Non-traumatic spontaneous acute epidural haematoma -- report of two cases and review of the literature

Acute epidural hemorrhage following burr-hole irrigation for chronic subdural hematoma: A possible association with the diploic veins

A 50-year-old man presented with headache and left hemiparesis. No noticeable preceding head trauma was observed. Computed tomography (CT) scans revealed a compressive chronic subdural hematoma (CSDH). The patient underwent burr-hole irrigation, during which he was considerably restless. In addition, extensive avulsion was found in the parietal dura mater posterior to the burr hole. CT performed immediately after the surgery revealed the emergence of a thick epidural hematoma (EDH) located posterior to the burr-hole. During emergency craniotomy for the EDH, there was no identifiable injury to the dura mater or the meningeal vessels. However, a review of the CT scans confirmed well-developed diploic spaces just above the center of the EDH, with connecting channels between the diploic spaces and extracranial sites. Based on these observations, we assumed that the diploic vein might have caused the EDH. Diploic veins can cause AEDH after burr hole irrigation for CSDH. Appropriate intraoperative sedation and protective irrigation maneuvers can reduce the risk of such AEDH.

Cryptogenic recurrent spontaneous intracranial epidural hematoma: A case report and literature review

Background

Spontaneous epidural hematoma (EDH) has been suggested to be associated with adjacent infective pathologies, dural vascular malformations, extradural metastases, or coagulopathies. Cryptogenic spontaneous EDH is extremely rare.

Case presentation

The present study reports the case of a cryptogenic spontaneous EDH in a young woman following sexual intercourse. She was diagnosed with consecutive EDH at three different sites within a short time. After three timely operations, a satisfactory outcome was achieved.

Conclusion

EDH should be investigated when a young patient develops headaches and shows signs of increased ICP after emotional hyperactivity or hyperventilation. If early diagnosis and surgical decompression can be carried out in time, the prognosis would be satisfactory.

Association between spontaneous intracranial epidural hematoma and craniofacial infections: A systematic literature review

Background

Spontaneous and nontraumatic epidural hematoma (SEDH) is a rare entity. Etiology is various, including vascular malformations of the dura mater, hemorrhagic tumors, and coagulation defects. The association between SEDH and craniofacial infections is rather unusual.

Methods

We performed a systematic review of the available literature using the PubMed, Cochrane Library, and Scopus research databases. Literature research was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. We exclusively included studies reporting demographic and clinical data, published until October 31, 2022. We also report one case from our experience.

Results

A total of 18 scientific publications, corresponding to 19 patients, met the inclusion criteria for the qualitative and quantitative analysis. Patients were mostly adolescents, with a clear male predominance. SEDHs frequently occurred in the frontal area, usually near the site of the infection. Surgical evacuation was the treatment of choice with good postoperative outcomes. Endoscopy of the involved paranasal sinus should be achieved as soon as possible to remove the cause of the SEDH.

Conclusion

SEDH may occur as a rare and life-threatening complication of craniofacial infections; therefore, prompt recognition and treatment are mandatory.

Intracranial Idiopathic Acute Epidural Hematoma Presenting with a Stroke-like Attack and Rapid Neurological Deterioration: A Case Report

A 36-year-old woman presented with sudden onset of a right-sided headache that awoke her from sleep. She had no episodes of trauma or abuse. She was initially able to speak, but fell into a coma within an hour. The right pupil was dilated, with slow pupillary reflexes to light on both sides, and she showed left hemiparalysis. Computed tomography scan showed a right acute epidural hematoma, approximately 4 cm in thickness, and there were no findings of trauma such as skin wounds, subcutaneous hematomas, or skull fractures. In the emergency room, decompression of intracranial pressure by one burr hole was performed, and her dilated right pupil improved to normal size. She was then moved to the operating room, and hematoma removal was performed by craniotomy. Her blood pressure trended downward despite rapid blood transfusion and vasopressor therapy. There were no abnormal findings apparent intraoperatively, except for oozing from the whole surface of the dura mater and epidural space. Her consciousness improved postoperatively, and her left hemiparalysis improved within a few days. No causative diseases, risk factors, or vascular abnormalities were found on laboratory and radiological surveys. Two months postoperatively, the bone flap was removed because of infection. Eight months postoperatively, a cranioplasty using artificial skull was performed, and her postoperative course was uneventful. One year after the initial surgery, she has no neurological deficits, and there has been no recurrence of epidural hematoma.

