Chronic expanding epidural haematoma. Case report

Chronic epidural hematoma evacuated through surgical treatment: a case report

Epidural hematoma (EDH) can sometimes be life-threatening, although small-volume EDHs can resolve spontaneously like other intracranial hematomas. However, in rare cases, EDH can transform into a chronic form instead of disappearing. In contrast to subdural hematoma, there is no agreed-upon definition or treatment of chronic EDH. A 41-year-old male patient with acute EDH in the bilateral paravertical area due to partial rupture of the sagittal sinus was operated first, and then remnant contralateral hematoma was treated conservatively. One month after surgery, he showed hemiparesis, and brain imaging revealed chronic EDH at the location of the remnant acute hematoma. We performed surgery again to treat chronic EDH through a large craniotomy. Although many cases of EDH are self-limited, clinicians must keep in mind that some cases of EDH, especially those of venous origin and arising in young people, can become chronic and require surgical treatment.

Chronic epidural hematoma presenting with diplopia

Background:

Epidural hematomas are common intracranial pathologies secondary to traumatic brain injuries and are associated with overlying skull fractures up to 85% of the time. Although many require immediate surgical evacuation, some are observed for stability and followed up conservatively with serial imaging or enlarge slowly overtime, similar to chronic subdural hematomas. Those in the latter category may present with vague symptoms such as diplopia or headache and are often found on routine outpatient evaluation. When concerning findings such as significant mass effect are present, surgical evacuation is necessary.

Case Description:

Here, we present the case of a 32-year-old man who presented with diplopia 6 weeks after experiencing head trauma and was found to have a chronic epidural hematoma. On resection, thick, inflammatory tissue was observed and carefully resected, revealing normal dura underneath. Six weeks after evacuation of the hematoma, the patient had near-complete resolution of his diplopia and complete resolution of his epidural hematoma.

Conclusion:

Given the consistency and nature of the fibrous material observed intraoperatively in this case, near-complete resection of the tissue was likely necessary to help facilitate adequate reexpansion of brain parenchyma and improve clinical outcomes.

Chronic Epidural Hematoma Caused by Traumatic Intracranial Pseudoaneurysm of the Middle Meningeal Artery: Review of the Literature with a Focus on this Unique Entity

BACKGROUND

Pseudoaneurysms of the middle meningeal artery represent fewer than 1% of all intracranial aneurysms; it can be associated with different patterns of intracranial hemorrhages. A chronic epidural hematoma (CEDH) caused by post-traumatic pseudoaneurysm of the middle meningeal artery (MMA) has not yet been reported.

CASE DESCRIPTION

A 17-year-old male patient was referred to our unit after a car accident, with head trauma and presented motor and language deficits. After a brain computed tomography scan that revealed a left temporal epidural hematoma, the patient underwent surgery with complete hematoma drainage and recovery. After 5 months, he developed a chronic epidural hematoma secondary to a pseudoaneurysm of the MMA, as shown by cerebral angiography. We also reviewed the literature to evaluate the state of the art concerning the diagnosis and management of patients affected by CEDH.

CONCLUSIONS

Pseudoaneurysms are considered unstable because of the poor support of the aneurysmal wall. They tend to progressively increase in size and ultimately rupture, leading to delayed intracranial bleeding. A univocal definition of the interval of time between the acute head trauma and the diagnosis to classify the CEDH is still debated. To our knowledge, this is the first case described of a CEDH secondary to a pseudoaneurysm of the MMA. In our study we suggest defining CEDHs as extradural hematomas diagnosed and/or treated 21 days or more after a head injury.

Asymptomatic Chronic Epidural Hematoma in a Child As a Result of Extracranial Decompression

BACKGROUND

Epidural hematoma (EDH) in children is a diagnostic challenge due to its nonspecific clinical presentation. Asymptomatic chronic epidural hematoma is a very rare entity. Reports of spontaneous decompression into the subgaleal spaces are limited with acute epidural hematomas in the literature.

OBJECTIVE

We report a child presenting with chronic epidural hematoma at 15 days after a head trauma. She remained asymptomatic, owing to spontaneous decompression via a skull fracture. We intend to remind emergency physicians to be alert about epidural hematomas in asymptomatic children in the presence of a history of, even minor and distant, trauma.

CASE PRESENTATION

An 8-year-old girl presented to the Emergency Department with a swelling in the right parietal region. She had fallen at the playground and struck her head on the ground 15 days prior. Computed tomography showed a mixed-density subacute-chronic parietal epidural hematoma with a linear fracture overlying it. There was no evidence of midline shift or ipsilateral ventricular compression.

CONCLUSION

An initially minimal but expanding EDH in a child can remain asymptomatic even in the later phases, owing to the spontaneous decompression through a skull fracture.

Chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy

Background:

Enlargement of intracerebral hematoma without rebleeding in chronic phase is a rare but well-known clinical condition, and is well-described as chronic expanding intracerebral hematoma. However, chronic enlargement of pituitary hematoma without rebleeding after pituitary apoplexy is extremely rare.

Case Description:

We report a case of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy. A 29-year-old male presented with sudden onset of headache and vomiting. Magnetic resonance imaging (MRI) demonstrated a pituitary mass lesion with hematoma, consistent with pituitary apoplexy. Neuro-ophthalmological examination revealed no visual field defect, and endocrinological evaluations showed an elevated prolactin level. Pituitary apoplexy due to a prolactinoma was the most likely diagnosis. He was conservatively treated because he exhibited no visual disturbance. Three weeks after the onset, he gradually began to complain of blurred vision and neuro-ophthalamological examination revealed bitemporal upper quadrant hemianopsia. MRI showed enlargement of the pituitary hematoma without any finding suggestive of rebleeding. This enlarged mass lesion compressed the chiasm. The patient was operated on via transsphenoidal approach. After dural opening, xanthochromic fluid spouted out, but no fresh clot could be detected within the cyst. After the operation, the visual field disturbance resolved completely. The possible mechanism of hematoma enlargement is considered to be expansion due to the serum exudation from capillaries of the hematoma capsule. This pathogenetic mechanism is common in enlargement of chronic subdural hematoma.

Conclusions:

This case is the first report of chronic expanding pituitary hematoma without rebleeding after pituitary apoplexy.

Post-Traumatic Frontal and Parieto-Occipital Extradural Haematomas: a Retrospective Analysis of 41 Patients and Review of the Literature

The purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors.

In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a “good” or “favourable outcome”, whereas severe disability, a vegetative state or death was a “poor outcome”.

In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had “good outcomes” than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.

Chronic epidural hematoma of the vertex

Epidural hematomas of the cranial vertex can be rarely found in patients victims of head trauma. The diagnosis of the vertex hematoma may be delayed by the odd location of the bleeding site and the absence of a clear localization symptomatology. The current method of choice for investigation of head trauma patients, the computed tomography (CT) scans, may also give misleading diagnostic clues. Epidural hematomas of the vertex can be also encountered in a chronic form, and re-bleeding is possibly the underlying mechanism for the long term permanence of the hematoma. We report a case of a patient with a chronic epidural hematoma of the cranial vertex with a long interval between the trauma and the symptoms onset. We review the current literature focusing on the diagnostic pitfalls and forms of treatment of the chronic epidural hematoma of the vertex.