood loss. However, only 1 patient (11.1%) undergoing strip craniotomy experienced significant blood loss, but no intraoperative shock. All patients experiencing massive blood loss and intraoperative shock underwent simple craniotomy. There was no statistical difference in the outcome between the conservative and surgical groups.

CONCLUSIONS

When operating on SIEDH, the possibility of vigorous bleeding from the injured TS and intraoperative massive bleeding should be kept in mind. Strip craniotomy that allows hitching the stripped dura to the bone strip overlying the TS may be a better method for the evacuation of SIEDH.

Prognostic Factors and Outcome of Surgically Treated Supratentorial versus Infratentorial Epidural Hematoma in Pediatrics: A Comparative Study of 350 Patients at a Tertiary Center of a Developing Country

PURPOSE

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients.

METHODS

This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score.

RESULTS

Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups.

CONCLUSIONS

Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.

Modified surgical method of supra- and infratentorial epidural hematoma and the related anatomical study of the squamous part of the occipital bone

BACKGROUND

Supra- and infratentorial acute epidural hematoma (SIEDH) is a common posterior cranial fossa epidural hematoma located at the inner surface of the squamous part of the occipital bone (SOB). Traditionally, surgical treatment of the SIEDH requires a combined supra-infratentorial craniotomy.

AIM

To analyze the morphological characteristics of the SOB and introduce a single supratentorial craniotomy for SIEDH.

METHODS

Skull computed tomography (CT) scan data from 32 adult patients were collected from January 1, 2019 to January 31, 2020. On the median sagittal plane of the CT scan, the angle of the SOB (ASOB) was defined by two lines: Line A was defined from the lambdoid suture (LambS) to the external occipital protuberance (EOP), while line B was defined from the EOP to the posterior edge of the foramen magnum (poFM). The operative angle for the SIEDH (OAS) from the supra- to infratentorial epidural space was determined by two lines: The first line passes from the midpoint between the EOP and the LambS to the poFM, while the second line passes from the EOP to the poFM. The ASOB and OAS were measured and analyzed.

RESULTS

Based on the anatomical study, a single supratentorial craniotomy was performed in 8 patients with SIEDH. The procedure and the results of the modified surgical method were demonstrated in detail. For males, the ASOB was 118.4 ± 4.7 and the OAS was 15.1 ± 1.8; for females, the ASOB was 130.4 ± 5.1 and the OAS was 12.8 ± 2.0. There were significant differences between males and females both in ASOB and OAS. The smaller the ASOB was, the larger the OAS was. The bone flaps in 8 patients were designed above the transverse sinus intraoperatively, and the SIEDH was completely removed without suboccipital craniotomy. The SOB does not present as a single straight plane but bends at an angle around the EOP and the superior nuchal lines. The OAS was negatively correlated with the ASOB.

CONCLUSION

The single supratentorial craniotomy for SIEDH is reliable and effective.

Supra- and infra-tentorial subacute extradural hematoma

Extradural hematoma (EDH) is a rare but serious complication of brain injury. The supra- and infra-tentorial EDH is even rarer and only a few articles focusing on this topic have been published. The clinical manifestations are nonspecific but early diagnosis of supra- and infra-tentorial EDH and prompt treatment are mandatory to avoid complications. We report this case of a supra- and infra-tentorial subacute EDH on a 4 years old child.