Epidural hematoma with detachment of the dural sinuses

Technique notes on the management of superior sagittal or transverse sinus during the falcotentorial meningioma surgery: a case report

Background

Falcotentorial meningiomas (FM) are surgical challenges for protecting sinus, and the technique notes on the management of superior sagittal or transverse sinus are required for good results.

Methods

We improved the technique notes on the management of superior sagittal or transverse sinus in three FM patients with signs of increased intracranial pressure or chronic headache.

Results

All patients underwent surgeries in the prone position, and occipital/sup-occipital/sub-occipital craniotomy was performed. In one patient, the skull was removed traditionally with exposure of the confluence of sinuses, superior sagittal, and transverse sinus, while the longitudinal skull bridge was left to suspend the dura for protecting the superior sagittal sinus in one patient, and the transverse skull bridge was left to suspend the dura for protecting the transverse sinus in one patient. The dura was opened infratentorially or supratentorially to spare the sinus and then the "skull bridge" was suspended. The tumor was then removed completely without brain swelling or significant venous bleeding. Complete tumor resection was confirmed by early postoperative imaging, and all patients recovered well without postoperative morbidity.

Conclusion

The authors recommend the "skull bridge" to suspend the dura for optimal control of the venous sinuses during FM surgery (less venous bleeding).

Head Trauma Associated with Supra- and Infratentorial Epidural Hematoma: Diagnostic and Surgical Considerations

BACKGROUND

Supra- and infratentorial epidural hematoma (SIEDH) is a rare type of intracranial epidural hematoma. Due to the potential of vigorous hemorrhage from the injured transverse sinus (TS), it poses a challenge for neurosurgeons to evacuate the SIEDH.

METHODS

The medical records and radiographic studies were retrospectively reviewed to investigate the clinical and radiographic characteristics, clinical course, surgical findings and outcome in 34 patients with head trauma associated with SIEDH.

RESULTS

Patients treated surgically had a lower Glasgow Coma Scale score than those treated conservatively (P = 0.005). The surgical group had statistically larger thickness and volume of the SIEDH than those in the conservative group (P < 0.0001 and P < 0.0001, respectively). Six patients experienced significant intraoperative blood loss, and copious bleeding from the injured TS was noted in 5 (83.3%) of these patients. Five (50%) of 10 patients undergoing simple craniotomy experienced significant blood loss. However, only 1 patient (11.1%) undergoing strip craniotomy experienced significant blood loss, but no intraoperative shock. All patients experiencing massive blood loss and intraoperative shock underwent simple craniotomy. There was no statistical difference in the outcome between the conservative and surgical groups.

CONCLUSIONS

When operating on SIEDH, the possibility of vigorous bleeding from the injured TS and intraoperative massive bleeding should be kept in mind. Strip craniotomy that allows hitching the stripped dura to the bone strip overlying the TS may be a better method for the evacuation of SIEDH.

Diploic Bone Channel Drilling Facilitates Dissection of the Midline Dura and Protects the Superior Sagittal Sinus in Hyperostosis Frontalis Interna

Patients with space-occupying lesions adjacent to the superior sagittal sinus (SSS) present several technical considerations. For craniotomies crossing the SSS, a two-part method allows for dissection of the epidural space and dura under direct vision after removing a more lateral parasagittal bone flap. However, when the inner table surface of the medial component of the two-part bone flap is irregular, this can be difficult. We describe a method for channel drilling of the diploic bone, which allows for the piecemeal removal of the inner table using an upbiting rongeur. This article presents the case of meningioma with documented growth and provides a technical note of this technique to facilitate safe dissection of the midline dura. A patient presented with headaches and an anterior one-third parasagittal meningioma with documented growth. She selected surgical removal for treatment. A right frontal two-part parasagittal craniotomy was recommended. The preoperative imaging showed that the frontal bone was thick, with irregularity of the inner table. Intraoperatively, a channel was drilled in the diploic space of the bone, leaving the outer table intact. This provided a thin lip of the inner table that could be dissected over a short distance and then removed with a 2-mm upbiting rongeur. This allowed for further dissection of the dura crossing the midline under direct vision and safe secondary bone piece removal. The dura was opened to the edge of the SSS, allowing full exposure of the parasagittal region and interhemispheric fissure, thus limiting retraction of the medial right frontal lobe. The bone flap was removed in two pieces without a dural tear over the midline in spite of inner table irregularities. A Simpson grade 1 removal was accomplished, including excision of the affected falx, and the postoperative course was uncomplicated. In conclusion, diploic bone channel drilling is a technique that can be used to create a thin lip of the inner table, which can be removed piecemeal for safe dissection of the midline dura crossing the midline.

Vertex epidural hematoma: Diagnosis, therapeutic consideration and outcome

OBJECTIVE

Vertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging.

MATERIALS AND METHODS

A retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome.

RESULTS

Patients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively (p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional "simple craniotomy". No patients undergoing "strip craniotomy" experienced massive bleeding. Thrombocytopenia (p = 0.008), headache (p = 0.015), consciousness disturbance (p = 0.043), pupil reactivity (p = 0.010), GCS score (p < 0.0001) and the relationship between skull fracture and the SSS (p = 0.037) were significant prognostic factors.

CONCLUSION

Our study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.

Spontaneous epidural hematoma induced by rivaroxaban: A case report and review of the literature

Background:

Trauma is the most frequent reason for epidural bleeding. However, numerous investigation had discovered that anticoagulants such as rivaroxaban could cause epidural hematoma. Here, we present a case of epidural hematoma in young man who got rivaroxaban as treatment of deep vein thrombosis.

