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Acute simultaneous bilateral extradural hematoma
Surg N eurol 1985;23:411-3
41 l
Acute Simultaneous Bilateral Extradural Hematoma Philip Barlow, F.R.C.S. and Yadon M. Kohi, F.R.C.S. Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland
Barlow P, Kohi YM. Acute simultaneous bilateral extradural hematoma. Surg Neurol 1985;23:411-3.
A patient with acute simultaneous bilateral extradural hematomas is presented and the mechanism of formation and the sequence of operations necessary to reduce the risk of disability are discussed. The recent literature is reviewed and it is suggested that two types of bilateral extradural hematoma may be found, depending upon whether venous or arterial bleeding is responsible. KEY WORDS: Head injury; Bilateral extradural hematoma, treatment
Previous reports of acute bilateral extradural hematomas have emphasized their rarity [5,7,9], difficulty in diagnosis [4,10], and frequent poor outcome [2,11]. Since the introduction of computed tomography scanning, four cases of bilateral extradural hematoma have been reported [2,8,9,11], but in only one of these were both hematomas diagnosed simultaneously and acutely [8]. We present an unusual case of acute simultaneous bilateral extradural hematoma, and discuss the mechanism of formation and management.
Unit where upon arrival he was flexing bilaterally, did not open his eyes, and gave no verbal responses. Pupils were equal and reacting and he had a very mild weakness of his right arm. Blood was seen behind both tympanic membranes. Blood gases were normal. An emergency computed tomography scan done 1.5 hours after the fall showed bilateral extradural hematomas, the right looking larger than the left, with minimal shift of the midline to the left. T h e r e was also the suggestion of an associated subdural hematoma on the right (Figure 1). Under general anesthesia an emergency craniotomy on the right side was made and the extradural clot removed. T h e r e was a linear fracture of the vault, together with a fracture of the sphenoid. The middle meningeal artery was the source of the bleeding. In view of the appearances on the computed tomography scan, the dura mater was opened, but no subdural blood was present. After closure of the first craniotomy a second craniotomy was made on the left side, and the extradural clot removed. Again, the bleeding was from the middle meningeal artery, although no fracture of the vault was seen. T h e r e was a fracture of the petrous temporal bone.
Progress Case Report A 43-year-old window cleaner fell from a ladder, after which he was unconscious for 5 minutes. On admission to a primary surgical ward he was obeying commands, opening his eyes to speech, and giving an inappropriate verbal response. His pupils were equal and reacting. There was no hemiparesis. H e had a right periorbital hematoma and x-ray films of the skull showed a right temporoparietal fracture. Over the next half hour his level of consciousness deteriorated, and he was referred to the Neurosurgical
Address reprint requests to." Mr. P. Barlow, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, Scotland.
© 1985 by Elsevier Science PublishingCo., Inc.
After the operation the patient improved steadily. Within 24 hours he was speaking, although confused, and movements of his limb were normal. A computed tomography scan 10 days after the operation showed some low-density changes in the left temporal lobe, but there was no mass lesion or midline displacement evident. Two weeks after the injury, he was oriented and physically well, but psychological testing revealed a moderate anomia and deficit of verbal memory. T h e r e were no deficits usually associated with the nondominant hemisphere (for example, nonverbal memory or drawing apraxia). H e was irritable and had no insight into his disabilities. The patient returned home to an independent life. Nine months after his accident he had improved significantly, but there was still impairment of verbal memory. H e regained some insight, but there was an associated 0090-3019/85/$3.30
412
Surg Neurol 1985;23:411-3
F i g u r e 1. Computed tomography scan showing bilateral extradural he-
matomas, 1.5 hours after injury.
depression. H e had not returned to work and was classed as moderately disabled on the Glasgow Outcome Scale.
