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Bilateral traumatic extradural haematomas: report of 12 cases with a review of the literature
L'linid Nrwok~~qk-und IV~lJ~c~.S/.Wger~~ 94 (1902)137 131 0 1992 Etsrvier Science Publishers B.V. All rights reserved 0303-X467j9X OS.00
127
CLlNEU 00183
Bilateral traumatic extradural haematomas: report of 12 cases with a review of the literature Sunil K. Gupta, Shiv C. Tandon, Sureshwar M~hanty, Sanjaya Asthana and Sandeep Sharma
(Received 17 December, 1990) (Revised. received 1I November. 1991) (Accepted 11November. 1991)
Key i+~,&s: Bilateral extradural hematoma; Head injury: CT scan; Surgical treatment: Trauma summary We are reporting 12 cases of traumatic bilateral extradurat haematomas. The incidence was 4.8% of al1 cases of extradural haematomas. The most ~om~non site was the frontal region. CT scan examination was necessary for early diagnosis. Ten patients were operated upon while one patient was treated conservatively. Two patients died. The relevant literature is reviewed.
The occurence of bilateral extradural haematoma (EDH) is rare. A report of more than 100 cases of EDH by Hooper [I] did not contain a single case of bilateral EDH. The first case of bilateral EDH was reported by Roy [2]. Since then there have been sporadic reports of this entity [2-283. The incidence ranges from 0.5 to 10% of all extradural haematomas (7,10,12,13,15,21]. We present 12 cases of t~umatic bilateral extradural haematomas from the Neurosurgery Section, University Hospital, Varanasi, India.
Clinical materiai In the last 12 years we have encountered 250 cases of EDH which form 4.1% of all cases of head injury managed in the Section of Neurosurgery, University Hospital, Varanasi. India. Out of these 250 cases of EDH. 12 C’ovrcspon&rzw fo: Dr. Suni1 Kumar Gupta, 2GF Old Medical Enclave, Hanaras Hindu ~Jniversit~. V~r~n~si 221 005. India.
patients had bilateral extradural haematomas comprising the case material of this report. Eleven patients were male. The age distribution is shown in Table 1. Five patients had injury in road traffic accidents and an equal number due to fall from height. Two patients were hit over the head by a wooden stick (“lath?‘). The Glasgow Coma Scale of the patients upon arrival in the casualty department is depicted in Table 2. Lucid interval was present in only 2 patients. In only 2 of the patients was pupillary abnormality present and 2 patients had focal neurological deficits. Eight patients had an associated skull fracture and in 3 of these patients, bilateral skull fractures were present including coronal sutural diastatic fracture in one. The location of the EDH in each of the 12 patients is depicted in Table 3. In 11 patients, the diagnosis was established by CT scan while in the remaining one case, it was a per operative diagnosis, after making exploratory burr holes. Most common location of bilateral EDH was frontal either alone or in combination with other sites (Table 3). In 2 patients there were 3 extradural haematomas (cases no. 7 and 11, Fig. I). In case no. 6, there was an associated il~tra~ereb~~l haematoma (Fig. 2). Bilateral
128 TABLE I
TABLE 3
AGE DISTRIBUTION OF PATIENTS WITH BILATERAL EXTRADURAL HAEMATOMAS
LOCATION OF THE EXTRADURAL HAEMATOMAS AND SOURCE OF BLEEDING IN EACH OF THE 12 PATIENTS
Age (years)
No. of patients
10 1l-20 21-30 3140
2 5 4 1
Case Location of the extradural No. haematomas 1 2 3
craniectomy/trephine craniotomy was performed in 10 patients. One patient with a small bilateral frontal EDH was managed successfully conservatively. During operation, in no case was an arterial source identified. The presumed source of bleeding was the diploic veins in 10 cases and superior sagittal sinus in 2 cases (Table 3). In case no. 2, the left sided haematoma traversed across the transverse sinus, extending both into supratentorial and infratentorial compartments. There was an associated fracture of the occipital bone. The site of bleeding in this case was probably a tear in the left transverse sinus. Out of the 10 patients who were operated upon one died. This patient (case no. 10) had a GCS of 3 and bilaterally dilated and fixed pupils. One patients (case no. 11) died while being wheeled to the operation theatre (Fig. 3). Rest of the patients improved without any residual neurologic deficit.