Causes and Risk Factors of Pediatric Spontaneous Intracranial Hemorrhage—A Systematic Review

Previous studies suggest that the most common cause of spontaneous intracerebral hemorrhage in children and adolescents is arteriovenous malformations (AVMs). However, an update containing recently published data on pediatric spontaneous intracranial hemorrhages is lacking. The aim of this study is to systematically analyze the published data on the etiologies and risk factors of pediatric spontaneous intracranial hemorrhage. This systematic review was performed in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A search in PubMed, Embase, Scopus, Web of Science and Cochrane Library was conducted aiming for articles published in year 2000 and later, containing data on etiology and risk factors of spontaneous intracranial hemorrhages in unselected cohorts of patients aged between 1 month and 18 years. As a result, forty studies were eligible for data extraction and final analysis. These included 7931 children and adolescents with 4009 reported etiologies and risk factors. A marked variety of reported etiologies and risk factors among studies was observed. Vascular etiologies were the most frequently reported cause of pediatric spontaneous intracranial hemorrhages (n = 1727, 43.08% of all identified etiologies or risk factors), with AVMs being the most common vascular cause (n = 1226, 70.99% of all vascular causes). Hematological and systemic causes, brain tumors, intracranial infections and cardiac causes were less commonly encountered risk factors and etiologies.

Calvarial diploic venous channels: delineation with maximal intensity projection technique

PURPOSE

To date, very few studies have explored the three-dimensional architecture of calvarial diploic venous channels (CDVCs). This study aimed to characterize the three-dimensional architecture of CDVCs using maximum intensity projection (MIP) images based on contrast-enhanced magnetic resonance imaging (MRI).

METHODS

A total of 77 patients with intact calvarial hemispheres and underlying dura mater and dural sinuses underwent contrast-enhanced MRI. Among them, we extracted the data of 49 with at least a part of the major CDVC pathways identified on the MIP images for analysis.

RESULTS

On serial contrast-enhanced MRI images, the CDVCs were commonly detected as curvilinear structures with inhomogeneous diameters and tributaries, while the MIP images delineated the three-dimensional architecture of the developed CDVC pathways. More than such CDVC pathway was entirely delineated on the right in 67.3% and on the left in 71.4%, most frequently in the frontal and temporal regions, with their connecting sites to the sphenoparietal and superior sagittal sinuses. The morphology, distribution, and course of the identified CDVCs were highly variable. In 55.1%, the CDVCs formed fenestrations that were variable in size, shape, and number.

CONCLUSIONS

The developed CDVC pathways may be characterized by morphological variability and fenestrations. Thin-sliced, contrast-enhanced MRI is useful to depict diploic veins, while MIP images allow for better appreciation of the entire course of the developed CDVC pathways. Traumatic and intraoperative disconnection between the dura mater overlying the dural sinuses and the adjacent inner table of the skull can cause epidural venous bleeding.

Spontaneous epidural hematoma: A case report of rare crisis of sickle cell disease

Introduction:

Sickle cell disease (SCD) is defined as an autosomal recessive disorder characterized by the production of abnormal hemoglobin S and is correlated with high morbidity and mortality. The clinical consequences of SCD include pain crisis, acute chest syndrome, and strokes. Spontaneous epidural hematoma is a rare manifestation in sicklers with few cases reported in the literature.[6] The pathophysiology is not completely understood. However, a few explanations have been reported over the years that include vaso-occlusion of the bone resulting in bone infarction, microfracture due to rapid expansion of hematopoiesis of the inner cortex, and sludging of the sickle cells in the diploic veins—all result in leaking of blood in the epidural or in the subgalea space.

Patient Concerns:

A 14-year-old boy known to have SCD (Hb SS) presented to the Security Forces Hospital with a history of diffuse headache associated with nausea that started 12 h prior to presentation.

Diagnosis:

Computed tomography (CT) showed bilateral frontal epidural hematoma and subgaleal space.

Intervention:

A multidisciplinary team was created (hematology, neurology, neurosurgery, and interventional radiology) and a plan was formulated as follows: Continuous monitoring of the patient’s neuro vital signs and transfuse the patient with blood and platelets in addition with Levetiracetam.