Discussion It is to be expected that with the regular use of computed tomography scanning, more bilateral extradural hematomas will be diagnosed without the delay that characterized former cases. However, in the four reports in the literature o f cases diagnosed by computed tomography scan, two emphasized the problem o f a delayed clot developing after the scan made on the first admission [2,4], and a third demonstrated hematomas in a 2year-old child diagnosed 6 days after injury [9]. The fourth case was exceptional: a patient with osteogenesis imperfecta who, after minor trauma, had multiple fractures o f the skull [8]. O f these four patients, two made a moderate or good recovery, one died, and one remained severely disabled. In most o f the patient series reported before the computed tomography scan, the mortality has been h i g h - - 1 0 0 % in one series [11]. It would appear, therefore, that although the condition is still rare, computed tomography has aided in earlier and more effective management. The mechanism o f production o f the hematomas in our patient is different from that suggested by Frank et
Barlow and Kohi
al [2]. Although some [1,6] have claimed that nearly all unilateral extradural blood clots are caused by arterial bleeding and develop soon after injury, Frank et al thought that venous oozing was responsible in most cases of bilateral hematomas. The computed tomography scan in our patient was performed 1.5 hours after injury, and at operation the bleeding was coming from the meningeal artery on both sides--findings similar to those described by MacCarty et al [5]. The trauma was to the right side of the head, and it is reasonable to assume, therefore, that this single blow gave rise to the contralateral lesion by causing the necessary skull deformation and negative pressure at the antipole of the site o f impact as described by Gurdjian [3]. There seem to be two classes o f bilateral extradural hematoma. In the first type (and perhaps the more common one) one or both hematomas are delayed and are caused by venous bleeding. In the second type, which our case illustrates, both clots are caused by arterial bleeding and are present soon after injury. In the acute type, the problem is that of which hematoma to remove first. In our patient, the clot on the right side looked larger than the one on the left side, and it was therefore removed first. However, the residual neurological deficits (reduced verbal memory and anomia) and late appearance on a computed tomography scan (seen as low-density in the left temporal lobe) pointed to damage to the left hemisphere. In retrospect it may have been better to have operated upon the dominant side first. Before the operation our patient had no definite focal signs (it was not possible to test for dysphasia), and the computed tomography scan showed only minimal midline shift. The scan did, however, show slightly greater compression of the left ventricle, and perhaps this should have been the clue that the left hemisphere was being compromised more than the right. Theoretically it should be possible to operate on both sides simultaneously, or at least decompress by means o f burr holes. Unfortunately, in practice this would lead to difficulty with positioning of the head, and in patients with hematomas due to arterial bleeding (as in our case) there would be considerable blood loss. We suggest that unless the hematoma on the left side is very small, or unless there are definite signs signifying greater dysfunction of the right hemisphere, then the dominant side should be dealt with first. Bilateral extradural hematomas represent a rare and life-threatening complication of head injury. Early diagnosis and operation will reduce the risk o f disability.
W e are grateful to Mr. J.W. T u r n e r for permission to report this patient,
Bilateral Extradural H e m a t o m a
References 1. Ford LE, McLaurin RN. Mechanisms of extradural hematomas. J Neurosurg 1963;20:760-5. 2. Frank E, Berger TS, Tew JM. Bilateral epidural hematomas. Surg Neurol 1982;17:218-22. 3. Gurdjian ES. Impact head injury. Mechanistic, clinical and preventive correlations. Springfield, Ill: Charles C Thomas, 1975. 4. Koulouris S, Rizzoli HV. Acute bilateral extradural hematoma: case report. Neurosurgery 1980;7:608-10. 5. MacCarty CS, Horning FD, Weaver EN. Bilateral extradural hematoma. J Neurosurg 1948;5:88-90. 6. McLaurin RL, Ford LE. Extradural hematoma. Statistical survey of 47 cases. J Neurosurg 1964;21:364-71.
Surg N e u r o l 1985;23:411-3
413
7. Maurer JJ, Mayfield FH. Acute bilateral extradural hematomas. J Neurosurg 1965;23:63. 8. Pozzati E, Poppi M, Gaist G. Acute bilateral extradural hematoma in a case of osteogenesis imperfecta congenita. Neurosurgery 1983;13:66-8. 9. Saeki N, Hinokuma K, Uemura K, Makino H. Subacute bilateral epidural haematomas in an infant. Surg Neurol 1979; l 1:67-9. 10. Soni SR. Bilateral asymmetrical extradural hematomas. J Neurosurg 1973;38:647-9. l l . Subrahmanian MV, Razendraprasad GB, Dibbala RB. Bilateral extradural haematomas, B r J Surg 1975;62:397-400.