4 5 6 7 8 9 10 11 12
Left frontoparietal and right temporal Right occipital and left occipital extending into post. fossa Right frontal and left fronto-temporo-parietal Bifrontal Right posterior parietal and left temporo-parietal (Fig. 4) Bilateral frontoparietal (and left intracerebral haematoma) Bilateral temporoparietal and left frontal Bilateral frontal Bilateral frontal Biparietal Bilateral frontal and left parietal Bilateral temporoparietal
Presumed bleeding site Diploic veins Diploic veins and transverse sinus Diploic veins Sup. sagittal sinus Diploic veins Diploic veins Diploic veins Diploic veins Sup. sagittal sinus Diploic veins Diploic veins Diploic veins
Discussion
To produce bilateral extradural haematomas, the dura mater must be detached at two sites by a singly directed force. A lateral force can strip the dura mater at the side of impact by the inward and outward bending of the skull. On the opposite side dural stripping may occur due to motion of the skull further aggravated by the negative intracranial pressure formed at the antipode of the comTABLE 2 GLASGOW COMA SCALE OF THE PATIENTS UPON ARRIVAL IN THE CASUALTY GCS
No. of patients
8
2 4 6
9-12 7-12
Fig. 1. CT scan showing a frontal and two parietal extradural haematomas.
129
Fig ;. 2. CT scan showing bilateral fronto-parietal left intracerebral haematomas.
extradural and
Fig. 4. CT scan showing right posterior parietal and left temporo-parietal extradural haematomas.
pression forces of the skull [29]. Midline forces may be redirected bilaterally by the buttress of the frontal bone in the glabellar midline
is spared
the sagittal sinus. The recognition
area [5]. Detachment by the strong of bilateral
dural EDH
of the dura in the attachments
over
has become
much
simpler because of the routine availability of CT scan. The reported incidence of bilateral EDH in the literature is low. In a series of 167 patients of EDH, only 4 had bilateral haematomas [7]. Jamieson and Yelland [12] reported 5 cases of bilateral EDH in another 167 cases. Gruskiewicz et al. [lo] reviewed 1841 cases of head injuries and found 97 cases of EDH. Out of these only 3 had bilateral EDH. Frank et al. [6] encountered a single case of bilateral EDH and reviewed a total of 64 cases from the available literature. Maurer and ported a case of acute bilateral EDH
Mayfield [ 171 rewhile Saeki et al.
[22] reported a case of subacute bilateral EDH in an infant. Of the 51 patients of EDH reported by Kalyanar-
Fig5. 3. CT scan showing bilateral fronto-parietal haematomas.
extradural
aman et al. [13] one had a bilateral EDH. Rao [21] encountered one case of bilateral EDH among 98 cases of EDH. McKissock et al. [18] and Phillips and Azariah [19] reported 3 cases each out of 125 and 115 cases of EDH, respectively. A case of ipsilateral double epidural haematomas was reported by Bharti et al. [3]. Sharma
no difference
in incidence
groups of patients, al. [6]. Frank
in contrast
was less frequently present
managed
Frank
with bilateral
delayed
of lucid interval
pared
to patients
eral EDH,
was
among
that bilateral
neurological
of slow accumulation
ries, pupillary
EDH.
EDH (19.6%).
cause
were present
et
only (16.6%). This was not statisti-
et al. [6] were of the opinion develop
of Frank
by us, lucid interval
from the incidence
with unilateral
patients
in the two
that lucid interval
seen in patients
in 2 patients
patients
to the findings
et al. [6] also reported
Out of the 12 patients cally different
of skull fracture
of unilateral abnormalities
of venous EDH. and
in 16.7% of patients
EDH
deterioration blood,
In the present
neurological
be-
as comse-
deficits
each, in cases of bilat-
while the corresponding
figures for patients
with unilateral EDH, were 28.4% and 53.6%, respectively. Therefore, the diagnosis of bilateral EDH is more likely to be delayed on clinical grounds al. [23] reported a case of bilateral matic patient following apparently and advocated
CT scanning
head injury, a statement ment.
alone. Servadei et
EDH in an asymptominor head trauma
in patients
even with minor
with which we are in total agree-
Fig. 5. CT scan showing bilateral frontal extradural haematomas.
