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Vertex Epidural Hematoma: A Diagnostic Challenge
CASE REPORT
Vertex Epidural Hematoma: A Diagnostic Challenge From the Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Washington. Received for publication July t4, 1993. Revision received November 10, ] 993. Accepted.fi~r publication November 26, 1993.
Frederic R Plotkin, MD Thomas F Burke, MD
We present the case of a 27-year-old man who sustained a minor head injury and presented with complaints of headache and vomiting. The diagnosis of vertex epidural hematoma is discussed. [Plotkin FR, Burke TF: Vertex epidural hematoma: A diagnostic challenge. Ann EmergMed August 1994;24:312-315.]
INTRODUCTION Vertex epidural hematoma (VEH) is an uncommon type of epidural blood collection. Its atypical presentation and relative invisibility to standard trauma computed tomography (CT) scanning present a diagnostic challenge to the emergency physician. We describe a case of VEH in a patient complaining of headache and vomiting 3 days after sustaining a minor head injury.
CASE REPORT A 27-year-old man presented to the emergency department complaining of severe, generalized "vice-like" headache and intractable vomiting. Three days before presentation, the patient had jumped backward, striking his occiput against a wooden bed frame. He experienced a 1-minute loss of consciousness and became alert immediately on awakening. He had no amnesia to the event. The patient vomited several times during the night with gradual onset of headache. Headache and vomiting progressed so that he was unable to tolerate oral intake. The patient went to a local medical clinic and was prescribed ibuprofen the morning before his ED presentation. He denied visual changes, arm or leg weakness, sensory complaints, walking difficulties, or neck stiffness. There was no history of other trauma, and his medical and surgical histories were unremarkable. He was taking no medications. Examination revealed a well-developed, well-nourished man lying on the examination table holding his head with both hands. He was in moderate distress and drowsy, but
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EPIDURAL HEMATOMA Plotkin & Burke
was easily arousable and appropriately oriented. Blood pressure was 149/68 mm Hg; pulse, 53; respirations, 16; and temperature, 36.7~ Head, neck, and funduscopic examinations were normal except for a 3• 2 scalp contusion in the right occipital area. There was no palpable stepoff. Detailed neurol0gic examination revealed unsteady heel-toe walking and an upgoing left big toe. Otherwise, motor, sensory, reflex, cerebellar, and proprioception examinations were normal. The emergency physician interpreted a noncontrast, standard trauma head CT scan as demonstrating a right occipital scalp hematoma, small bilateral frontal contusions, and a "white blotch artifact" (Figure 1). Because a senior radiology resident was unsure of the "artifact" interpretation, coronal reconstructions were created. The coronal image clearly demonstrated a 4x2-cm 2 VEH (Figure 2).
Figure 1. A, B, and C show the three most superior images of the axial trauma CT scan. B demonstrates vertex hyperdensity, raising the question of hematoma versus averaging with bone (arrows). C reveals scalp hematoma (arrow).
DISCUSSION A wealth of literature details incidence, patterns of occurrence, and clinical management of epidural hematomas. Epidural hematomas occurring at the skull vertex represent a distinct and noteworthy subgroup of traumatic intracranial bleeds. The incidence of VEH is between 2% and 8% of all epidural hematomas, 1-4 with a mortality rate of 18% to 50%. 5 In 1959, a clinical and radiologic report of VEH described five cases, four of which were studied angiographically 6 This study was the first to separate VEH from other extradural effusions on the basis of clinical and radiographic presentation, operative peculiarities, and outcome. VEH has been reported only once in the emergency medicine literature, r The clinical presentation of VEH is nonspecific, creating a diagnostic challenge for the emergency physician. The strategic location of a VEH results in a nonlocalizing clinical syndrome, s The most prominent symptom is generally severe and persistent headache unrelieved by analgesics. 6,8,9 Occasionally, patients experience temporary loss of consciousness followed by headache. 1,5,6,8,10 In obtunded patients, careful retrospective historical evaluation often elicits a history of a lucid interval. 1,9,11 However, emergency physicians frequently are without detailed history when managing patients with altered mental status. Other variably associated signs and symptoms include nausea and vomiting,
AUGUST 1994
24:2
ANNALS OF EMERGENCY MEDICINE
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EPIDURAL HEMATOMA Plothin & Burke
VEH is difficult to diagnose using current standard imaging techniques. Cerebral angiography and skull plain film radiography have been performed routinely in patients with suspected epidural hematoma. ~,9 Most cases of VEH present with a linear skull fracture intersecting the sagittal suture in the region of the superior longitudinal sinus, t,5,~o Angiography typically demonstrates separation of the superior sagittal sinus from the skull inner table. ~,7,8 However, over the past 20 years, routine carotid angiography and plain film skull radiography have been replaced by CT scanning as the imaging study of choice in patients with acute head injuries. Despite the many advantages of CT scanning, several case reports have demonstrated its fallibility in diagnosing VEH.r,aj 3 The vertex location represents a relative blind spot in a trauma head CT scan. Slices in the standard trauma head CT scan are 5 mm thick in anaxial orientation and are obtained in 5-mm increments through the posterior fossa and 10-mm increments through the supratentorial brain. 14 Axial cuts parallel a vertex hematoma and create difficulty in distinguishing blood from volume averaging with bone or from streak artifact. 13 Thus, the lesion is misinterpreted easily as artifact. CT images obtained with an orientation perpendicular to the VEH (coronal) clearly define the vertex anatomy 5,7,~,13 Figure 2. This image is a coronal reconstruction Jiom the axial trauma CT scan. The bilateral extra-axial collection of VEH is defined clearly.