Outcomes:

The patient was discharged after 9 days of hospital admission. He has remained symptom-free post-transfusion. Post-discharge CT scan showed a reduction in the hematoma size.

Conclusion:

A high index of suspicion is needed for a prompt diagnosis and treatment of this rare complication of SCD. The management strategy of EDH depends on the level of consciousness of the patient upon presentation. Surgical approach with craniotomy and evacuation or conservative management have been used with full recovery of the patients.

Spontaneous Epidural and Corpus Callosum Hemorrhage in Sickle Cell Disease - An Unusual Presentation in a Ghanaian Patient

Spontaneous intracranial bleed in sickle cell disease is a rare presentation and complication of the disease, with a few cases presenting with epidural hematoma. We present an 18-year-old boy with sickle cell, hemoglobin FS, who presented with non-traumatic scalp swelling, headaches, and vomiting six days following an episode of vaso-occlusive crisis with bone pain. A head CT scan showed extensive epidural hematoma with mass effect and acute corpus callosum bleed. The patient, however, had a cardiac arrest with unsuccessful resuscitation before neurosurgical interventions could be instituted. Of all reported cases, none has reported associated bleeding in the corpus callosum, making our case the firstwith such a combination, possibly worsening the outcome.

Eosinophilic Granuloma of the Skull Presenting as Non-Traumatic Extradural Haematoma in Children

Cranial extradural haematoma (EDH) is a neurosurgical emergency that can be caused by traumatic or non-traumatic causes with the former being more prevalent. Non-traumatic causes are variable and can include infection, vascular malformation and haematological disorders. This paper will address an extremely rare non-traumatic cause of EDH. More specifically, eosinophilic granuloma (EG), the localized form of Langerhans histiocytosis, may involve the skull and has rarely been reported to present with EDH. The case that will be presented is that of a three-year-old male patient, who presented with progressive vomiting and drowsiness, associated with left parietal swelling. CT scan of the brain showed an extradural haematoma and an osteolytic parietal lesion. He underwent emergent craniectomy, evacuation of the haematoma and dura resection as the lesion was infiltrating the dura. Histopathological examination of the dura and the bone edges showed eosinophilic granuloma (EG). The mechanism of a haemorrhage in this situation is poorly understood and the literature is extremely scarce. In conducting a thorough literature review, only 11 case reports of EG causing non-traumatic EDH were found. The details of these 11 cases will be reviewed and discussed in this paper, in addition to our illustrative case.

Spontaneous acute epidural hematoma associated with chronic subdural hematoma due to dural metastasis of gastric carcinoma: a case report and literature review

Background: Non-traumatic spontaneous acute epidural hematoma (EDH) happening to chronic subdural hematoma (SDH) caused by dural metastases is a rare entity. Pathogenesis can be derived from infection, coagulopathy, and inflammation. Malignant tumors metastasize to dura mater is one of the most infrequent causes. The exact mechanism remains elusive in spite of several possible speculations. The clinical manifestations, management and outcomes vary among reported cases.Case Description: A 45-year-old woman without history of trauma presented with headache, vomiting and disturbance of consciousness and developed brain hernia rapidly. On arival, she has lost into coma with Glasgow coma scale (GCS) score 5, bilateral pupils were not equal, with disappeared reflectance. Emergency imaging prompted large acute EDH, combined with SDH, arising from dural granular neoplasm confirmed intraoperatively. Four days after surgery, the bilateral pupils were equal in size and sensitive to light reflection.Conclusion: Dural metastases can cause EDH, chronic SDH can also be resulted from metastatic tumors of dura mater. When dealing with spontaneous non-traumatic hematoma around the dura mater, to make the precise diagnosis is sometimes doubtful and confusing. The stream of diagnostic thinking should be opened, including medical diseases such as liver and kidney disease, drug history, history of cancer and other possible clues. Thus, a detailed and purposeful systematic medical history review and physical examination is important in order to make more appropriate strategies for the clinic.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

Repeated Spontaneous Intracranial Epidural Hemorrhage After Hysterical Crying

BACKGROUND

Spontaneous epidural hemorrhage (EDH) is a rare occurrence that may be caused by vascular anomalies, infections, coagulopathies, or tumors. Spontaneous EDH occurring in patients without specific underlying disease has been reported only as intraspinal lesion but has never been demonstrated in the intracranial area. This study presents a 19-year-old patient with repeated spontaneous intracranial EDH caused twice by hysterical crying.

