- Neurosurgeon, Department of Neurological Surgery, Metropolitan Hospital of Urgencies and Emergencies, Belém, PA, Brazil
- Department of Neurosurgery, School of Medicine, State University of Para, Belém, PA, Brazil
Edmundo Luis Rodrigues Pereira
Neurosurgeon, Department of Neurological Surgery, Metropolitan Hospital of Urgencies and Emergencies, Belém, PA, Brazil
DOI:10.4103/2152-7806.150458Copyright: © 2015 Pereira ELR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Rodrigues Pereira EL, Rodrigues DB, Lima LO, Sawada LA, Mário de Nazareth Hermes. Bilateral assymetric epidural hematoma. Surg Neurol Int 30-Jan-2015;6:14
How to cite this URL: Rodrigues Pereira EL, Rodrigues DB, Lima LO, Sawada LA, Mário de Nazareth Hermes. Bilateral assymetric epidural hematoma. Surg Neurol Int 30-Jan-2015;6:14. Available from: http://sni.wpengine.com/surgicalint_articles/bilateral-assymetric-epidural-hematoma/
Background:Acute bilateral extradural hematoma is a rare presentation of head trauma injury. In sporadic cases, they represent 0.5–10% of all extradural hematomas. However, higher mortality rates have been reported in previous series.
Case Description:The authors described the case of a 28-year-old male presenting head injury, comatose, Glasgow Coma Scale of 6, anisocoric pupils without puppilary light reflex. Computed tomography showed asymmetric bilateral epidural hematomas, effacement of the lateral ventricles and sulci, midline shift and a bilateral skull fracture reaching the vertex. Surgical evacuation was performed with simultaneous hematoma drainage. Patient was discharged on the 29th postoperative day with no neurological deficit.
Conclusion:The correct approach on bilateral epidural hematomas depends on the volume, moment of diagnosis, and neurological deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique for it, which soon decreases the intracranial pressure and promotes an efficient resolution to the neurological damage.
Keywords: Bilateral, extradural, hematoma, trauma, traumatic brain injury
Trauma is the leading cause of death among young people. Head injury is associated with at least 50% of the fatalities related to trauma.[
Although extradural hematomas (EDH) are an uncommon (1–2%[
A 28-year-old male was admitted 3 h after a motorcycle accident. During admission, he was comatose with a Glasgow Coma Scale (GCS) of 6, his pupils were anisocoric (the right one bigger than left one), without any puppilary light reflex. His past medical history was unremarkable.
A Computed tomography (CT) was performed and showed asymmetric bilateral epidural hematoma (the major one at the right side measuring 109.1 × 44.2 × 60 mm, with a volume of 144.5 cm3 and the left one with a volume of 61.3 cm3, with a total volume of 205.8 cm3), an effacement of the lateral ventricles and sulci, a shifty midline, and a bilateral skull fracture reaching the vertex [Figures
The focal lesions were indicated to immediate surgery and he underwent emergency surgery to evacuation the epidural hematomas. The left temporal hematoma was the first to be drained. The patient was on supine position, head bent to the right. A left frontotemporal incision was performed and linear temporal bone fracture was found. Trepanation and decompressive craniectomy was performed and the hematoma was drained. The right hematoma was drained sequentially, the patient was on supine position, head round to the left. Right frontoparietal incision was performed, opening the temporal muscle. The linear fracture was identified, right frontotemporal craniotomy was done, and the hematoma was drained. Intraoperative findings included middle meningeal arteries hemorrhage, which was controlled, and the surgery was performed without further complications.
The patient had clinical complications in the intensive care unit (ICU), but his health improved after 2 weeks. Repeated CT head scan showed no residual collections [
Post operative computer tomography (CT). (a) Skull CT with bone window demonstrating bilateral fractures and on the left posterior side one of the trepanation points. (b) Bain CT indicating resolution of the bilateral hematomas and subsequently resolution of the midline shift (c) 3D skull reconstruction presenting the trepanation points
Cases of bilateral extradural hematomas (BEH) are rare in the literature.[
BEH is usually found in head injury cases. Nevertheless, Kuwayama[
After the diagnosis of BEH, immediate surgery is necessary. Unlike our case, of asymmetric EDH, a simultaneous approach should be first considered since it promotes a quicker treatment to the increased intracranial pressure and functional recovery even in patients under critical neurological conditions. However, subsequently hematomas removal can also be performed. The hematoma causing neurological deterioration should be first removed followed by the evacuation of contra lateral one and, in cases of symmetric BEH, the one in the dominant site should be removed first. Mortality in these patients is higher when there are large hematomas (>150 cm size).[
The intraoperative brain swelling in the epidural hematomas is essential for the management of these lesions, because it may be the first sign of the expansion of hematoma in the contra lateral side of the lesion. If the patient does not improve after the hematoma removal or if there is any neurological deficits, further brain imaging is indicated in order to evaluate the efficacy of the drainage and the possible hematoma expansion.[
Written consent was obtained from the patient for publication of the patient's details.
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