Therefore, coronal CT scan images should be obtained in cases of suspected VEH. r Epidural hematoma requires rapid diagnosis and treatment that usually consists of open craniotomy and clot evacuation. 5 However, surgery is often not necessary for VEH because this condition has a more chronic and favorable course, resulting occasionally in spontaneous recovery. Often, the hematoma is the result of a tear of the superior sagittal sinus. 15,16 Bleeding from this lowpressure venous system may account for the more benign and protracted course. In our review of 32 reported cases of VEH, we found that six demonstrated spontaneous return of normal angiographic intracranial anatomy.6,~ o,1 ~,17,~8 Criteria for surgical intervention are not well described. The decision to operate often is based on hematoma size and severity and progression of clinical signs. 8,9 Patients with small hematomas and progressive clinical improvement may require only observation. 9,12 Most patients with severe symptoms or progressive deterioration experience marked clinical improvement with rapid operative intervention. 1,5,7-9 SUMMARY
Signs and symptoms of vertex epidural hematoma often are nonspecific and nonlocalizing. Hematoma may be misinterpreted on standard trauma head CT scan, and its diagnosis requires a high index of suspicion and consideration for obtaining coronal CT images. The presented patient was admitted to the neurosurgery service; he was treated with dexamethasone and admitted for observation. By hospital day 3, his headache had resolved; repeat CT scan showed mild hematoma resolution. By day 4, the abnormal plantar reflex had resolved, and the patient was discharged. At 6-month follow-up he was normal except for moderate loss of taste and smell. REFERENCES 1. Borzone M, Gentile S, Perria C, et al: Vertex epidurar hematemas. SurgNeuro11979;11:277284. 2. Hooper R: Observations on extradural haemerrhage. Br J Surg1959;29:71-87. 3. Jamieson K, Yelland J: Extradural bernatemas (Report of 167 cases). J Neurosurg1968;29:1323. 4. Pbonprasert C, Suwanewela C, Hongsaprabhos C, et al: Extradural hematomas: Analysis of 138 cases. J Trauma1980;20:679-683. 5. Borzone M, Rivano C, Altomonte M, et al: Acute traumatic vertex epidural haematornas surgically treated. Acta Neurochir1979;93:55-60. 6. Columella F, Delzanne G8, Nicola GO: L'ernatorna epidurale al vertice. SistNerv1959;2:104118.
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EPIDURAL H E M A T O M A Plotkin & Burke
7. Cordell W, FeuerH: Premonitoryneurologicsigns in a patient with an acute vertex epidural hematema.Am J EmergMed 1983;3:288-291. 8. GuhaA, Perrin R, 6rossman 14,et ah Vertex epidural hematomas.Neurosurgery1988;25:824828. 9. Colurnella F, 6aist G, Piazza6, et ah Extradural haematomaat the vertex. J Neurel IVeuresurg Psychiatry1968;31:315320. 10. Da Plan R, Beoati A, BricoloA, et al: Ematomiextradurali traumatici del terzo medie del senD Iongitudinale superiore. OspedItaI-Chir1963;8:667-676. 11. AlexanderGL: Extraduralhaematomaat the vertex. J NeurolNeurosurgPsychiatry 1961;24:381-384. 12. Lin M: Diagnostic scintigraphic sign in epidural hematomaat the vertex: Casereport J Nucl Med 1976;17:972-974.