Two of our patients can be considered to have had biparasagittal EDH. (Cases no. 8 and 9, Fig. 5). In neither of these patients could a sagittal sinus tear be dem-
and Newton
onstrated
[24] reported
a case of spontaneous
bilateral
EDH. Weinman and Samartunga [28] reported 12 cases of biparasagittal EDH out of 224 cases of EDH. In a study of 1500 cases of head injuries, Jain and Kakanan-
at surgery.
References
dey [l I] reported 2 cases with sagittal sinus tear and bilateral parasagittal EDH. Our report of 12 is the largest
Hooper. R. (1959) Observations on extradural haematoma. Br. J. Surg., 47: 71-87.
single series reported in the available literature. The incidence of bilateral EDH in the present series was 4.8% of
Roy, G.C. (1884) Fracture of skull; extensive extravasation of blood on duramater producing compression of the brain, trephining, partial relief of death. Lancet, 2: 3 19. Bharti. P.. Nagar, A.M., Srivastava, M. and Garg, R.K. (1989) Ipsilateral double epidural haematoma. Neurol. Ind., 37: 285. Charlton, R.J.W. (1938) Case of bilateral middle meningeal haemorrhage. J. Med. Assoc. S. Afr.. 4: 136. Field, J.R. (1970) Head injuries: pathophysiology. J. Ark. Med. Sot., 66: 340.--347.
all cases of EDH. Nine patients (75%) were in the age group I l-30. Approximately 65% of patients out of the 250 cases of EDH seen during the same period were in the age group l l --40. Thus, there was no significant difference in the age distribution in cases of bilateral and unilateral EDH. The mean age among 64 cases of bilateral EDH reviewed by Frank et al. [6] was 24 years while it was 34 years in patients with unilateral EDH. Frank et al. [6] observed that in patients with unilateral EDH, 90% had an associated skull fracture while it was present in only 66% of patients with bilateral EDH. In our series also, 66.7% of patients with bilateral EDH had an associated skull fracture. Among the patients of unilateral EDH encountered during the same period, we found a skull fracture in 67% of patients. Thus, there was
Frank, E., Berger. ST., Tew, J.M., Jr. ( 1982) Bilateral epidural haematomas. Surg. Neurology. 17: 218-222. Gallagher, J.P. and Browder, E.J. (1968) Extradural haematoma: experience with 167 patients. J. Neurosurg., 29: l-22. Ganapathy, K. (1988) Subacute bilateral extrddural haematoma. Neurol. Ind., 36: 124. Ganapthy, K. (1989) Bilateral supra and infratentorial extradural haematoma with hydrocephalus. Neurol. Ind., 37: x9.
131 10 Gruskiewics, J., Daron, Y. and Peyser, E. (1976) Frontal extradural haematoma. Surg. Neurol., 5: 122-128. I1 Jain, S.P. and Kanakanady, V.D. (1969) A study of 1500 cases of head injury in Delhi. J. Ind. Med. Assoc., 52: 204 211. 12 Jamieson, K.G. and Yelland, J.D.N. (1968) Extradural haemdtoma. Report of 167 cases. J. Neurosurg., 29: 13-23. 13 Kalyanaraman, S., Ramamurthi, B., Ramanujam, P.B. and Ramanoorthy, K. (1970) Extradural haemorrhage. Neural. Ind., 18 (suppl. I): 12-17. 14 King, A.B. and Chambers, J.W. (1962) Delayed onset of symptoms due to extradural haematomas. Surgery, 3 I: 839844. 15 Lake, P.A. and Pitts, F.W. (1971) Recent experiences with epidural haematomas. J. Trauma, 11: 397-411. 16 MacCarty, C.S., Horning, ED. and Werver, L.E.N. (1948) Bilateral Extradural haematoma. J. Neurosurg., 5: 88890. 17 Maurer, J.J. and Mayfield, L.M. (1965) Acute bilateral extradural haematoma. J. Neurosurg., 23: 63. 18 M&&sock, W., Taylor, JC., Bloom, W.H. and Till, K. (1960) Extradural haematoma. Observation on I25 cases, Lance& 2: 167-172. 19 Phillips. D.G. and Azariah, R.G.S. (1965) Actue intracranial haematoma from head injury: a study in prognosis. Br. J. Surgery, 52: 218-222. 20 Pughazhendi and Sivakumar, S. (1988) Double epidural haematoma. Neurol. Ind., 36: 50.
