A series of post-traumatic midline epidural hematoma and review of the literature

Abstract

Background: Supratentorial midline epidural hematoma is rare but challenging in diagnosis and management. Indication for surgery can arise even following hospital admission. Being familiar to the presentation and watching out for direct and indirect signs on axial computed tomography (CT) such as suture diastasis or fracture traversing midline are essential to plan multi-planar CT enabling exact diagnosis including form and mass effect of hematoma.

Methods: Nine patients with midline epidural hematoma including two pediatric patients underwent surgery between 2013 and 2018. Pre-operative and post-operative patient status, radiological features, and surgical technique were analyzed.

Results: Four patients had deteriorating consciousness levels and two patients had paraparesis. All had fractures traversing midline and epidural hematomas with significant mass effect. They were operated through separated craniotomies around the midline and midline bone strip was used for dural tenting and as support for natural closure of bone flaps. No post-operative complications were developed. All patients were discharged with Glasgow Outcome Score of 5.

Conclusion: Because of the rarity of the lesion and small number of patients, definitive conclusions may be misleading but we think that, in experienced hands, midline epidural hematomas can safely be operated on and, preservation of midline bone strip pro-vides easier bleeding control.

Figure 1

Epidural exploration with separated craniotomies. The depressed occipital fracture and epidural space after evacuation and bleeding control appear preoperatively. Midline bone strip was preserved with separated craniotomies and planned to prepare as a roof for tenting sutures to provide further bleeding control and prevent rebleeding in the postoperative period.

Figure 2

58-year-old male patient was admitted to the hospital with a Glasgow Coma Score of 15 and operated due to deterioration of consciousness and paraparesis developing during follow-up. Axial (a), coronal (b) and sagittal plan (c) computed tomography imaging of patient shows a huge epidural hematoma extending both sides of convexity with mass effect on parenchyma and depressed occipital fracture.

Figure 3

Late period postoperative T2-sequance coronal plan cranial magnetic resonance (MR) (a) and MR venography (b) of 58 years old patient. Superior sagittal sinus without flow impairment after surgical intervention.