Copyright 9 by the A m e r i c a n College of E m e r g e n c y P h y s i c i a n s Reprint no. 47/1/57100
Address for reprints: Thomas F Burke, MD Department of Emergency Medicine Madigan Army Medical Center Fort Lewis, Washington 98431 206-968-1260
13. PomeranzS, Wald U, Zagzag D, et al: Chronic epidural bematomaof the vertex: Problems in detection with computedtomography. SurgNeurol1984;22:409-411. 14. Johnson MH, Lee SH: Computedtomographyof acute cerebral trauma. RadioIClio NorthAm /992;30:325-352. 15. DeatonW: The calvarium and extraaxial spaces, in RedmanHC, Purdy PD, Miller 6L, et al (eds): EmergencyRadiology.Philadelphia,WB Saunders, 1993, p 41-76. 16. Johnson MH, Lee SH: Computedtornograpbyof acute cerebraltrauma. RadiolClio NorthAm 1992;30:353-366. 17 Brodin t4: Extraderalhematomas(A surveyof cases covering a 2D-yearperiod with special reference to diagnosis). Acta ChirScand1952;102:99-109. 18. Lindgren SO: Acute severehead injuries. Acta ChirScand1960(supplno. 254):1-49,
Traumatic Optic Neuropathy Clinical Trial In some cases of cranio-facial trauma, there is visual loss that cannot be explained by injury to the glove and that seems to be due to optic nerve injury, possibiy in the optic canal. An international, multicenter, prospective, randomized, clinical trial is beginning, randomizing these patients into two groups: mega-dose steroids alone versus mega-dose steroids with extracranial optic nerve decompression. Eligible patients are persons who have suffered head injury and have lost vision due to optic nerve injury and who are adults, with vision 20/125 or worse and are able to cooperate for exam. Time from injury must be less than 3 days. For information about establishing a participating center please contact: Michael P Joseph, MD Massachusetts Eye and Ear Infirmary 243 Charles Street Boston Massachusetts 02114-3192 617-573-3192 Fax 617-573-3914
AUGUST 1994 24:2
ANNALS OF EMERGENCY MEDICINE
315
Vertex Epidural Hematoma: A Diagnostic Challenge From the Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, Washington. Received for publication July t4, 1993. Revision received November 10, ] 993. Accepted.fi~r publication November 26, 1993.
Frederic R Plotkin, MD Thomas F Burke, MD
We present the case of a 27-year-old man who sustained a minor head injury and presented with complaints of headache and vomiting. The diagnosis of vertex epidural hematoma is discussed. [Plotkin FR, Burke TF: Vertex epidural hematoma: A diagnostic challenge. Ann EmergMed August 1994;24:312-315.]
INTRODUCTION Vertex epidural hematoma (VEH) is an uncommon type of epidural blood collection. Its atypical presentation and relative invisibility to standard trauma computed tomography (CT) scanning present a diagnostic challenge to the emergency physician. We describe a case of VEH in a patient complaining of headache and vomiting 3 days after sustaining a minor head injury.
CASE REPORT A 27-year-old man presented to the emergency department complaining of severe, generalized "vice-like" headache and intractable vomiting. Three days before presentation, the patient had jumped backward, striking his occiput against a wooden bed frame. He experienced a 1-minute loss of consciousness and became alert immediately on awakening. He had no amnesia to the event. The patient vomited several times during the night with gradual onset of headache. Headache and vomiting progressed so that he was unable to tolerate oral intake. The patient went to a local medical clinic and was prescribed ibuprofen the morning before his ED presentation. He denied visual changes, arm or leg weakness, sensory complaints, walking difficulties, or neck stiffness. There was no history of other trauma, and his medical and surgical histories were unremarkable. He was taking no medications. Examination revealed a well-developed, well-nourished man lying on the examination table holding his head with both hands. He was in moderate distress and drowsy, but
3 12
ANNALS OF EMERGENCY MEDICINE
24:2 AUGUST 1994
EPIDURAL HEMATOMA Plotkin & Burke
was easily arousable and appropriately oriented. Blood pressure was 149/68 mm Hg; pulse, 53; respirations, 16; and temperature, 36.7~ Head, neck, and funduscopic examinations were normal except for a 3• 2 scalp contusion in the right occipital area. There was no palpable stepoff. Detailed neurol0gic examination revealed unsteady heel-toe walking and an upgoing left big toe. Otherwise, motor, sensory, reflex, cerebellar, and proprioception examinations were normal. The emergency physician interpreted a noncontrast, standard trauma head CT scan as demonstrating a right occipital scalp hematoma, small bilateral frontal contusions, and a "white blotch artifact" (Figure 1). Because a senior radiology resident was unsure of the "artifact" interpretation, coronal reconstructions were created. The coronal image clearly demonstrated a 4x2-cm 2 VEH (Figure 2).