21 Rao, B.D. (1977) Extradural haematoma. Neural. Ind., 25: 83-94. 22 Saeki, N., Hinokuma, K., Uemura, K. and Makino, H. (1979) Subacute bilateral epidural haematomas in an infant. Surg. Neural.. 11: 67-69. 23 Servadai, F., Staffer, G., Monoletti, A., Burzi, M. and Piazza, 6. (1988) As~ptomatic acute bilateral extradurai haematoma. Results of broader indication for computed tomographic scanning of patients with minor head injuries. Neurosurgery, 23: 4143. 24 Sharma, V. and Newton, 6. (1989) Spontaneous bilateral extradural haematoma. Neurol. Ind., 37: 283. 25 Soni, S.R. (1973) Bilateral asymmetrical extradural haematomas. Case report. J. Neurosurg., 38: 647-649. 26 Surbrmanian. M.V., Rajendra Prasad, G.B. and Rao. B.D. (1975) Bilateral extradural haematoma. Br. J. Surg., 62: 397-400. 27 Vinci. A., Cristi, G. and Lezzerini, L. (1971) Ematoma, extradural bilateral. Bull. Sci. Med. (BoIogna}, 143: 3743. 28 Weinman, D. and Samaratunga, K. (1973) Biparasagittal extradural haematoma. J. R. Coll. Surg. Edinb., 18: 3088 311. 29 Gurdjian, ES. (1972) Recent advances in the study of the mechanisms of impact injury of the head a summary. Clin. Neurosurg.. 19: 20421 I.
127
CLlNEU 00183
Bilateral traumatic extradural haematomas: report of 12 cases with a review of the literature Sunil K. Gupta, Shiv C. Tandon, Sureshwar M~hanty, Sanjaya Asthana and Sandeep Sharma
(Received 17 December, 1990) (Revised. received 1I November. 1991) (Accepted 11November. 1991)
Key i+~,&s: Bilateral extradural hematoma; Head injury: CT scan; Surgical treatment: Trauma summary We are reporting 12 cases of traumatic bilateral extradurat haematomas. The incidence was 4.8% of al1 cases of extradural haematomas. The most ~om~non site was the frontal region. CT scan examination was necessary for early diagnosis. Ten patients were operated upon while one patient was treated conservatively. Two patients died. The relevant literature is reviewed.
The occurence of bilateral extradural haematoma (EDH) is rare. A report of more than 100 cases of EDH by Hooper [I] did not contain a single case of bilateral EDH. The first case of bilateral EDH was reported by Roy [2]. Since then there have been sporadic reports of this entity [2-283. The incidence ranges from 0.5 to 10% of all extradural haematomas (7,10,12,13,15,21]. We present 12 cases of t~umatic bilateral extradural haematomas from the Neurosurgery Section, University Hospital, Varanasi, India.
Clinical materiai In the last 12 years we have encountered 250 cases of EDH which form 4.1% of all cases of head injury managed in the Section of Neurosurgery, University Hospital, Varanasi. India. Out of these 250 cases of EDH. 12 C’ovrcspon&rzw fo: Dr. Suni1 Kumar Gupta, 2GF Old Medical Enclave, Hanaras Hindu ~Jniversit~. V~r~n~si 221 005. India.
