Acute epidural hematoma extending bilaterally and infratentorially: illustrative case

Abstract

BACKGROUND

An acute epidural hematoma (AEDH) is a severe complication of traumatic brain injury, occurring in 1%–3% of all head trauma cases. Herein, the authors report a rare case of AEDH in a 51-year-old male, with the AEDH extending bilaterally across the superior sagittal sinus (SSS) and into the infratentorial region following a fall.

OBSERVATIONS

The patient underwent an emergency craniotomy and hematoma evacuation, and favorable outcomes were achieved.

LESSONS

This case highlights the importance of utilizing surgical and skin incision positions that allow for adequate removal of AEDH and show the effectiveness of prompt surgical intervention. Bleeding from the venous sinus is common in epidural hematomas that extend above and below the dural tentorium and to both sides of the SSS. To ensure adequate hemostasis, the bony flap near the venous sinus should be preserved to achieve hemostasis. Excessive compression of the venous sinus should be avoided to prevent obstruction. If time permits, the morphology of the dural sinus should be confirmed through CT venography or MR venography. After craniotomy, the patient should be positioned to avoid air embolization from the site of venous sinus injury.

https://thejns.org/doi/10.3171/CASE24756

Acute epidural hematoma (AEDH) is a potentially life-threatening condition that typically occurs unilaterally.¹ Bilateral AEDH is rare²,³ and is reported in only 2.58% of cases,² with those extending both supratentorially and infratentorially being exceptionally rare;^2,4–6 only four previously documented cases have been reported thus far. Here, we present a case of AEDH extending bilaterally across the superior sagittal sinus (SSS) and infratentorially and detail the necessary surgical approach for managing such extensive hematomas.

Illustrative Case

A 51-year-old male with no significant medical history was brought to our emergency department after falling down the stairs while intoxicated. The patient’s level of consciousness gradually deteriorated, and he became agitated approximately 3 hours postinjury. On admission, his Glasgow Coma Scale score was 12 (E3V4M5). Vital signs showed a blood pressure of 171/90 mm Hg, pulse of 51 bpm, temperature of 36.2°C, and SpO₂ of 97% on room air. The pupils were equal and reactive, measuring 3 mm bilaterally. A detailed neurological examination was difficult due to agitation. CT (Fig. 1) revealed extensive AEDH extending bilaterally across the SSS and infratentorially. No visible skull fractures were apparent on CT. The patient was intubated and underwent an emergency craniotomy for hematoma evacuation, following the management guidelines for severe traumatic brain injury.

FIG. 1.

Initial nonenhanced brain CT scans revealing a posterior cerebellar fossa EDH (A), EDH above and below the cerebellar tentorium at the level of the transverse venous sinus and extending to both sides of the SSS (B), and EDH extending to the right and left of the SSS above the cerebellar tentorium (C).

Surgical Technique

The patient was placed prone with a three-point pin fixation. A right-sided hockey stick incision was selected due to the hematoma being mainly on the right side. Because of the emergency nature of the case, preparation of the navigation system was not feasible. The surgical procedure was performed as follows. First, we made a skin incision spanning both the supra- and infratentorial regions. Next, we created a bone flap over the right tentorial region, where the hematoma was most prominent, using the midline and inion as anatomical landmarks. After evacuating and decompressing the epidural hematoma (EDH), we visually identified the SSS and transverse sinus (TS). These venous structures guided our placement of additional bone flaps in the infratentorial region and the left supratentorial area. Bone flaps were positioned above the TS and SSS to achieve hemostasis by means of tenting. Intraoperatively, occipital bone fractures and lambda suture diastasis were identified. The source of bleeding was a ruptured draining vein on the right side. EDHs were present bilaterally, both supratentorially and infratentorially (Fig. 2). The dura was partially opened, confirming the absence of a subdural hematoma. Following hematoma irrigation and removal, meticulous tenting was promptly performed, ensuring not to compress the venous sinuses. Additionally, owing to the potential for hematoma expansion after preoperative CT, a small craniotomy was conducted in the left supratentorial region for hematoma irrigation, aspiration, and tenting.

FIG. 2.

Intraoperative photograph obtained after removal of the EDH and hemostasis by dural tenting. The white line indicates the TS and the white dotted line indicates the SSS.

Postoperative Course

Postoperative CT confirmed an improvement in brainstem compression and no rebleeding (Fig. 3). MRI showed no new contusions. MR angiography showed no evidence of traumatic dissection, and MR venography (MRV) demonstrated patency of the right TS and sigmoid sinus.