Figure 1. A, B, and C show the three most superior images of the axial trauma CT scan. B demonstrates vertex hyperdensity, raising the question of hematoma versus averaging with bone (arrows). C reveals scalp hematoma (arrow).
DISCUSSION A wealth of literature details incidence, patterns of occurrence, and clinical management of epidural hematomas. Epidural hematomas occurring at the skull vertex represent a distinct and noteworthy subgroup of traumatic intracranial bleeds. The incidence of VEH is between 2% and 8% of all epidural hematomas, 1-4 with a mortality rate of 18% to 50%. 5 In 1959, a clinical and radiologic report of VEH described five cases, four of which were studied angiographically 6 This study was the first to separate VEH from other extradural effusions on the basis of clinical and radiographic presentation, operative peculiarities, and outcome. VEH has been reported only once in the emergency medicine literature, r The clinical presentation of VEH is nonspecific, creating a diagnostic challenge for the emergency physician. The strategic location of a VEH results in a nonlocalizing clinical syndrome, s The most prominent symptom is generally severe and persistent headache unrelieved by analgesics. 6,8,9 Occasionally, patients experience temporary loss of consciousness followed by headache. 1,5,6,8,10 In obtunded patients, careful retrospective historical evaluation often elicits a history of a lucid interval. 1,9,11 However, emergency physicians frequently are without detailed history when managing patients with altered mental status. Other variably associated signs and symptoms include nausea and vomiting,
AUGUST 1994
24:2
ANNALS OF EMERGENCY MEDICINE
3 13
EPIDURAL HEMATOMA Plothin & Burke
VEH is difficult to diagnose using current standard imaging techniques. Cerebral angiography and skull plain film radiography have been performed routinely in patients with suspected epidural hematoma. ~,9 Most cases of VEH present with a linear skull fracture intersecting the sagittal suture in the region of the superior longitudinal sinus, t,5,~o Angiography typically demonstrates separation of the superior sagittal sinus from the skull inner table. ~,7,8 However, over the past 20 years, routine carotid angiography and plain film skull radiography have been replaced by CT scanning as the imaging study of choice in patients with acute head injuries. Despite the many advantages of CT scanning, several case reports have demonstrated its fallibility in diagnosing VEH.r,aj 3 The vertex location represents a relative blind spot in a trauma head CT scan. Slices in the standard trauma head CT scan are 5 mm thick in anaxial orientation and are obtained in 5-mm increments through the posterior fossa and 10-mm increments through the supratentorial brain. 14 Axial cuts parallel a vertex hematoma and create difficulty in distinguishing blood from volume averaging with bone or from streak artifact. 13 Thus, the lesion is misinterpreted easily as artifact. CT images obtained with an orientation perpendicular to the VEH (coronal) clearly define the vertex anatomy 5,7,~,13 Figure 2. This image is a coronal reconstruction Jiom the axial trauma CT scan. The bilateral extra-axial collection of VEH is defined clearly.
