Keywords
extradural hematoma - posterior fossa - craniotomy
Introduction
Extradural hematoma (EDH) is one of the life-threatening conditions needing immediate
neurosurgical intervention. Occipital and posterior fossa EDHs are not uncommon, with
the incidence of posterior fossa EDH being 10 to 11%.[1] Combined EDH (CEDH) of supra- and infratentorial regions are rare[2] and difficult to diagnose due to their nonspecific symptomatology and small volume
but can cause sudden death.[1] CEDH are less described, and extension of the same into the temporal region has
not been described to the best of our knowledge. An unusual case of CEDH of supra-
and infratentorial regions with left temporal extension and its management is being
described.
Case Report
A 28-year-old male patient presented to emergency services with a 2-day-old history
of roadside accident. After initial conservative management from the referring hospital,
the patient presented with progressive drowsiness and irritability. Computed tomography
scan of head revealed posterior fossa EDH over both cerebellar hemispheres extending
to the bilateral occipital and left temporal regions. There was associated bifrontal
countercoup contusions and mild ventriculomegaly secondary to fourth ventricular compression
([Fig. 1A, B]). The presenting Glasgow Coma Scale (GCS) was E2V4M6 and pupillary asymmetry, left
being 4 mm nonreactive and right being normal. Surgical evacuation of CEDH was done
by putting the patient in park bench position under general anesthesia, enabling access
to all the involved regions. The incision extended superiorly from the midline suboccipital
region in a hockey stick fashion to include the bilateral occipital and left temporal
regions, enabling three separate craniotomies for evacuation of the CEDH ([Fig. 2A, B]). In view of fourth ventricular compression and hydrocephalus, suboccipital craniectomy
was performed. The source of bleed was from torcula/adjoining transverse sinus for
which a thin strip of overlying bone with adherent firm clot were left behind. Rest
of the CEDH was evacuated by a bilateral occipital and a left temporal craniotomy
([Fig. 1F]). Linear fractures were noted over the left lambdoid suture and the suboccipital
region ([Fig. 1C]). Postoperatively patient attained normal GCS and pupillary reaction with satisfactory
postoperative imaging ([Fig. 1D, E])
Fig. 1 (A) Axial computed tomography (CT) showing bilateral occipital and left temporal extradural
hematoma (EDH). (B) Axial CT showing posterior fossa EDH. (C) Three-dimensional (3D) recon image showing linear fracture over the left lambdoid
suture and the suboccipital bone. (D,E) Postoperative axial scan showing evacuated occipital, temporal, and posterior fossa
EDH. (F) 3D recon image showing suboccipital craniectomy, and bioccipital and left temporal
craniotomy.
Fig. 2 (A) Park bench position with hockey stick incision. (B) Intraoperative image showing suboccipital craniectomy (gray arrow), bioccipital craniotomy
(green arrow), left temporal craniotomy (white arrow), and fracture line over lambdoid
suture (blue arrow).
Discussion
The term bilateral EDH signifies occurrence of symmetrically or asymmetrically located EDH on either side
of the brain, which occurs due to dural detachment at two different locations by a
single impact. Ipsilateral double EDH, on the other hand, can be described as two
noncontiguous EDHs on the same side. Multiple EDHs refer to the situation where there
are more than two EDHs present in different territories.[2] The incidence of bilateral EDH varies from 2 to 25% in different series, and its
presence at more than two sites is rare.[3] Bilateral hematomas are usually due to venous or arterial bleed, the former being
common but delayed in nature.[1] Bilateral EDH is predicted to occur in majority of the cases, with the trajectory
of impact in the anteroposterior direction, which leads to stripping of dura as a
result of inbending or outbending of the skull.[4] The contralateral dural stripping is a result of motion of the skull, aggravated
by the negative intracranial pressure found at the antipode of the compression force[5] and extension of fracture line across midline. All these mechanisms can lead to
mixed arterial and venous bleeding, the latter due to disruption of emissary veins,
sinuses, and venous lakes. In the present case, the anteroposterior impact has led
to linear fractures involving the left lambdoid suture and the suboccipital bone,
with probable cause of bleed from the torcula and adjoining sinus, which led to the
CEDH formation.
Bilateral epidural hematomas present with high incidence of loss of consciousness,[6] the incidence being as high as 98% in some series.[4] However, Dharker and Bhargava[7] mentions 30% cases with GCS less than 8. Feuerman et al[8] reported asymptomatic acute bilateral epidural hematoma in a case with minor head
trauma. The present case maintained a GCS of 14 to 15 for 2 days, which worsened to
GCS of 12, warranting a referral to tertiary center. Since mortality associated with
bilateral hematomas is high,[2] surgical intervention is recommended at the earliest. To the best of our knowledge,
bilateral supra- and infratentorial EDH with extension into multiple territories has
not been described previously. Hence, the present case is unique where the EDH extends
into supra- and infratentorial regions with another EDH in the temporal region. Delayed
deterioration suggests the bleed to be of venous origin, which was confirmed during
surgery around the region of torcula.
Simultaneous bilateral craniotomies and fast evacuation of epidural hematomas has
led to good outcome in the past.[2] There is a description about evacuation of bilateral parietal EDH through single
bicoronal incision and bilateral craniotomies.[9] In the present case, a single hockey stick shaped incision was made to evacuate
the CEDH with further extension into the left temporal region for the third craniotomy
and EDH evacuation. This reduced operating time, with prompt relief of compression
and immediate postoperative recovery. To conclude, multiterritorial EDH involving
supra- and infratentorial territories is a rare presentation that should be evacuated
at the earliest. The planning of incision and the placement of craniotomies has to
be executed based on the radiological findings and the possible source of bleed.
