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Acute bilateral epidural hematoma
260
Surg Neurol 1985;24:260-2
Acute Bilateral Epidural Hematoma Fabio Reale, M.D., and Roberto
Biancotti, M.D.
Neurosurgical Department, Siena Hospital, Siena, Italy
Reale F, Biancotti R. Acute bilateral epidural hematoma. Surg Neurol 1985;24:260-2. A case of acute bilateral epidural hematoma with different onsets is presented. The pathogenesis of the two hematomas is discussed. The importance and the limits of computed tomography scanning in these cases are stressed.
of the middle meningeal artery was removed. While the patient was still on the operating table, he developed marked anisocoria (right greater than the left). A second computed tomography scan (Figure 3) showed considerable displacement of the midline by a large right parietotemporal epidural hematoma. The patient was returned to the operating room (5 hours after injury).
KEYWORDS: Bilateral epidural hematoma; Head injury; Computed tomography Operation
Fewer than 70 cases [1] o f acute bilateral epidural hematomas have been reported to date, although very few with different onsets [2,4]. Thus this type of hematoma is extremely rare, although since the advent o f computed tomography scanning, it has been diagnosed more frequently.
Case Report On N o v e m b e r 26, 1983 a man aged 45 years was admitted to the hospital for a head injury due to an accidental fall down a stairway 1 hour before. On examination the patient was drowsy but free from lateral neurological deficits. X-ray films o f the skull (Figure 1) showed a fracture o f the middle third o f the vertex radiating into the temporal bone on both sides and extending as far as the base o f the skull on the left side. Within half an hour he became comatose and had anisocoria (left greater than the right) and a right hemiparesis. A computed tomography scan (Figure 2) revealed a left parietotemporal epidural hematoma and a modest extravasation of blood on the right side. The patient was taken to the operating room at once (2 hours after injury). Operation A left frontotemporoparietal osteoplastic flap was made, and a large extradural hematoma arising from a rupture Address reprint requests to: Fabio Reale, M.D., Via S. Benedetto, 41, 53100 Siena, Italy. © 1985 by ElsevierSciencePublishingCo., Inc.
A right frontoparietal flap was made and an extradural hematoma originating from the ruptured superior sagittal sinus was removed. The anisocoria was completely corrected and the patient was left with a mild left hemiparesis. A third computed tomography scan showed that the midline structures were normally aligned with no signs of bleeding. The patient's neurological status improved rapidly. By day 3 he was responding to commands and performing them with a hint of left motor deficit. The patient was kept in the intensive care unit for 40 days after the operation because of a respiratory distress syndrome. On January 5, 1984 he was sent to the neurosurgery department, from which he was discharged as fit 8 days later. A computed tomography scan (Figure 4) on February 29, 1984 was normal. Discussion Unlike the overwhelming majority o f the cases published [1] to date, the two epidural hematomas o f our patient were formed in succession. This fact permits the following conjectures on their genesis: 1. It is reasonable to suppose that the removal o f the first hematoma, by relieving the pressure on the contralateral hemisphere, favored the formation o f the second. 2. The different nature of the two hematomas (arterial in the first instance and venous in the second) suggest that the venous hematoma developed more slowly, as one would expect, and that the "lucid interval" was masked by the operation on the other side. 3. The peculiar type of fracture involving the superior longitudinal sinus might have led to the assumption 0090-3019/85/$3.30
Acute Bilateral Epidural Hematoma
Surg Neurol 1985;24:260-2
261
Figure 1. X-ray picture of the skull showing a fracture that radiates from the vertex to temporal bone on both sides, reaching the base on the left. Figure 3. Computed tomography scan after the first operation showing
.
that the two hemorrhages had a single source [3], but this possibility was ruled out by the findings at the operation. It has to be added that the herniation after the first operation did not take us entirely by surprise because the presence of the right temporoparietal fracture and o f the underlying computed tomographic hyperdensity had alerted us to a possible evolution o f the lesion.
Figure 2. Preoperative computed tomography scan showing left temporoparietal epidural hematoma and modest extravasation of blood on the right side.
the presence of a large right parietotemporal epidural hematoma and no more blood on the left side.
The neurotraumatologist mustAn fact always be prepared for a posttraumatic brain lesion to emerge at a later stage. A negative computed tomography scan should not be taken as altogether reassuring in the presence of a fracture or of even mild signs of neurological involvement. In the same way with unilateral lesions (see our case), a lesion of the opposite hemisphere may arise at Figure 4. Computed tomography scan 2 months postoperatively appears normal.
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Surg N e u r o l 1985;24:260-2
a later stage. The value of serial computed tomography scannings is therefore obvious. References 1. Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surg Neurol 1982; 17:218-22.
Reale and Biancotti
2. Koulouris S, Rizzoli HV. Acute bilateral extradural hematoma: case report. Neurosurgery 1980;7:608-9. 3. Robertson JH, Clark WC, Acker JD. Bilateral occipital epidural hematomas. Surg Neurol 1982;17:468-72. 4. Soni SR. Bilateral asymmetrical extradural hematomas: case report. J Neurosurg 1973;38:647-9.
