Bilateral Acute Epidural Hematoma with Good Outcome

Abstract

An unknown middle aged man was found unconscious and was brought to our service. On the admission, the patient was comatose and his Glasgow Coma Scale was 8/15. Both the pupils were isochoric and reactive to light with left periorbital edema and a report of seizure. ATLS (Advanced Trauma Life Support) primary survey did not reveal any other abnormality. A Computed Tomography (CT) was taken which showed asymmetric Bilateral Epidural Hematoma (BEH) that measuring 127cm³ at left and 57cm³ at right, with a total volume of 184cm³, and bilateral overlying skull fracture [Table/ Fig-1]. He underwent emergency surgery for removal of the Epidural Haematomas (EDH). Both the focal lesions had immediate surgical indication and the drainage was performed simultaneously. The head was placed in Mayfield tongs in neutral position; this cranial fixation system was placed in the midline of the skull, with the tongs fixation slightly diverted to avoid holes on the sagittal sinus.Tongs application on the skull fractures was avoid. Incisions were made at the same time. The craniotomies were also performed simultaneously. Once completed trepanation on one side, already was performed and the other side, quickly performed the two large craniotomies without complications, with satisfactory CT control [Table/ Fig-2]. The patient had a prolonged hospitalization due to clinical complications and the need for inpatient rehabilitation and was discharged after one month. During follow-up he presented with Glasgow Outcome Scale 4/5 ninety days after the trauma. DisCussionThe first BEH case was described by Roy in 1884. Since then, BEH reports have been sporadic with an incidence rangs from 0,5 to 2% of all EDH [1,2]. High mortality rates (42-100%) have been reported in old series of BEH. With the widespread use of CT scan, early diagnosis has changed the surgical results and prognosis with recent series reported a decrease in mortality rates to 15,7% [1].Linear skull fractures are associated with EDH in 61-95% of cases. In over one-half of all patients, the middle meningeal artery gives rise to the haematoma [3,4]. However, the main cause of bleeding in the BEH is usually venous bleeding [1]. We suppose that our case of BEH was caused by arterial bleeding after the laceration of both right and left middle meningeal arteries as a result of bilateral skull fracture. In general, haematomas secondary to arterial bleeding require more urgent evacuation since it can rapidly lead to intracranial hypertension (ICH). When surgery is indicated, either arterial or venous EDH are treated by craniotomy, with haematoma evacuation, haemostasis and dural retention sutures (along bone edges and centrally).Once the diagnosis of BEH is made, urgent surgical treatment should be considered, and in cases of asymmetric EDH, the responsible one for the neurological deterioration (when possible to identify) must be removed first. In cases which the hematoma is small, it can be followed with close clinical and tomographic abstractEpidural haematomas are one of the mos...

Acute contrecoup epidural hematoma that developed without skull fracture in two adults: two case reports

“…AEDH accounts for 1–3% of all head injury cases [ 3 ], and is a common disease in neurosurgery and emergency medicine. It develops right below the impact point accompanied by linear fracture in most cases [ 1 – 4 ], and reportedly, cases not accompanied by fracture account for 10–20% [ 2 , 3 ]. Generally, the incidence of AEDH is high in people in their 10–20s and low in infants aged 2 years or younger and the elderly.…”

“…The incidence of traumatic acute epidural hematoma (AEDH) is high in young people, and hematoma is formed right below the impact point accompanied by skull fracture in most cases [ 1 – 4 ]. In contrast, the incidence of AEDH not accompanied by fracture is low and most cases occur right below the impact point in children [ 2 , 3 ].…”