41 l
Acute Simultaneous Bilateral Extradural Hematoma Philip Barlow, F.R.C.S. and Yadon M. Kohi, F.R.C.S. Institute of Neurological Sciences, Southern General Hospital, Glasgow, Scotland
Barlow P, Kohi YM. Acute simultaneous bilateral extradural hematoma. Surg Neurol 1985;23:411-3.
A patient with acute simultaneous bilateral extradural hematomas is presented and the mechanism of formation and the sequence of operations necessary to reduce the risk of disability are discussed. The recent literature is reviewed and it is suggested that two types of bilateral extradural hematoma may be found, depending upon whether venous or arterial bleeding is responsible. KEY WORDS: Head injury; Bilateral extradural hematoma, treatment
Previous reports of acute bilateral extradural hematomas have emphasized their rarity [5,7,9], difficulty in diagnosis [4,10], and frequent poor outcome [2,11]. Since the introduction of computed tomography scanning, four cases of bilateral extradural hematoma have been reported [2,8,9,11], but in only one of these were both hematomas diagnosed simultaneously and acutely [8]. We present an unusual case of acute simultaneous bilateral extradural hematoma, and discuss the mechanism of formation and management.
Unit where upon arrival he was flexing bilaterally, did not open his eyes, and gave no verbal responses. Pupils were equal and reacting and he had a very mild weakness of his right arm. Blood was seen behind both tympanic membranes. Blood gases were normal. An emergency computed tomography scan done 1.5 hours after the fall showed bilateral extradural hematomas, the right looking larger than the left, with minimal shift of the midline to the left. T h e r e was also the suggestion of an associated subdural hematoma on the right (Figure 1). Under general anesthesia an emergency craniotomy on the right side was made and the extradural clot removed. T h e r e was a linear fracture of the vault, together with a fracture of the sphenoid. The middle meningeal artery was the source of the bleeding. In view of the appearances on the computed tomography scan, the dura mater was opened, but no subdural blood was present. After closure of the first craniotomy a second craniotomy was made on the left side, and the extradural clot removed. Again, the bleeding was from the middle meningeal artery, although no fracture of the vault was seen. T h e r e was a fracture of the petrous temporal bone.
Progress Case Report A 43-year-old window cleaner fell from a ladder, after which he was unconscious for 5 minutes. On admission to a primary surgical ward he was obeying commands, opening his eyes to speech, and giving an inappropriate verbal response. His pupils were equal and reacting. There was no hemiparesis. H e had a right periorbital hematoma and x-ray films of the skull showed a right temporoparietal fracture. Over the next half hour his level of consciousness deteriorated, and he was referred to the Neurosurgical
Address reprint requests to." Mr. P. Barlow, Southern General Hospital, 1345 Govan Road, Glasgow G51 4TF, Scotland.
© 1985 by Elsevier Science PublishingCo., Inc.
After the operation the patient improved steadily. Within 24 hours he was speaking, although confused, and movements of his limb were normal. A computed tomography scan 10 days after the operation showed some low-density changes in the left temporal lobe, but there was no mass lesion or midline displacement evident. Two weeks after the injury, he was oriented and physically well, but psychological testing revealed a moderate anomia and deficit of verbal memory. T h e r e were no deficits usually associated with the nondominant hemisphere (for example, nonverbal memory or drawing apraxia). H e was irritable and had no insight into his disabilities. The patient returned home to an independent life. Nine months after his accident he had improved significantly, but there was still impairment of verbal memory. H e regained some insight, but there was an associated 0090-3019/85/$3.30
412
Surg Neurol 1985;23:411-3
F i g u r e 1. Computed tomography scan showing bilateral extradural he-
matomas, 1.5 hours after injury.
depression. H e had not returned to work and was classed as moderately disabled on the Glasgow Outcome Scale.