Surg Neurol 1985;24:260-2
Acute Bilateral Epidural Hematoma Fabio Reale, M.D., and Roberto
Biancotti, M.D.
Neurosurgical Department, Siena Hospital, Siena, Italy
Reale F, Biancotti R. Acute bilateral epidural hematoma. Surg Neurol 1985;24:260-2. A case of acute bilateral epidural hematoma with different onsets is presented. The pathogenesis of the two hematomas is discussed. The importance and the limits of computed tomography scanning in these cases are stressed.
of the middle meningeal artery was removed. While the patient was still on the operating table, he developed marked anisocoria (right greater than the left). A second computed tomography scan (Figure 3) showed considerable displacement of the midline by a large right parietotemporal epidural hematoma. The patient was returned to the operating room (5 hours after injury).
KEYWORDS: Bilateral epidural hematoma; Head injury; Computed tomography Operation
Fewer than 70 cases [1] o f acute bilateral epidural hematomas have been reported to date, although very few with different onsets [2,4]. Thus this type of hematoma is extremely rare, although since the advent o f computed tomography scanning, it has been diagnosed more frequently.
Case Report On N o v e m b e r 26, 1983 a man aged 45 years was admitted to the hospital for a head injury due to an accidental fall down a stairway 1 hour before. On examination the patient was drowsy but free from lateral neurological deficits. X-ray films o f the skull (Figure 1) showed a fracture o f the middle third o f the vertex radiating into the temporal bone on both sides and extending as far as the base o f the skull on the left side. Within half an hour he became comatose and had anisocoria (left greater than the right) and a right hemiparesis. A computed tomography scan (Figure 2) revealed a left parietotemporal epidural hematoma and a modest extravasation of blood on the right side. The patient was taken to the operating room at once (2 hours after injury). Operation A left frontotemporoparietal osteoplastic flap was made, and a large extradural hematoma arising from a rupture Address reprint requests to: Fabio Reale, M.D., Via S. Benedetto, 41, 53100 Siena, Italy. © 1985 by ElsevierSciencePublishingCo., Inc.
A right frontoparietal flap was made and an extradural hematoma originating from the ruptured superior sagittal sinus was removed. The anisocoria was completely corrected and the patient was left with a mild left hemiparesis. A third computed tomography scan showed that the midline structures were normally aligned with no signs of bleeding. The patient's neurological status improved rapidly. By day 3 he was responding to commands and performing them with a hint of left motor deficit. The patient was kept in the intensive care unit for 40 days after the operation because of a respiratory distress syndrome. On January 5, 1984 he was sent to the neurosurgery department, from which he was discharged as fit 8 days later. A computed tomography scan (Figure 4) on February 29, 1984 was normal. Discussion Unlike the overwhelming majority o f the cases published [1] to date, the two epidural hematomas o f our patient were formed in succession. This fact permits the following conjectures on their genesis: 1. It is reasonable to suppose that the removal o f the first hematoma, by relieving the pressure on the contralateral hemisphere, favored the formation o f the second. 2. The different nature of the two hematomas (arterial in the first instance and venous in the second) suggest that the venous hematoma developed more slowly, as one would expect, and that the "lucid interval" was masked by the operation on the other side. 3. The peculiar type of fracture involving the superior longitudinal sinus might have led to the assumption 0090-3019/85/$3.30
Acute Bilateral Epidural Hematoma
Surg Neurol 1985;24:260-2
261
Figure 1. X-ray picture of the skull showing a fracture that radiates from the vertex to temporal bone on both sides, reaching the base on the left. Figure 3. Computed tomography scan after the first operation showing
.
that the two hemorrhages had a single source [3], but this possibility was ruled out by the findings at the operation. It has to be added that the herniation after the first operation did not take us entirely by surprise because the presence of the right temporoparietal fracture and o f the underlying computed tomographic hyperdensity had alerted us to a possible evolution o f the lesion.
Figure 2. Preoperative computed tomography scan showing left temporoparietal epidural hematoma and modest extravasation of blood on the right side.
the presence of a large right parietotemporal epidural hematoma and no more blood on the left side.
The neurotraumatologist mustAn fact always be prepared for a posttraumatic brain lesion to emerge at a later stage. A negative computed tomography scan should not be taken as altogether reassuring in the presence of a fracture or of even mild signs of neurological involvement. In the same way with unilateral lesions (see our case), a lesion of the opposite hemisphere may arise at Figure 4. Computed tomography scan 2 months postoperatively appears normal.
262
Surg N e u r o l 1985;24:260-2
a later stage. The value of serial computed tomography scannings is therefore obvious. References 1. Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surg Neurol 1982; 17:218-22.
Reale and Biancotti
2. Koulouris S, Rizzoli HV. Acute bilateral extradural hematoma: case report. Neurosurgery 1980;7:608-9. 3. Robertson JH, Clark WC, Acker JD. Bilateral occipital epidural hematomas. Surg Neurol 1982;17:468-72. 4. Soni SR. Bilateral asymmetrical extradural hematomas: case report. J Neurosurg 1973;38:647-9.