CASE DESCRIPTION

The patient had spontaneous left frontal EDH after hysterical crying. Two years later, she had a similar episode after crying and a new spontaneous right frontal EDH was revealed. There was no obvious risk factor revealed by laboratory and radiologic survey. We postulated that hyperventilation during crying resulted in a sudden decrease in intracranial pressure. The intracranial hypotension induced detachment of the dura from the skull and spontaneous EDH occurred.

CONCLUSIONS

Crying or hyperventilation may trigger spontaneous EDH and should be suspected when there are signs of persisting headache and increased intracranial pressure. The prognosis is excellent if early diagnosis and surgical decompression are achieved.

A review of spontaneous intracranial extradural hematoma in sickle-cell disease

Sickle-cell disease is common among patients of Afro-Caribbean origin. Though it can precipitate neurological conditions, it only rarely causes neurosurgical problems, with very few reported cases. We describe the case of a 7-year-old girl with a background of sickle-cell disease (SCD) brought into an acute neurosurgical unit in extremis, signs of a raised ICP, and with no history of recent trauma. Following further investigations, an acute drop in the hemoglobin and hematocrit levels were noted, with the cause of her presentation being attributed to a sickling crisis causing skull convexity infarction and resulting in spontaneous bilateral extradural hematomas requiring emergency evacuation. We review the current literature and propose the pathophysiological mechanism behind this phenomenon.

HbSC Disease and Spontaneous Epidural Hematoma with Kernohan's Notch Phenomena

Spontaneous (nontraumatic) acute epidural hematoma is a rare and poorly understood complication of sickle cell disease. A 19-year-old African American male with hemoglobin SC disease (HbSC) presented with generalized body aches and was managed for acute painful crisis. During his hospital stay he developed rapid deterioration of his mental status and computed topography revealed a spontaneous massive epidural hematoma with mass effect and midline shift with Kernohan's notch phenomena for which urgent craniotomy and evacuation was done. We report the first case of HbSC disease associated with catastrophic epidural hematoma progressing to transtentorial herniation and Kernohan's notch phenomena within few hours with rapid clinical deterioration. The etiopathogenesis and the rare presentation are discussed in detail in this case report.

Spontaneous Intracranial Extradural Hematoma in Sickle Cell Disease

Spontaneous extradural hematoma is rare in patients with sickle cell disease. We report a clinical case of a 19-year-old young man with sickle cell anemia who presented a sickle cell crisis complicated by the development of multiple acute extradural and subgaleal hematomas that had not been treated surgically. We discuss the physiopathology of this event. Although it is rare, clinicians should be aware of this phenomenon as part of a spectrum of neurologic complications in these patients.

Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery

Background:

Preoperative anemia may affect postoperative mortality and morbidity following elective cranial operations.

Methods:

The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify elective cranial neurosurgical cases (2006-2012). Morbidity was defined as wound infection, systemic infection, cardiac, respiratory, renal, neurologic, and thromboembolic events, and unplanned returns to the operating room. For 30-day postoperative mortality and morbidity, adjusted odds ratios (ORs) were estimated with multivariable logistic regression.

Results:

Of 8015 patients who underwent elective cranial neurosurgery, 1710 patients (21.4%) were anemic. Anemic patients had an increased 30-day mortality of 4.1% versus 1.3% in non-anemic patients (P < 0.001) and an increased 30-day morbidity rate of 25.9% versus 14.14% in non-anemic patients (P < 0.001). The 30-day morbidity rates for all patients undergoing cranial procedures were stratified by diagnosis: 26.5% aneurysm, 24.7% sellar tumor, 19.7% extra-axial tumor, 14.8% intra-axial tumor, 14.4% arteriovenous malformation, and 5.6% pain. Following multivariable regression, the 30-day mortality in anemic patients was threefold higher than in non-anemic patients (4.1% vs 1.3%; OR = 2.77; 95% CI: 1.65-4.66). The odds of postoperative morbidity in anemic patients were significantly higher than in non-anemic patients (OR = 1.29; 95% CI: 1.03-1.61). There was a significant difference in postoperative morbidity event odds with a hematocrit level above (OR = 1.07; 95% CI: 0.78-1.48) and below (OR = 2.30; 95% CI: 1.55-3.42) 33% [hemoglobin (Hgb) 11 g/dl].