Discussion It is to be expected that with the regular use of computed tomography scanning, more bilateral extradural hematomas will be diagnosed without the delay that characterized former cases. However, in the four reports in the literature o f cases diagnosed by computed tomography scan, two emphasized the problem o f a delayed clot developing after the scan made on the first admission [2,4], and a third demonstrated hematomas in a 2year-old child diagnosed 6 days after injury [9]. The fourth case was exceptional: a patient with osteogenesis imperfecta who, after minor trauma, had multiple fractures o f the skull [8]. O f these four patients, two made a moderate or good recovery, one died, and one remained severely disabled. In most o f the patient series reported before the computed tomography scan, the mortality has been h i g h - - 1 0 0 % in one series [11]. It would appear, therefore, that although the condition is still rare, computed tomography has aided in earlier and more effective management. The mechanism o f production o f the hematomas in our patient is different from that suggested by Frank et
Barlow and Kohi
al [2]. Although some [1,6] have claimed that nearly all unilateral extradural blood clots are caused by arterial bleeding and develop soon after injury, Frank et al thought that venous oozing was responsible in most cases of bilateral hematomas. The computed tomography scan in our patient was performed 1.5 hours after injury, and at operation the bleeding was coming from the meningeal artery on both sides--findings similar to those described by MacCarty et al [5]. The trauma was to the right side of the head, and it is reasonable to assume, therefore, that this single blow gave rise to the contralateral lesion by causing the necessary skull deformation and negative pressure at the antipole of the site o f impact as described by Gurdjian [3]. There seem to be two classes o f bilateral extradural hematoma. In the first type (and perhaps the more common one) one or both hematomas are delayed and are caused by venous bleeding. In the second type, which our case illustrates, both clots are caused by arterial bleeding and are present soon after injury. In the acute type, the problem is that of which hematoma to remove first. In our patient, the clot on the right side looked larger than the one on the left side, and it was therefore removed first. However, the residual neurological deficits (reduced verbal memory and anomia) and late appearance on a computed tomography scan (seen as low-density in the left temporal lobe) pointed to damage to the left hemisphere. In retrospect it may have been better to have operated upon the dominant side first. Before the operation our patient had no definite focal signs (it was not possible to test for dysphasia), and the computed tomography scan showed only minimal midline shift. The scan did, however, show slightly greater compression of the left ventricle, and perhaps this should have been the clue that the left hemisphere was being compromised more than the right. Theoretically it should be possible to operate on both sides simultaneously, or at least decompress by means o f burr holes. Unfortunately, in practice this would lead to difficulty with positioning of the head, and in patients with hematomas due to arterial bleeding (as in our case) there would be considerable blood loss. We suggest that unless the hematoma on the left side is very small, or unless there are definite signs signifying greater dysfunction of the right hemisphere, then the dominant side should be dealt with first. Bilateral extradural hematomas represent a rare and life-threatening complication of head injury. Early diagnosis and operation will reduce the risk o f disability.
W e are grateful to Mr. J.W. T u r n e r for permission to report this patient,
Bilateral Extradural H e m a t o m a
References 1. Ford LE, McLaurin RN. Mechanisms of extradural hematomas. J Neurosurg 1963;20:760-5. 2. Frank E, Berger TS, Tew JM. Bilateral epidural hematomas. Surg Neurol 1982;17:218-22. 3. Gurdjian ES. Impact head injury. Mechanistic, clinical and preventive correlations. Springfield, Ill: Charles C Thomas, 1975. 4. Koulouris S, Rizzoli HV. Acute bilateral extradural hematoma: case report. Neurosurgery 1980;7:608-10. 5. MacCarty CS, Horning FD, Weaver EN. Bilateral extradural hematoma. J Neurosurg 1948;5:88-90. 6. McLaurin RL, Ford LE. Extradural hematoma. Statistical survey of 47 cases. J Neurosurg 1964;21:364-71.
Surg N e u r o l 1985;23:411-3
413
7. Maurer JJ, Mayfield FH. Acute bilateral extradural hematomas. J Neurosurg 1965;23:63. 8. Pozzati E, Poppi M, Gaist G. Acute bilateral extradural hematoma in a case of osteogenesis imperfecta congenita. Neurosurgery 1983;13:66-8. 9. Saeki N, Hinokuma K, Uemura K, Makino H. Subacute bilateral epidural haematomas in an infant. Surg Neurol 1979; l 1:67-9. 10. Soni SR. Bilateral asymmetrical extradural hematomas. J Neurosurg 1973;38:647-9. l l . Subrahmanian MV, Razendraprasad GB, Dibbala RB. Bilateral extradural haematomas, B r J Surg 1975;62:397-400.