Case Description:

A 27-year-old male with a history of deep vein thrombosis and one month of rivaroxaban medication presented with seizure and loss of consciousness following a severe headache. A CT scan of the head revealed epidural bleeding, and emergency blood clot removal was performed. As a reversal, prothrombin complex was utilized.

Conclusion:

Rivaroxaban has the potential to cause an epidural hemorrhage. Reversal anticoagulant should be administered before doing emergency surgery.

A series of post-traumatic midline epidural hematoma and review of the literature

BACKGROUND

Supratentorial midline epidural hematoma is rare but challenging in diagnosis and management. Indication for surgery can arise even following hospital admission. Being familiar to the presentation and watching out for direct and indirect signs on axial computed tomography (CT) such as suture diastasis or fracture traversing midline are essential to plan multi-planar CT enabling exact diagnosis including form and mass effect of hematoma.

METHODS

Nine patients with midline epidural hematoma including two pediatric patients underwent surgery between 2013 and 2018. Pre-operative and post-operative patient status, radiological features, and surgical technique were analyzed.

RESULTS

Four patients had deteriorating consciousness levels and two patients had paraparesis. All had fractures traversing midline and epidural hematomas with significant mass effect. They were operated through separated craniotomies around the midline and midline bone strip was used for dural tenting and as support for natural closure of bone flaps. No post-operative complications were developed. All patients were discharged with Glasgow Outcome Score of 5.

CONCLUSION

Because of the rarity of the lesion and small number of patients, definitive conclusions may be misleading but we think that, in experienced hands, midline epidural hematomas can safely be operated on and, preservation of midline bone strip pro-vides easier bleeding control.

Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH)

INTRODUCTION

Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed.

METHODS AND ANALYSIS

This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04229966.

Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data

Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.

Management of Venous Sinus-Related Epidural Hematomas

BACKGROUND

Epidural hematomas (EDHs) involving the venous sinuses are uncommon and carry the risk of hemorrhage or venous infarction. We report the largest case series for superior sagittal sinus- and transverse sinus-related EDHs including surgical and nonsurgical management. We compare our findings to the relevant literature.

METHODS

A retrospective review of the EDH cases at our center was performed from 2013-2018. Patients were analyzed by surgical versus conservative management, outcomes, and complications.

RESULTS

Of the 268 EDH patients identified, 32 involved the venous sinuses (23 supratentorial and 9 infratentorial). Ten of the patients had surgery, and 22 were managed conservatively. No surgical complications occurred, and all had a Glasgow Outcome Scale score of 5 at follow-up. All of the nonsurgical patients had a Glasgow Outcome Scale score of 4 or 5 at follow-up except for 1 patient with prior disability. The literature search resulted in 39 infratentorial and 47 supratentorial EDHs involving venous sinuses.

CONCLUSIONS

Surgical and nonsurgical management of EDHs involving the venous sinuses are both viable options with good outcomes. Surgical intervention is based on location, size, neurologic examination, expansion on serial imaging, and vascular imaging findings. Surgery has the potential for significant complications, but all surgical patients in our series had good outcomes at follow-up. Similarly, nonsurgically managed patients had good outcomes and our overall series demonstrates better outcomes with fewer complications than other similar series in the literature.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Unusual, Acute, and Delayed Traumatic Torcular Herophili Epidural Hematoma Causing Malignant Encephalocele During Surgery: A Case Report

Patient: Male, 40

Final Diagnosis: Traumatic torcular herophili unusual acute and delayed epidural hematoma

Symptoms: Coma

Medication: —

Clinical Procedure: Craniotomy

Specialty: Neurosurgery

Traumatic bifrontoparietal extradural hematomas with detachment of superior sagittal sinus: a case report and review of the literature

A 45-year-old man suffered bifrontoparietal extradural hematoma resulting from head injury, which cause superior sagittal sinus detachment from its subperiosteal loggia. We present the patient who was treated by early surgical evacuation of the hematoma with an excellent outcome and we also perform a review of the current literature.

Surgical Management of Vertex Epidural Hematoma: Technical Case Report and Literature Review

BACKGROUND

Vertex epidural hematoma (VEH) is an uncommon presentation of extra-axial hematomas. It can represent a surgical dilemma regarding when and how to operate, particularly considering the potential implication of the superior sagittal sinus (SSS).

OBJECTIVE

Here, we illustrate the surgical technique for VEH as well as a review of the existing literature.

METHODS

A 60-year-old man sustained a ground-level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bihemispheric convexities. Twenty-four hours later, the patient deteriorated, with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies, was performed. A central island of bone was left intact to spare the diastatic fracture from the craniotomies. This was done to ensure a stable anchor point for tacking-up the underlying displaced dura and SSS. The central bone prevents extensive bleeding from the diastatic fracture and eliminates the risk of further blood reaccumulation and tearing of a possible injured sinus during bone flap elevation.

RESULTS

The technique performed allowed us to evacuate completely the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation.

CONCLUSIONS

Because of its rare nature, VEH represents a surgical challenge. Because neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted.

Vertex epidural hematoma: A rare cause of post-traumatic headache and a diagnostic challenge

Background:

Vertex epidural hematomas (VEH) account for only 8% of all epidural hematomas. However, these traumatic injuries may be underestimated or overlooked altogether when only computed tomography (CT) scans are used for diagnosis. The vertex may be a potential anatomic “blind spot” on this radiological method. In such cases, magnetic resonance (MRI) offers a great diagnostic aid.

Case Description:

This manuscript reports a patient of a head trauma who developed progressive and intractable headache. MRI made the diagnosis of progressive VEH and highlighted the detachment of the superior sagittal sinus by the hematoma. Surgical treatment, because of the refractory clinical findings, was performed with good postoperative recovery.

Conclusion:

Multiple trauma patients with progressive and refractory headache should have their head CT thoroughly reviewed and, if necessary, be investigated with MRI.