Pitfalls regarding the neurosurgical management of traumatic supra and infratentorial extradural haematomas

Exploring Rare Traumatic Injuries: A Miniseries of 4 Cases Discussing Epidural Hematomas Bridging the Infratentorial and Supratentorial Regions

Supratentorial-infratentorial epidural hematomas (SIEH) are a rare occurrence following traumatic head injuries, representing only 2% of traumatic epidural hematomas. Given the unique anatomical characteristics of the infratentorial region, mainly its small size, surgical intervention is commonly undertaken to alleviate the pressure on the posterior fossa components. Consequently, there is ongoing debate surrounding the optimal surgical approaches.In this report, we present four cases of SIEH that were treated surgically. Furthermore, we conduct a comprehensive review of existing literature, encompassing clinical, radiological, and therapeutic aspects associated with this condition.SIEH are uncommon post-traumatic lesions that require urgent and individualized management on a case-by-case basis, as guided by multiplanar cerebral computed tomography scan findings. Preoperative planning is essential; however, intraoperative exploration and identification of transverse sinus and torcula lesions are crucial for optimal patient care. The surgical approach may be modified intraoperatively based on the nature and extent of these lesions. In all cases, prompt hematoma evacuation and meticulous hemostasis are the two primary objectives of this surgery.

Clinical Significance of Isolated Third Cranial Nerve Palsy in Traumatic Brain Injury: A Detailed Description of Four Different Mechanisms of Injury through the Analysis of Our Case Series and Review of the Literature

Third cranial nerve palsy (3cnP) following traumatic brain injury (TBI) is a worrying neurological sign and is often associated with an expanding mass lesion, such as extradural or acute subdural haematomas. Isolated 3cnP can be found in the absence of posttraumatic space-occupying mass lesion, yet it is often considered as a devastating prognostic factor in the context of diffuse axonal injury (DAI). Through the analysis of five exemplificative cases and a thorough review of the literature, we identified four possible mechanisms leading to 3cnP: (1) a partial rootlet avulsion at the site of exit from the midbrain, representing a direct shearing injury to the nerve; (2) a direct traction injury due to the nerve stretching against the posterior petroclinoid ligament at the base of the oculomotor triangle secondary to the downward displacement of the brainstem at the time of impact; (3) a direct vascular compression as a result of internal carotid artery (ICA) dissection or pseudoaneurysm; (4) an indirect injury caused by impaired blood supply to the third nerve in addition to the detrimental biochemical effects of the underlying brain injury itself. Understanding the exact mechanism underlying the onset of 3cnP is key to provide an informed clinical decision-making to the patients and ensure their best chances of recovery. Our experience corroborates data from the literature showing that, even in Grade III DAI, prompt recognition of isolated 3cnP can guide adequate treatment. Nonetheless, even when an overall good neurological outcome is achieved, recovery of isolated 3cnP is dismal, and only rarely the visual deficit completely resolves.