Keywords
craniotomy - epidural hematoma - fall - hemostasis - vertex
Introduction
Vertex epidural hematoma (vEDH) is a rare type of intracranial hematoma, which accounts
for 0.024% of all head injuries and 0.47 to 8.2% of intracranial hematoma, with high
mortality rate of approximately 50% if not detected early.[1]
[2] It is commonly caused by linear crossing skull fracture over the sinus caused by
direct insult to the vertex or diastasis of the sagittal suture. Other possible cause
is tear of superior sagittal sinus (SSS), post-surgery.[1]
[2] vEDH can be presented with nonspecific symptoms or signs, acute or chronic presentation.[1]
[3] vEDH radiological features and diagnosis are challenging because of its higher location
that can be missed if radiologist takes a large cuts and also because of its similarity
in density to the surrounding bone.[1] So, thin-slice cuts of computed tomography (CT) brain with coronal and sagittal
cuts reconstructions were advised or even requesting magnetic resonance imaging (MRI)
brain.
Discussion
vEDH is a relatively uncommon entity that accounts for 0.47 to 8.2% of intracranial
hematoma, with high mortality rate of approximately 50% if not detected early.[1]
[2] vEDHs are EDH occurring in the quadrangular area of the skull, bounded anteriorly
by bregma and coronal sutures, posteriorly by lambda and lambdoid suture, and laterally
by the parietal eminence.[4] It is commonly caused by linear crossing skull fracture over the sinus caused by
direct insult to the vertex or diastasis of the sagittal suture. Other possible cause
is tear of SSS, post-surgery.[1]
[2] In our case, source of bleeding is from draining veins into SSS as no dural tear
was seen over the SSS.
vEDH usually has nonspecific features, hence making it difficult to localize clinically.
vEDH may have acute or chronic presentation; headache and vomiting are the most common
symptoms. Paraplegia and hemiparesis can also be seen owing to compression of motor
homunculus where upper limbs and lower limbs lie in close proximity.[5] Our case presents with headache and bradycardia most likely due to increase in intracranial
pressure.[1]
[3]
vEDH can be difficult to diagnose in CT especially if CT is taken in large cuts and
no sagittal or coronal cuts is taken. In axial cuts, vEDH can be seen as vague hyperdense
area in highest cuts. Therefore, thin CT cuts, sagittal and coronal cuts should be
taken in a suspected case of vEDH. MRI scans are very useful in diagnosing vEDH, due
to multiplanar capability and lack of bone artifacts. However, the MRI is not used
routinely because of the longer time taken and higher cost.[2]
[5] In our case, CT was done that showed fracture line over the vault of skull, diastasis
of sagittal sinus, and vague hyperdense area in axial cuts of CT in highest locations.
Management of vEDH varies from case to case. It depends upon location of hematoma,
size of hematoma, clinical presentation of patient, and rapidity of evolving of vEDH.
Small hematomas can be managed conservatively. Broadly, the indications for surgery
in the case of vEDH are deteriorating consciousness, features of severely increased
intracranial pressure, features of focal neurological deficit, and hematoma measuring
more than 30 mL in volume.[6] Surgical management consists of craniotomy with complete hematoma evacuation with
hemostasis using hemostat agents like gelatin foam or using dural hitch stitches.
Conclusion
vEDH is a relatively rare entity and in suspected case of vEDH one should always get
thin cuts of CT along with sagittal and coronal cuts. When operating on such cases,
surgical team should prepare for possibility of massive blood loss and shock.
