Posttraumatisches epidurales Hämatom mit arteriovenöser Fistel der Arteria meningica media

Vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery: a case report

BACKGROUND

Vertex epidural hematomas are rare. We describe the features of a vertex epidural hematoma associated with an arteriovenous fistula (AVF) of the meningeal artery created by a laceration of the dura mater underlying a linear skull fracture. Although AVF associated with convexity epidural hematomas has been reported, we know of no such previous report of vertex epidural hematomas.

CASE DESCRIPTION

A 65-year-old woman presented with generalized headache following head injury. On hospital day 3, she developed a left hemiparesis. Magnetic resonance imaging (MRI) disclosed a thick epidural hematoma at the vertex. Cerebral angiography showed an AVF between the middle meningeal artery and a venous lake. On hospital day 4, the epidural hematoma was evacuated.

CONCLUSION

Although coronal MRI was important for diagnosis of this vertex epidural hematomas, the case particularly illustrates the importance of cerebral angiography. The delayed onset of hemiparesis most likely reflected a continuing increase in hematoma volume because of bleeding from the lacerated meningeal artery.

Comparative analysis of experimental epidural and subarachnoid bleedings in dogs

The difference in the course and the lethal mechanism between intracranial, subarachnoid and epidural bleedings was studied in a dog model under varying conditions. Subarachnoid bleedings were usually shortlasting, self-restricting, and generally survivable. The epidural bleedings differed quantitatively and qualitatively from the subarachnoid bleedings in being larger and having a longer duration. The difference seems related mainly to the development of an arterio-venous shunt in the epidural space during the bleeding. It is suggested that the epidural arterio-venous shunt may be of importance for the course and the lethal mechanism in epidural bleeding.

Traumatic arteriovenous fistulae of the middle meningeal artery and neighbouring veins or dural sinuses

Systematic review of the cerebral angiograms of 446 head trauma patients (1971-1978) revealed the presence of an arteriovenous (AV) fistula of the middle meningeal artery (MMA) in 8 cases (1.8%), the total number of angiographically demonstrable injuries of the MMA being 18 (4%). AV fistulae of the MMA may prevent formation of epidural haematoma, but they are frequently associated with so severe damage to skull and brain that prognosis is nevertheless grave. A close relationship between the tighter adherence of the dura to bone in older age and development of an AV fistula of the MMA following trauma to the skull may be presumed.