Neurology India
Open access journal indexed with Index Medicus
  Users online: 102  
 Home | Login 
  About Current Issue Archive Ahead of print Search Instructions Online Submission Subscribe Etcetera Contact  
  Navigate Here 
 Search
 
  
 Resource Links
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (1,372 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this Article
   References
   Article Figures

 Article Access Statistics
    Viewed993    
    Printed27    
    Emailed3    
    PDF Downloaded26    
    Comments [Add]    
    Cited by others 2    

Recommend this journal

 


 
Table of Contents    
LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 935-937

A large vertex extradural hematoma due to traumatic bilateral coronal suture diastasis


Department of Neurosurgery, Manipal Super Specialty Hospital, Vijayawada, Andhra Pradesh, India

Date of Submission25-Sep-2011
Date of Decision06-Oct-2011
Date of Acceptance15-Oct-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
P Arun
Department of Neurosurgery, Manipal Super Specialty Hospital, Vijayawada, Andhra Pradesh
India
Login to access the Email id


DOI: 10.4103/0028-3886.91395

Get Permissions



How to cite this article:
Arun P. A large vertex extradural hematoma due to traumatic bilateral coronal suture diastasis. Neurol India 2011;59:935-7

How to cite this URL:
Arun P. A large vertex extradural hematoma due to traumatic bilateral coronal suture diastasis. Neurol India [serial online] 2011 [cited 2014 Jul 28];59:935-7. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/935/91395


Sir,

Vertex extradural hematomas (VEHs) account for only 1.3-8.2% of all traumatic intracranial hematomas with a reported mortality of 18-50% in the pre-magnetic resonance imaging (MRI) era. [1] This report presents a unique case with a large vertex extradural due to traumatic bilateral coronal suture diastasis.

A 32-year-old male was brought in an unconscious state, with a history of being forcefully hit by a truck door while trying to climb inside it in a hurry 2 h earlier. There was a lucid interval of about half an hour. Examination revealed the patient in a decerebrating state with bilateral non-reacting pupils and a bruise over the vertex. An emergent computed tomography (CT) brain scan revealed bilateral coronal suture diastasis causing a large vertex EDH extending bilaterally (L>R) 4-5 cm from the midline, measuring 10 cm in length 4 cm in depth, with transtentorial herniation [Figure 1]. He was taken up for an emergency operation and a special surgical strategy was planned in order to evacuate the hematoma without disturbing the superior sagittal sinus (SSS). An S-shaped skin incision was placed over the vertex [Figure 2] and bilateral fronto-parietal craniotomy was performed leaving a strip of bone over the SSS [Figure 3]. There was no injury noted to the SSS, which was stripped away from the inner table. The hematoma was completely evacuated and dural hitch stitches were applied all around the lateral edges of the bilateral craniotomies. Wet gelfoam strips was placed on either side of the sinus. A bilateral outer dural stitch was taken at the centre of the craniotomies and knots were applied over the replaced bone fragments to prevent re-accumulation of blood [Figure 4]. Postoperative neurological recovery was good. He was tracheostomized for adequate chest toileting. At the time of discharge, his Glasgow Outcome Scale (GOS) was 3. On follow-up at one month, he was weaned off tracheostomy and at six months' follow-up, the patient was able to perform his day-to-day activities independently (GOS - 5).
Figure 1: CT brain axial sections (a) show a large vertex hematoma extending bilaterally; the axial (b) and coronal (c) bony cuts clearly show bilateral coronal suture diastasis

Click here to view
Figure 2: The S-shaped skin incision applied over the vertex

Click here to view
Figure 3: The bilateral coronal suture diastasis (a) and large extradural hematoma bilaterally with strip of bone in the midline (b)

Click here to view
Figure 4: Dural hitch stitches taken in the center of bilateral craniotomies (a) and knots applied over the replaced bone flaps (b)

Click here to view


VEHs are a rare subset with unique radiological and clinical presentation, frequently causing a diagnostic dilemma. The majority of the reported cases have an associated vertex fracture with the fracture line usually crossing the sagittal suture or there is diastasis of the sagittal suture. [1] The bleeding source is believed to be veins, venous sinus, the fracture itself, and diffuse dural bleeding caused by dural stripping. Consistent with this hypothesis of venous bleed are the indolent course and favorable prognosis of VEHs as compared to other epidural hematomas. In cases where SSS is lacerated, the course is much more acute with high mortality. [1] Elevated intracranial pressure is often a feature of VEHs and obstruction of cerebral venous drainage by the expanding vertex epidural mass has been cited as a possible cause of elevated intracranial pressure. [1],[2] Smaller VEHs may be missed on axial CT images but are evident on coronal sequence. MRI or thin-section CT should be performed to exclude the diagnosis in patients with trauma to the skull vertex. [3],[4] In the pre-CT scan era, separation of the sagittal sinus from the inner table was a characteristic angiographic finding. Retarded venous flow to the sinus has been frequently noted on arteriogram. [1]

As in any extradural hematoma, the role of surgery depends on the volume of hematoma, presenting neurological deficits, and clinical course. [5] The majority of the reported cases have been managed conservatively with recovery. Our case report is unique in the clinical presentation, acute course without SSS tear; the radiological findings, bilateral coronal suture diastasis with large hematoma; and the surgical strategy chosen. Jones et al, [6] have described a similar strategy with a bicoronal skin incision and this strategy provided a wide exposure bilaterally and opportunity to complete evacuation without disturbing the SSS. Tears in SSS may significantly complicate the surgery and result in increased morbidity and mortality. Leaving a strip of bone over the SSS may considerably reduce these risks. Tears if noted can be sutured. Also, the use of multiple hitch stitches all around the craniotomy site, including along the SSS would control bleeding effectively. [7] The other significant lesson learnt from this case is that regardless of poor GCS, early decompression of extradural hematomas may result in excellent recovery without significant morbidity.

 
  References Top

1.Wylen EL, Nanda A. Vertex epidural hematoma with coronal suture diastasis presenting with paraplegia. J Trauma 1998;45:413-5.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Liliang PC, Liang CL, Chen HJ, Cheng CH. Vertex epidural hematoma presented with paraplegia. Injury 2001;32:252-3.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: Imaging findings and diagnostic pitfalls. Eur J Radiol 2000;36:150-7.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Server A, Tollesson G, Solgaard T, Haakonsen M, Johnsen UL. Vertex epidural hematoma - neuroradiological findings and management. Acta Radiol 2002;43:483-5.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: Surgical versus conservative management: Two case reports and review of the literature. Neurosurgery 1999;45:621-4.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Jones TL, Crocker M, Martin AJ. A surgical strategy for vertex epidural hematoma. Acta Neurochir (Wien) 2011;153:1819-20.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  
7.Chagla A, Muzumdar D, Goel A. A massive extradural hematoma at the vertex. Neurol India 2000;48:88.  Back to cited text no. 7
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

This article has been cited by
1 Horse shoe appearance of vertex extradural hematoma
Amit Agrawal,Kishor V. Hegde,V. Umamaheswara Reddy,Harneet Singh Ghotra
The Indian Journal of Neurotrauma. 2014;
[Pubmed]
2 Vertex extradural hematoma
Ramesh, V.G.
Neurology India. 2012; 60(3): 369
[Pubmed]



 

Top
Print this article  Email this article
   
Online since 20th March '04
Published by Medknow