Chronic epidural hematoma presenting with diplopia

Abstract

Background: Epidural hematomas are common intracranial pathologies secondary to traumatic brain injuries and are associated with overlying skull fractures up to 85% of the time. Although many require immediate surgical evacuation, some are observed for stability and followed up conservatively with serial imaging or enlarge slowly overtime, similar to chronic subdural hematomas. Those in the latter category may present with vague symptoms such as diplopia or headache and are often found on routine outpatient evaluation. When concerning findings such as significant mass effect are present, surgical evacuation is necessary.

Case description: Here, we present the case of a 32-year-old man who presented with diplopia 6 weeks after experiencing head trauma and was found to have a chronic epidural hematoma. On resection, thick, inflammatory tissue was observed and carefully resected, revealing normal dura underneath. Six weeks after evacuation of the hematoma, the patient had near-complete resolution of his diplopia and complete resolution of his epidural hematoma.

Conclusion: Given the consistency and nature of the fibrous material observed intraoperatively in this case, near-complete resection of the tissue was likely necessary to help facilitate adequate reexpansion of brain parenchyma and improve clinical outcomes.

Keywords: Chronic epidural hematoma; Diplopia; Hemorrhage.

Figure 1:

Preoperative imaging of the head and brain. Magnetic resonance imaging of the brain shows a sagittal T1 sequence hyperintense rim and heterointense core (a) and a T2 fluid-attenuated inversion recovery sequence revealing a hyperintense (b) lesion. Diffusion restricting (c) and apparent diffusion coefficient (d) images, respectively, demonstrate a hyperintense and hypointense lesion. Computed tomography images of the head with (e) and without (f) contrast enhancement highlight a hyperdense lesion in the left temporal region.

Figure 2:

Operative photograph of thick hematoma capsule with fibrosis. The thick epidural hematoma capsule that was found after the bone flap was removed after craniotomy.

Figure 3:

Postoperative follow-up imaging. (a and b) Serial axial computed tomography head images without contrast enhancement demonstrating resolution of the left temporal epidural hematoma.