Therefore, coronal CT scan images should be obtained in cases of suspected VEH. r Epidural hematoma requires rapid diagnosis and treatment that usually consists of open craniotomy and clot evacuation. 5 However, surgery is often not necessary for VEH because this condition has a more chronic and favorable course, resulting occasionally in spontaneous recovery. Often, the hematoma is the result of a tear of the superior sagittal sinus. 15,16 Bleeding from this lowpressure venous system may account for the more benign and protracted course. In our review of 32 reported cases of VEH, we found that six demonstrated spontaneous return of normal angiographic intracranial anatomy.6,~ o,1 ~,17,~8 Criteria for surgical intervention are not well described. The decision to operate often is based on hematoma size and severity and progression of clinical signs. 8,9 Patients with small hematomas and progressive clinical improvement may require only observation. 9,12 Most patients with severe symptoms or progressive deterioration experience marked clinical improvement with rapid operative intervention. 1,5,7-9 SUMMARY
Signs and symptoms of vertex epidural hematoma often are nonspecific and nonlocalizing. Hematoma may be misinterpreted on standard trauma head CT scan, and its diagnosis requires a high index of suspicion and consideration for obtaining coronal CT images. The presented patient was admitted to the neurosurgery service; he was treated with dexamethasone and admitted for observation. By hospital day 3, his headache had resolved; repeat CT scan showed mild hematoma resolution. By day 4, the abnormal plantar reflex had resolved, and the patient was discharged. At 6-month follow-up he was normal except for moderate loss of taste and smell. REFERENCES 1. Borzone M, Gentile S, Perria C, et al: Vertex epidurar hematemas. SurgNeuro11979;11:277284. 2. Hooper R: Observations on extradural haemerrhage. Br J Surg1959;29:71-87. 3. Jamieson K, Yelland J: Extradural bernatemas (Report of 167 cases). J Neurosurg1968;29:1323. 4. Pbonprasert C, Suwanewela C, Hongsaprabhos C, et al: Extradural hematomas: Analysis of 138 cases. J Trauma1980;20:679-683. 5. Borzone M, Rivano C, Altomonte M, et al: Acute traumatic vertex epidural haematornas surgically treated. Acta Neurochir1979;93:55-60. 6. Columella F, Delzanne G8, Nicola GO: L'ernatorna epidurale al vertice. SistNerv1959;2:104118.
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EPIDURAL H E M A T O M A Plotkin & Burke
7. Cordell W, FeuerH: Premonitoryneurologicsigns in a patient with an acute vertex epidural hematema.Am J EmergMed 1983;3:288-291. 8. GuhaA, Perrin R, 6rossman 14,et ah Vertex epidural hematomas.Neurosurgery1988;25:824828. 9. Colurnella F, 6aist G, Piazza6, et ah Extradural haematomaat the vertex. J Neurel IVeuresurg Psychiatry1968;31:315320. 10. Da Plan R, Beoati A, BricoloA, et al: Ematomiextradurali traumatici del terzo medie del senD Iongitudinale superiore. OspedItaI-Chir1963;8:667-676. 11. AlexanderGL: Extraduralhaematomaat the vertex. J NeurolNeurosurgPsychiatry 1961;24:381-384. 12. Lin M: Diagnostic scintigraphic sign in epidural hematomaat the vertex: Casereport J Nucl Med 1976;17:972-974.
Copyright 9 by the A m e r i c a n College of E m e r g e n c y P h y s i c i a n s Reprint no. 47/1/57100
Address for reprints: Thomas F Burke, MD Department of Emergency Medicine Madigan Army Medical Center Fort Lewis, Washington 98431 206-968-1260
13. PomeranzS, Wald U, Zagzag D, et al: Chronic epidural bematomaof the vertex: Problems in detection with computedtomography. SurgNeurol1984;22:409-411. 14. Johnson MH, Lee SH: Computedtomographyof acute cerebral trauma. RadioIClio NorthAm /992;30:325-352. 15. DeatonW: The calvarium and extraaxial spaces, in RedmanHC, Purdy PD, Miller 6L, et al (eds): EmergencyRadiology.Philadelphia,WB Saunders, 1993, p 41-76. 16. Johnson MH, Lee SH: Computedtornograpbyof acute cerebraltrauma. RadiolClio NorthAm 1992;30:353-366. 17 Brodin t4: Extraderalhematomas(A surveyof cases covering a 2D-yearperiod with special reference to diagnosis). Acta ChirScand1952;102:99-109. 18. Lindgren SO: Acute severehead injuries. Acta ChirScand1960(supplno. 254):1-49,
Traumatic Optic Neuropathy Clinical Trial In some cases of cranio-facial trauma, there is visual loss that cannot be explained by injury to the glove and that seems to be due to optic nerve injury, possibiy in the optic canal. An international, multicenter, prospective, randomized, clinical trial is beginning, randomizing these patients into two groups: mega-dose steroids alone versus mega-dose steroids with extracranial optic nerve decompression. Eligible patients are persons who have suffered head injury and have lost vision due to optic nerve injury and who are adults, with vision 20/125 or worse and are able to cooperate for exam. Time from injury must be less than 3 days. For information about establishing a participating center please contact: Michael P Joseph, MD Massachusetts Eye and Ear Infirmary 243 Charles Street Boston Massachusetts 02114-3192 617-573-3192 Fax 617-573-3914
AUGUST 1994 24:2
ANNALS OF EMERGENCY MEDICINE
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