Conclusions:

Preoperative anemia in elective cranial neurosurgery was independently associated with an increased risk of 30-day postoperative mortality and morbidity when compared to non-anemic patients. A hematocrit level below 33% (Hgb 11 g/dl) was associated with a significant increase in postoperative morbidity.

Gigantic ossified chronic epidural haematoma and contralateral postoperative subdural haematoma: A case report and literature review

A 21-year-old woman was found to have a dramatic intracranial space-occupying lesion found via CT scan performed to investigate headache. Craniotomy was performed and the mass found to be a chronic extradural haematoma, whose aetiology was likely to have been spontaneous, due to thrombocytopenia in infancy. Although this was removed, her recovery was complicated by the need to treat a contralateral delayed subdural haematoma.

Non-traumatic spontaneous acute epidural hematoma in a patient with sickle cell disease

A 19-year-old female with sickle cell anemia (SCD) was referred to our hospital after two days of hospitalization at another hospital for a headache crisis. This headache crisis was due to a raised intracranial pressure; these symptoms were noted and included in her comprehensive list of symptoms. There was an acute drop in the hemoglobin and hematocrit levels. The cranial CT scan demonstrated a left fronto-parietal acute epidural hematoma (AEH) and a calvarial bone expansion, which was suggestive of medullary hematopoiesis. The patient underwent emergent craniotomy and evacuation of the hematoma. There were no abnormal findings intra-operatively apart from the AEH, except skull thickening and active petechial bleeding from the dural arteries. Repeated CT scan showed a complete evacuation of the hematoma. The possible underlying pathophysiological mechanisms were discussed. In addition to the factors mentioned in the relevant literature, any active petechial bleeding from the dural arteries on the separated surface of the dura from the skull could have contributed to the expanding of the AEH in our patient. Neurosurgeons and other health care providers should be aware of spontaneous AEH in patients with SCD.

Spontaneous epidural haematoma in sickle cell anaemia: case report and literature review

Non traumatic spontaneous epidural Haematoma is a rare and often unmentioned complication of sickle cell disease. It is often associated with skull bone infarction. We report an eighteen year old boy with sickle cell anaemia who developed persistence headache during a vaso-occlusive crisis. Brain computed tomography (CT) revealed a right frontal epidural Haematoma (EDH) compressing on the brain. No other etiologic factor was identified. A right frontal craniotomy and evacuation of the Haematoma was performed and he made good recovery. The possible pathogeneses of this rare condition are discussed.

Epidural hematoma accompanied by oculomotor nerve palsy due to sphenoid sinusitis

Spontaneous epidural hematoma (EDH) is rarely mentioned in the literature as an intracranial complication of sinusitis. We report a 17-year-old female patient who developed spontaneous EDH accompanied by isolated oculomotor nerve palsy as a complication of sphenoid sinusitis. Sphenoid sinusitis could be considered as the causative disease in a patient with spontaneous EDH accompanied by isolated oculomotor nerve palsy without history of head trauma.

Spontaneous intracranial epidural hematoma originating from dural metastasis of hepatocellular carcinoma

Spontaneous intracranial epidural hematoma (EDH) due to dural metastasis of hepatocellular carcinoma is very rare. A 53-year-old male patient with hepatocellular carcinoma, who was admitted to the department of oncology, was referred to department of neurosurgery because of sudden mental deterioration to semicoma with papillary anisocoria and decerebrate rigidity after transarterial chemoembolization for hepatoma. Brain computed tomography (CT) revealed large amount of acute EDH with severe midline shifting. An emergent craniotomy and evacuation of EDH was performed. Active bleeding from middle cranial fossa floor was identified. There showed osteolytic change on the middle fossa floor with friable mass-like lesion spreading on the overlying dura suggesting metastasis. Pathological examination revealed anaplastic cells with sinusoidal arrangement which probably led to spontaneous hemorrhage and formation of EDH. As a rare cause of spontaneous EDH, dural metastasis from malignancy should be considered.