patients had bilateral extradural haematomas comprising the case material of this report. Eleven patients were male. The age distribution is shown in Table 1. Five patients had injury in road traffic accidents and an equal number due to fall from height. Two patients were hit over the head by a wooden stick (“lath?‘). The Glasgow Coma Scale of the patients upon arrival in the casualty department is depicted in Table 2. Lucid interval was present in only 2 patients. In only 2 of the patients was pupillary abnormality present and 2 patients had focal neurological deficits. Eight patients had an associated skull fracture and in 3 of these patients, bilateral skull fractures were present including coronal sutural diastatic fracture in one. The location of the EDH in each of the 12 patients is depicted in Table 3. In 11 patients, the diagnosis was established by CT scan while in the remaining one case, it was a per operative diagnosis, after making exploratory burr holes. Most common location of bilateral EDH was frontal either alone or in combination with other sites (Table 3). In 2 patients there were 3 extradural haematomas (cases no. 7 and 11, Fig. I). In case no. 6, there was an associated il~tra~ereb~~l haematoma (Fig. 2). Bilateral
128 TABLE I
TABLE 3
AGE DISTRIBUTION OF PATIENTS WITH BILATERAL EXTRADURAL HAEMATOMAS
LOCATION OF THE EXTRADURAL HAEMATOMAS AND SOURCE OF BLEEDING IN EACH OF THE 12 PATIENTS
Age (years)
No. of patients
10 1l-20 21-30 3140
2 5 4 1
Case Location of the extradural No. haematomas 1 2 3
craniectomy/trephine craniotomy was performed in 10 patients. One patient with a small bilateral frontal EDH was managed successfully conservatively. During operation, in no case was an arterial source identified. The presumed source of bleeding was the diploic veins in 10 cases and superior sagittal sinus in 2 cases (Table 3). In case no. 2, the left sided haematoma traversed across the transverse sinus, extending both into supratentorial and infratentorial compartments. There was an associated fracture of the occipital bone. The site of bleeding in this case was probably a tear in the left transverse sinus. Out of the 10 patients who were operated upon one died. This patient (case no. 10) had a GCS of 3 and bilaterally dilated and fixed pupils. One patients (case no. 11) died while being wheeled to the operation theatre (Fig. 3). Rest of the patients improved without any residual neurologic deficit.
4 5 6 7 8 9 10 11 12
Left frontoparietal and right temporal Right occipital and left occipital extending into post. fossa Right frontal and left fronto-temporo-parietal Bifrontal Right posterior parietal and left temporo-parietal (Fig. 4) Bilateral frontoparietal (and left intracerebral haematoma) Bilateral temporoparietal and left frontal Bilateral frontal Bilateral frontal Biparietal Bilateral frontal and left parietal Bilateral temporoparietal
Presumed bleeding site Diploic veins Diploic veins and transverse sinus Diploic veins Sup. sagittal sinus Diploic veins Diploic veins Diploic veins Diploic veins Sup. sagittal sinus Diploic veins Diploic veins Diploic veins
Discussion
To produce bilateral extradural haematomas, the dura mater must be detached at two sites by a singly directed force. A lateral force can strip the dura mater at the side of impact by the inward and outward bending of the skull. On the opposite side dural stripping may occur due to motion of the skull further aggravated by the negative intracranial pressure formed at the antipode of the comTABLE 2 GLASGOW COMA SCALE OF THE PATIENTS UPON ARRIVAL IN THE CASUALTY GCS
No. of patients
8
2 4 6
9-12 7-12
Fig. 1. CT scan showing a frontal and two parietal extradural haematomas.
129
Fig ;. 2. CT scan showing bilateral fronto-parietal left intracerebral haematomas.
extradural and
Fig. 4. CT scan showing right posterior parietal and left temporo-parietal extradural haematomas.
pression forces of the skull [29]. Midline forces may be redirected bilaterally by the buttress of the frontal bone in the glabellar midline
is spared
the sagittal sinus. The recognition
area [5]. Detachment by the strong of bilateral
dural EDH
of the dura in the attachments
over
has become
much
simpler because of the routine availability of CT scan. The reported incidence of bilateral EDH in the literature is low. In a series of 167 patients of EDH, only 4 had bilateral haematomas [7]. Jamieson and Yelland [12] reported 5 cases of bilateral EDH in another 167 cases. Gruskiewicz et al. [lo] reviewed 1841 cases of head injuries and found 97 cases of EDH. Out of these only 3 had bilateral EDH. Frank et al. [6] encountered a single case of bilateral EDH and reviewed a total of 64 cases from the available literature. Maurer and ported a case of acute bilateral EDH
Mayfield [ 171 rewhile Saeki et al.
