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Year : 2000  |  Volume : 48  |  Issue : 1  |  Page : 88

A massive extradural haematoma at the vertex.






How to cite this article:
Chagla A, Muzumdar D, Goel A. A massive extradural haematoma at the vertex. Neurol India 2000;48:88


How to cite this URL:
Chagla A, Muzumdar D, Goel A. A massive extradural haematoma at the vertex. Neurol India [serial online] 2000 [cited 2019 Sep 15];48:88. Available from: http://www.neurologyindia.com/text.asp?2000/48/1/88/1465



Extradural haematomas (EDH) are relatively uncommon intracranial clots following head injury but generally have good prognosis. We report a case of an EDH who had a rare location, massive size and catastrophic presentation.
A 33 year old chronic alcoholic was admitted in an unconscious state. No proper history was available except that he had a binge of alcohol the previous night and was found unconscious the next morning. On examination, he was unresponsive to deep painful stimuli. He had shallow and laboured respiration. His pulse and blood pressure were maintained. Both the pupils were dilated and fixed; the left being larger in size. Doll's eye movements were restricted in all directions. Local examination of the head revealed bogginess over the vertex and both fronto-parietal regions, suggesting trauma to the head. CT scan showed a huge EDH over vertex, overflowing into both fronto-parietal region, right more than left [Figure 1a]& [Figure 1b]. An emergency bilateral frontoparietal parasagittal craniotomy was performed. Multiple fractures involving the fronto-parietal bones crossing the midline were seen. A huge extradural clot measuring approximately 800 ml. was evacuated. There were two irregular tears in the superior sagittal sinus corresponding to the fractures on the skull vault. These were repaired using 4-0 polyglactin stitches. Multiple hitch stitches were taken all round the craniotomy site. At the time of closure, the brain had begun to pulsate but it still was at the depth of approximately 8 cm from the vertex. The bone was replaced and a few parasagittal hitch stitches were taken from holes made in the bone in order to reduce the dead space which was partially filled with gelfoam. Following surgery, the patient was placed on respiratory support. He never regained consciousness and finally succumbed after four days.
EDH occur in approximately 1-5% of head trauma victims.[1],[2],[3] EDH are usually produced by bleeding from meningeal vessels. They also occur infrequently due to bleeding from diploic spaces or venous sinuses. EDH at vertex are rare.[2],[4] A few large series have not mentioned even a single case of vertex EDH.[1],[5] This is probably due to dense dural adhesion of superior sagittal sinus to the overlying bone, particularly at the sagittal suture. The extradural blood clot occurring from venous origin are usually small and progress gradually presenting with features of raised intracranial pressure without lateralising signs. The general prognosis is good in these cases.[2],[6] Our patient had a huge clot with a catastrophic clinical presentation and a fatal outcome. In vertex EDH, venous bleeding from superior sagittal sinus is expected to seal off, once the pressure of the clot exceeds the venous pressure in the sinus. Massive clots of venous origin can occur when there are large tears in the dura of the venous sinuses along with extensive stripping of the dura off the bone. The presented patient had cortical atrophy. His hepatic functions might have been affected due to chronic alcohol intake producing coagulopathy, adding to the size of huge EDH. Massive extradural clots of venous origin indicate extensive dural tears with underlying cerebral atrophy and/or coagulopathies. They are associated with extremely grave prognosis.

 

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1.Borzone M, Gentile S, Perria C et al: Vertex Epidural haematomas. Surg Neurol 1979; 11: 277-284.   Back to cited text no. 1    
2.Cordobes F, Lobato D, Rivas J et al: Observations on 82 patients with extradural haematomas. J Neurosurg 1981; 54: 179-186.   Back to cited text no. 2    
3.Guha A, Perrin R, Grossman H et al: Vertex Epidural haematomas. Neurosurgery 1989; 25: 825-827.   Back to cited text no. 3    
4.Rivas JJ, Lobato RD, Sarbaric R et al: Extradural Haematomas, Analysis of factors influencing the course of 161 patients. Neurosurgery 1988; 23: 44-51.   Back to cited text no. 4    
5.Phonpraset C, Suwanewala C, Hongsaprabhos C et al: Extradural Haematomas. J Trauma 1980; 20: 679-683.   Back to cited text no. 5    
6.Ramesh G, Sivakumar S: Extradural haematomas at the vertex. A case report. Surg Neurol 1995; 43: 138-139.   Back to cited text no. 6    

 

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Online since 20th March '04
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