Cerebral epidural hematoma following cerebrospinal fluid drainage during thoracoabdominal aortic repair

Cerebrospinal fluid (CSF) drainage is a common adjunct to thoracoabdominal aortic aneurysm (TAAA) repair. CSF drainage may improve perioperative spinal cord perfusion and thereby decrease the incidence of paraplegia or paraparesis. Complications of CSF drainage may arise. We present a case of cerebral epidural hematoma (EDH), possibly arising from excessive CSF drainage, during thoracoabdominal aortic repair.

A spontaneous spinal epidural hematoma in a hemodialysis patient: a rare entity

Hemodialysis patients are at an increased risk of bleeding due to the platelet dysfunction caused by uremia and the use of anticoagulants during dialysis. Spontaneous spinal hematoma is a rare disorder as a complication in hemodialysis patients. Also it includes the hematoma secondary to coagulopathy, vascular malformation and hemorrhagic tumors. Here, we report the case of 77-year-old woman who presented with spinal cord compression due to spontaneous spinal epidural hematoma associated with hemodialysis. When an end-stage renal disease patient suffers from back pain and neurological deficits, the clinician should be alerted for the spontaneous spinal epidural hematoma as well as cerebrovascular events.

Spontaneous epidural hematoma due to skull metastasis of hepatocellular carcinoma

Although "spontaneous" epidural hematomas are rare, they can occur in patients with metastatic skull tumors. We describe a case caused by skull metastasis of hepatocellular carcinoma (HCC), and review the relevant literature. In patients with HCC, potential skull metastasis should be kept in mind, since skull metastases from HCC seem to often cause devastating epidural hematoma.

Nontraumatic intracranial epidural hematoma: a case report

An outwardly mummified and inwardly badly decomposed body was found in a garage. At autopsy, no injuries were detected. Apart from coronary heart disease, with an old myocardial scar and a hepatic steatosis, the most striking finding was a large intracranial epidural hemorrhage situated at the left frontal lobe. As a relevant traumatic genesis could be ruled out, we deemed this a nontraumatic epidural hematoma. This finding is extremely rare. Several underlying disorders have been discussed as causes of spontaneous epidural hematomas. In this presented case, the authors discuss possible etiological factors.

Clinical features of temporal tip epidural hematomas

OBJECT

The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs).

METHODS

A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury.

RESULTS

A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score.

CONCLUSIONS

A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.

The radiological manifestations of sickle cell disease

Sickle cell disease (SCD) is an inherited abnormality of the beta-globin chain, which causes a spectrum of haemolytic anaemias. Clinical manifestations in SCD include anaemia, jaundice, recurrent vaso-occlusive crises, and infections (particularly by encapsulated bacteria) due to functional asplenia and cerebrovascular accidents. Radiological investigations play a critical role both in the diagnosis and in the primary prevention of the complications of SCD.

Treatment and prevention of stroke in children with sickle cell disease

Stroke is one of the major complications in children with sickle cell disease (SCD). Ischemic stroke is associated with small asymptomatic subcortical infarcts to large territorial lesions causing major disability. Intracranial hemorrhages may be caused by aneurysm rupture or by leakage from moyamoya vessels or venous sources. There have been no acute stroke treatment studies in SCD, but hydration and exchange transfusion are often recommended. However, there is an evidence base for primary and to some extent secondary stroke prevention. Primary prevention of stroke was demonstrated in the Stroke Prevention Trial in Sickle Cell Anemia (STOP), in which children with transcranial Doppler (TCD) mean blood flow velocities of 200 cm/second (previously shown to indicate high stroke risk) or higher were randomized to either regular blood transfusions or no transfusion. The study showed a very significant 90% reduction in first stroke with transfusion. In STOP2, discontinuing transfusions after 30 months or more (even with normal TCD) resulted in a high rate of reversion to abnormal TCD values and stroke. TCD screening of all children with SCD, and initiation and maintenance of chronic transfusion to maintain hemoglobin S below 30% in the high-risk group, is the only proven prevention strategy for stroke in SCD. Hydroxyurea is being studied as secondary stroke prevention at this time. No recommendation specific to SCD regarding the use of antiplatelet agents or anticoagulants in ischemic stroke can be made. Bone marrow transplantation can be curative for SCD, and limited data support its use to prevent stroke in SCD.