[22] reported a case of subacute bilateral EDH in an infant. Of the 51 patients of EDH reported by Kalyanar-
Fig5. 3. CT scan showing bilateral fronto-parietal haematomas.
extradural
aman et al. [13] one had a bilateral EDH. Rao [21] encountered one case of bilateral EDH among 98 cases of EDH. McKissock et al. [18] and Phillips and Azariah [19] reported 3 cases each out of 125 and 115 cases of EDH, respectively. A case of ipsilateral double epidural haematomas was reported by Bharti et al. [3]. Sharma
no difference
in incidence
groups of patients, al. [6]. Frank
in contrast
was less frequently present
managed
Frank
with bilateral
delayed
of lucid interval
pared
to patients
eral EDH,
was
among
that bilateral
neurological
of slow accumulation
ries, pupillary
EDH.
EDH (19.6%).
cause
were present
et
only (16.6%). This was not statisti-
et al. [6] were of the opinion develop
of Frank
by us, lucid interval
from the incidence
with unilateral
patients
in the two
that lucid interval
seen in patients
in 2 patients
patients
to the findings
et al. [6] also reported
Out of the 12 patients cally different
of skull fracture
of unilateral abnormalities
of venous EDH. and
in 16.7% of patients
EDH
deterioration blood,
In the present
neurological
be-
as comse-
deficits
each, in cases of bilat-
while the corresponding
figures for patients
with unilateral EDH, were 28.4% and 53.6%, respectively. Therefore, the diagnosis of bilateral EDH is more likely to be delayed on clinical grounds al. [23] reported a case of bilateral matic patient following apparently and advocated
CT scanning
head injury, a statement ment.
alone. Servadei et
EDH in an asymptominor head trauma
in patients
even with minor
with which we are in total agree-
Fig. 5. CT scan showing bilateral frontal extradural haematomas.
Two of our patients can be considered to have had biparasagittal EDH. (Cases no. 8 and 9, Fig. 5). In neither of these patients could a sagittal sinus tear be dem-
and Newton
onstrated
[24] reported
a case of spontaneous
bilateral
EDH. Weinman and Samartunga [28] reported 12 cases of biparasagittal EDH out of 224 cases of EDH. In a study of 1500 cases of head injuries, Jain and Kakanan-
at surgery.
References
dey [l I] reported 2 cases with sagittal sinus tear and bilateral parasagittal EDH. Our report of 12 is the largest
Hooper. R. (1959) Observations on extradural haematoma. Br. J. Surg., 47: 71-87.
single series reported in the available literature. The incidence of bilateral EDH in the present series was 4.8% of
Roy, G.C. (1884) Fracture of skull; extensive extravasation of blood on duramater producing compression of the brain, trephining, partial relief of death. Lancet, 2: 3 19. Bharti. P.. Nagar, A.M., Srivastava, M. and Garg, R.K. (1989) Ipsilateral double epidural haematoma. Neurol. Ind., 37: 285. Charlton, R.J.W. (1938) Case of bilateral middle meningeal haemorrhage. J. Med. Assoc. S. Afr.. 4: 136. Field, J.R. (1970) Head injuries: pathophysiology. J. Ark. Med. Sot., 66: 340.--347.
