Single piece craniotomy in the management of a patient with large vertex epidural haematoma and deteriorating brain function in a limited resources community. Case report from Southwestern Uganda

Abstract

Introduction and importance: Vertex epidural haematoma is a rare form of epidural haemorrhage and a complication of head trauma that is both a diagnostic and therapeutic challenge for the trauma surgeon. It's usually as result of laceration in the superior sagittal sinus. Whereas most patients with small vertex epidural hematomas improve with conservative treatment, large or rapidly expanding lesions are fatal and require emergency craniotomy.

Case presentation: Ours was a 28-year-old male patient who arrived at our emergency department in rural Southwestern Uganda with Glasgow coma scale of 12/15 following a head on collision of two Boda Boda motorcycles. CT scan imaging revealed a large acute Vertex Epidural haematoma and a linear skull fracture of the parietal bones crossing the midline. The haematoma was evacuated through a single piece craniotomy and hemostasia achieved by surgicel. Patient was transfused with two units of whole blood. Patients Glasgow coma scale improved to 15/15 after 24 h postoperatively.

Clinical discussion: Vertex epidural hematomas are both diagnostic and therapeutic challenges. Small haematomas do not require surgical intervention. Large and expanding haematomas are fatal and require urgent surgical evacuation by neurosurgeons. In rural centres in lower- and middle-income countries like our own, surgery is often more challenging. This is mainly due to nonavailability of neurosurgeons and lack of medical supplies. With careful planning, available midlevel medical doctors can safely evacuate a large vertex epidural hematoma through a single piece craniotomy.

Conclusion: When performed timely, emergency surgical decompression results into rapid improvement of brain function in patients with large vertex epidural hematoma and deteriorating brain function as observed in our patient. Massive haemorrhage from superior sagittal sinus and air embolism are important intraoperative complications that should be kept in mind. Careful pre operative planning is of paramount importance especially in centres without neurosurgeons and essential neurosurgery supplies.

Keywords: Case report; Massive haemorrhage; Rural communities; Single piece craniotomy; Southwestern Uganda; Vertex epidural haematoma.

Fig. 1

CT scan images showing large acute vertex epidural haematoma crossing the midline.

Fig. 2

Linear skull fracture on craniotomy (with blue arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Large Vertex Epidural haematoma under pressure lifting the bone flap after craniotomy (Blue arrows). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)