FIG. 3.

A and B: Postoperative nonenhanced CT scan indicating total removal of the AEDH. C: Postoperative FLAIR image indicating no cerebellar contusion. D: Postoperative MR venogram indicating patency of the right TS to the sigmoid sinus.

The patient was discharged and was able to walk on postoperative day 16. One year after the surgery, the patient returned to work and resumed normal daily activities.

Informed Consent

The necessary informed consent was obtained in this study.

Discussion

Observations

We present an exceptionally rare case of an AEDH that extended bilaterally and infratentorially across the SSS. Because of the absence of brain parenchymal injury,⁷ prompt hematoma removal and hemostasis resulted in favorable outcomes.⁷,⁸ While such occurrences are rare, our approach can be relevant for cases extending across the SSS bilaterally or above and below the TS, making this a significant case report for many patients with head trauma. Görgülü et al.² reported 19 cases (2.58%) of lesions extending bilaterally across the SSS among 736 AEDH cases, with only 1 case extending infratentorially, similar to our case. In a case report by Pandey et al.⁵ describing “a bilateral occipital extradural hematoma in a pediatric patient,” radiological findings demonstrated bilateral hematoma extension both supratentorially and infratentorially, bearing a striking resemblance to our case. This observation raises the possibility that among previously reported cases of bilateral EDHs, there might be underrecognized instances of combined bilateral and transtentorial extension. Consequently, the true incidence of EDHs with both bilateral and transtentorial involvement might be higher than currently documented in the literature.² Görgülü et al.² also confirmed venous bleeding intraoperatively in 17 of the 19 cases extending across the SSS, similar to our case. Of these 19 patients, 16 had favorable outcomes.

Lessons

The surgical strategy in such cases should primarily be guided by the presumption of venous sinus injury as the source of hemorrhage.¹,⁷,⁸ This approach necessitates careful consideration of not only individual variations in venous sinus morphology, but also both the extent and location of the injury. Notably, in all four previously reported cases, with the addition of ours, emergency surgical intervention precluded preoperative cerebral angiography or MRV.^2,4–6 Furthermore, significant anatomical variations exist in the continuity between the SSS and the TS. Some patients even exhibit asymmetric TSs or unilateral SSS-to-TS drainage patterns.⁹

These varied circumstances often necessitate surgical intervention without prior confirmation of the specific venous drainage pattern or precise hemorrhage location in EDHs that traverse both the supra- and infratentorial regions bilaterally.¹,^4–6 While sinus tenting to the skull represents a crucial hemostatic technique, excessive pressure on the venous sinus must be avoided to prevent sinus occlusion and severe postoperative complications.¹,⁴,⁷ Therefore, our surgical approach emphasized hemostasis while maintaining venous sinus patency.

When time permits, a preoperative evaluation of venous sinus drainage patterns using MRV or CT venography is strongly recommended.¹,⁷ Careful surgical planning is essential to address extensive hematomas while preserving critical venous structures.^4–6,⁹ The optimal extent of craniotomy must be precisely determined for each case, with careful consideration of venous sinus locations during creation of the bone flap.

Our case highlights how important it is for neurosurgeons to be prepared for such atypical presentations and to adapt their surgical strategies accordingly. Moreover, they must pay particular attention to the risk of air embolism following venous sinus injury during craniotomy. Our surgical protocol incorporated several preventive measures against air embolism, including 1) sequential irrigation and evacuation of the suprasinus hematoma, 2) postoperative management of head position through adjustment of bed elevation, and 3) adequate maintenance of saline filling in the surgical field.

These precautionary measures are particularly crucial in cases in which direct visualization of venous sinus injury sites beneath the bone can be limited.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: all authors. Acquisition of data: Murai, Nakae, Igarashi, Yokobori. Analysis and interpretation of data: all authors. Drafting the article: Murai, Aoki, Higuchi, Nounaka, Matano. Critically revising the article: Murai, Aoki, Higuchi, Nounaka, Matano. Reviewed submitted version of manuscript: Murai, Aoki, Higuchi, Nounaka, Matano. Approved the final version of the manuscript on behalf of all authors: Murai. Statistical analysis: Matano. Administrative/technical/material support: Murai, Nakae, Igarashi, Yokobori. Study supervision: Murai.

Correspondence

Yasuo Murai: Nippon Medical School, Tokyo, Japan. ymurai@nms.ac.jp.