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LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 6  |  Page : 940-942

Traumatic bilateral frontal extradural hematomas with coronal suture diastases


PG Department of Neurosurgery, SCB Medical College and Hospital, Cuttack, Orissa, India

Date of Submission18-Oct-2011
Date of Decision06-Nov-2011
Date of Acceptance05-Dec-2011
Date of Web Publication2-Jan-2012

Correspondence Address:
Satya Bhusan Senapati
PG Department of Neurosurgery, SCB Medical College and Hospital, Cuttack, Orissa
India
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DOI: 10.4103/0028-3886.91398

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How to cite this article:
Mishra SS, Senapati SB, Deo RC. Traumatic bilateral frontal extradural hematomas with coronal suture diastases. Neurol India 2011;59:940-2

How to cite this URL:
Mishra SS, Senapati SB, Deo RC. Traumatic bilateral frontal extradural hematomas with coronal suture diastases. Neurol India [serial online] 2011 [cited 2014 Oct 24];59:940-2. Available from: http://www.neurologyindia.com/text.asp?2011/59/6/940/91398


Sir,

Bilateral extradural hematoma (EDH) is an uncommon consequence of closed head injury and the reported incidence ranges from 2 to 25%. Bilateral frontal EDH with coronal suture diastases is rarely reported. This report presents four cases of venous EDH where sinus is lacerated due to coronal suture diastases. All the patients had cranial scalp flap with craniotomy extending to either side of midline. The source of bleeding was found to be due to laceration of superior sagittal sinus.

The clinical details of all the four patients are given in [Table 1]. All were males and the age ranged between 22 and 33 years. Glasgow Coma Scale (GCS) at admission ranged between 8 (E1 V2 M5) and 13 (E4 V4 M5). Arrival time at the hospital from the time of accident ranged between 5 and 8 hours (mean 6.5 hours). Only two patients had focal neurological deficits. In all the patients, cranial computed tomography (CT) showed bilateral frontal EDH with coronal suture diastases [Figure 1], [Figure 2] and [Figure 3]. Surgery was performed with bicoronal scalp flap and fronto-parietal craniotomy extending to either side of midline. After evacuation of the clot, the bleeding source was found to be superior sagittal sinus laceration. The bleeding was controlled with sinoraphy and gel foam. Blood loss ranged between 600 and 700 ml (mean 662.5 ml). Patients required blood transfusions during surgery. All patients had GOS of 5 at follow-up.
Figure 1: (a) Axial CT scan showing bilateral frontal EDH; (b) axial CT scan showing bilateral frontal EDH in another case

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Figure 2: Skull scout film showing coronal suture diastasis

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Figure 3: Axial CT scan showing diastasis of coronal suture

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Bilateral EDH results when dura mater is separated at two locations by a single directed impact. [1] Besides that, it can also occur due to extension of fracture line across midline, leading to bilateral EDH under fracture line, as was seen in our patients. Barlow and Kohi reported that in the case of bilateral EDH with different volumes, the side with a larger volume of hemorrhage has to be evacuated primarily, followed by the opposite side. When the volumes of the hematomas are equal, the dominant-sided hematoma is first evacuated. [2] In our patients, we evacuated hematoma through the single bicoronal scalp flap with frontal craniotomy extending to either side of midline [Figure 4], [Figure 5], [Figure 6] and [Figure 7]. Advantages of approaching this way are that evacuating hematoma of both sides and most importantly, controlling bleeding from sinus are better as the midline is exposed.
Figure 4: Fronto-parietal craniotomy done extending to both sides of midline. Rt side bone flap shows sutural diastasis

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Figure 5: Post-op axial CT scan showing complete evacuation of EDH

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Figure 6: Post-op CT scan with 3D reconstruction showing burr hole sites

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Figure 7: One of my patients, on first follow-up 1 month after surgery

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High mortality (42-100%) [3],[4] has been reported in previous series. However, in our series, there was no death and the outcomes were excellent. This may be due to widespread use of CT scan, diagnosis before deterioration of neurological status and surgical methods adopted by us. From our experience with these four patients, we suggest that in those head injury patients presenting with CT findings showing bilateral frontal EDH with coronal suture diastasis [Figure 1], [Figure 2] and [Figure 3], the source of bleeding is from superior sagittal sinus and the bilateral hematoma is actually a single hematoma extending to either side. As the source of bleeding is from sinus in all the cases, it is always better to approach through bicoronal scalp flap with frontal craniotomy extending to either side of midline as controlling bleeding from sinus is better.

 
  References Top

1.Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surg Neurol 1982;17:218-22.  Back to cited text no. 1
[PUBMED]    
2.Barlow P, Kohi YM. Acute simultaneous bilateral extra- dural hematoma. Surg Neurol 1985;23:411-3.  Back to cited text no. 2
[PUBMED]    
3.Dharker SR, Bhargava N. Bilateral epidural haematoma. Acta Neurochir 1991;110:29-32.   Back to cited text no. 3
    
4.Huda MF, Mohanty S, Sharma V, Tiwari Y, Choudhary A, Singh VP. Double extradural hematoma: An analysis of 46 cases. Neurol India 2004;52:450-2.  Back to cited text no. 4
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
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This article has been cited by
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