| Article Access Statistics | | | Viewed | 591 | | | Printed | 21 | | | Emailed | 3 | | | PDF Downloaded | 19 | | | Comments | [Add] | | |
|
Click on image for details.
|
|
 |
| LETTER TO EDITOR |
|
|
|
| Year : 2011 | Volume
: 59
| Issue : 6 | Page : 935-937 |
A large vertex extradural hematoma due to traumatic bilateral coronal suture diastasis
P Arun
Department of Neurosurgery, Manipal Super Specialty Hospital, Vijayawada, Andhra Pradesh, India
| Date of Submission | 25-Sep-2011 |
| Date of Decision | 06-Oct-2011 |
| Date of Acceptance | 15-Oct-2011 |
| Date of Web Publication | 2-Jan-2012 |
Correspondence Address:
P Arun
Department of Neurosurgery, Manipal Super Specialty Hospital, Vijayawada, Andhra Pradesh
India
DOI: 10.4103/0028-3886.91395
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 |
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 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 | |  |
| 1. | Wylen EL, Nanda A. Vertex epidural hematoma with coronal suture diastasis presenting with paraplegia. J Trauma 1998;45:413-5. 
[PUBMED] [FULLTEXT] |
| 2. | Liliang PC, Liang CL, Chen HJ, Cheng CH. Vertex epidural hematoma presented with paraplegia. Injury 2001;32:252-3.
[PUBMED] [FULLTEXT] |
| 3. | Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: Imaging findings and diagnostic pitfalls. Eur J Radiol 2000;36:150-7.
[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.
[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.
[PUBMED] [FULLTEXT] |
| 6. | Jones TL, Crocker M, Martin AJ. A surgical strategy for vertex epidural hematoma. Acta Neurochir (Wien) 2011;153:1819-20.
[PUBMED] [FULLTEXT] |
| 7. | Chagla A, Muzumdar D, Goel A. A massive extradural hematoma at the vertex. Neurol India 2000;48:88.
[PUBMED]  |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
|