all cases of EDH. Nine patients (75%) were in the age group I l-30. Approximately 65% of patients out of the 250 cases of EDH seen during the same period were in the age group l l --40. Thus, there was no significant difference in the age distribution in cases of bilateral and unilateral EDH. The mean age among 64 cases of bilateral EDH reviewed by Frank et al. [6] was 24 years while it was 34 years in patients with unilateral EDH. Frank et al. [6] observed that in patients with unilateral EDH, 90% had an associated skull fracture while it was present in only 66% of patients with bilateral EDH. In our series also, 66.7% of patients with bilateral EDH had an associated skull fracture. Among the patients of unilateral EDH encountered during the same period, we found a skull fracture in 67% of patients. Thus, there was
Frank, E., Berger. ST., Tew, J.M., Jr. ( 1982) Bilateral epidural haematomas. Surg. Neurology. 17: 218-222. Gallagher, J.P. and Browder, E.J. (1968) Extradural haematoma: experience with 167 patients. J. Neurosurg., 29: l-22. Ganapathy, K. (1988) Subacute bilateral extrddural haematoma. Neurol. Ind., 36: 124. Ganapthy, K. (1989) Bilateral supra and infratentorial extradural haematoma with hydrocephalus. Neurol. Ind., 37: x9.
131 10 Gruskiewics, J., Daron, Y. and Peyser, E. (1976) Frontal extradural haematoma. Surg. Neurol., 5: 122-128. I1 Jain, S.P. and Kanakanady, V.D. (1969) A study of 1500 cases of head injury in Delhi. J. Ind. Med. Assoc., 52: 204 211. 12 Jamieson, K.G. and Yelland, J.D.N. (1968) Extradural haemdtoma. Report of 167 cases. J. Neurosurg., 29: 13-23. 13 Kalyanaraman, S., Ramamurthi, B., Ramanujam, P.B. and Ramanoorthy, K. (1970) Extradural haemorrhage. Neural. Ind., 18 (suppl. I): 12-17. 14 King, A.B. and Chambers, J.W. (1962) Delayed onset of symptoms due to extradural haematomas. Surgery, 3 I: 839844. 15 Lake, P.A. and Pitts, F.W. (1971) Recent experiences with epidural haematomas. J. Trauma, 11: 397-411. 16 MacCarty, C.S., Horning, ED. and Werver, L.E.N. (1948) Bilateral Extradural haematoma. J. Neurosurg., 5: 88890. 17 Maurer, J.J. and Mayfield, L.M. (1965) Acute bilateral extradural haematoma. J. Neurosurg., 23: 63. 18 M&&sock, W., Taylor, JC., Bloom, W.H. and Till, K. (1960) Extradural haematoma. Observation on I25 cases, Lance& 2: 167-172. 19 Phillips. D.G. and Azariah, R.G.S. (1965) Actue intracranial haematoma from head injury: a study in prognosis. Br. J. Surgery, 52: 218-222. 20 Pughazhendi and Sivakumar, S. (1988) Double epidural haematoma. Neurol. Ind., 36: 50.
21 Rao, B.D. (1977) Extradural haematoma. Neural. Ind., 25: 83-94. 22 Saeki, N., Hinokuma, K., Uemura, K. and Makino, H. (1979) Subacute bilateral epidural haematomas in an infant. Surg. Neural.. 11: 67-69. 23 Servadai, F., Staffer, G., Monoletti, A., Burzi, M. and Piazza, 6. (1988) As~ptomatic acute bilateral extradurai haematoma. Results of broader indication for computed tomographic scanning of patients with minor head injuries. Neurosurgery, 23: 4143. 24 Sharma, V. and Newton, 6. (1989) Spontaneous bilateral extradural haematoma. Neurol. Ind., 37: 283. 25 Soni, S.R. (1973) Bilateral asymmetrical extradural haematomas. Case report. J. Neurosurg., 38: 647-649. 26 Surbrmanian. M.V., Rajendra Prasad, G.B. and Rao. B.D. (1975) Bilateral extradural haematoma. Br. J. Surg., 62: 397-400. 27 Vinci. A., Cristi, G. and Lezzerini, L. (1971) Ematoma, extradural bilateral. Bull. Sci. Med. (BoIogna}, 143: 3743. 28 Weinman, D. and Samaratunga, K. (1973) Biparasagittal extradural haematoma. J. R. Coll. Surg. Edinb., 18: 3088 311. 29 Gurdjian, ES. (1972) Recent advances in the study of the mechanisms of impact injury of the head a summary. Clin. Neurosurg.. 19: 20421 I.