Quartet of catastrophe: Bilateral epidural hematoma in both supratentorial and infratentorial compartments - A case report and a novel surgical technique to approach

Abstract

Background: Epidural hematoma (EDH) is the most common form of traumatic brain lesion in the posterior fossa. This condition is rapidly fatal if not identified and treated accordingly, due to the proximity of the brain stem. Prompt diagnosis is made by early computed tomography (CT) of the head and emergent evacuation is of utmost importance.

Case description: A 28-year-old male presented to the emergency room with complaints of headache and vomiting following a road traffic accident. CT scan revealed EDH around the transverse sinus extending into supratentorial and infratentorial compartment bilaterally. The patient was planned for emergency surgery but relatives did not give consent initially they agreed after 24 h when the patient became unconscious. A midline incision was made and a small infratentorial craniectomy with two burr holes was made bilaterally above the transverse sinus. Excellent recovery was seen following a surgical procedure.

Conclusion: Posterior fossa EDH is a rare but potentially fatal entity. Bilateral extension in supratentorial and infratentorial compartments makes it a "quartet of catastrophe." Prompt diagnosis and emergent evacuation lead to excellent recovery. Two burr holes in supratentorial compartments and a small infratentorial craniectomy can avoid sinus injury.

Keywords: Epidural hematoma; Infratentorial; Posterior fossa; Supratentorial.

Figure 1:

Preoperative computed tomography scan of the head bony window showing fractured occipital bone (thick arrow and thin arrow).

Figure 2:

(a) Preoperative axial computed tomography (CT) scan head showing posterior fossa Epidural hematoma (EDH) with swirl sign (thin arrow) (b) preoperative sagittal CT scan head showing EDH in both supratentorial and infratentorial compartments (thin arrow).

Figure 3:

(a) Preoperative axial computed tomography (CT) scan head after 24 h of admission showing an increase in the size of hematoma (thin arrow) with an increase in the size of temporal horns (thick arrow) (b) preoperative sagittal CT scan head after 24 h of admission showing an increase in the size of hematoma (thin arrow).

Figure 4:

Intraoperative image showing two burr holes in supratentorial compartments which are enlarged by Kerrison punch (thin arrows) and small craniectomy in infratentorial compartment covered by gel foam (thick arrow).

Figure 5:

(a) Postoperative axial computed tomography (CT) scan head on day 1 showing evacuated Epidural hematoma (EDH) (thin arrow) and decrease in size of ventricles (thick arrow) (b) postoperative sagittal CT scan head showing evacuated infratentorial EDH (thin arrow) and a small amount of residual blood (thick arrow).