Bifrontal Mirror Image-Like Extradural Hematoma: A Rare Entity

Abstract

Extradural hematoma (EDH) is a collection of blood between the dura and the calvarium. The most common cause of EDH is road traffic injury. The most common age of presentation is 20 to 40 years. The EDH can cross the midline, unlike the subdural hematomas. The source of EDH is mostly arterial. It can bleed from the venous source like the midline sinus as well as from the fractured bones. EDH is mostly present below the fractured bony segment. Presentation of a bifrontal mirror image-like EDH is quite a rare occurrence. We present to you a 24-year-old male with an alleged history of road traffic accident followed by altered sensorium with three episodes of vomiting. Imaging of the brain was done which was suggestive of a bifrontal mirror-like EDH with a depressed fracture in the midline. EDHs are acute emergencies that should be managed with utmost care and prompt decision of surgery. The decision of early surgery can save the patient from prolonged mortality or morbidity.

 

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Keywords

craniotomy - depressed skull fractures - extradural hematoma - skull bone fracture - traumatic brain injury

Introduction

Extradural hematoma (EDH) is a collection of blood between the dura and the calvarium. It is seen in 10% of all traumatic brain injuries. The most common cause of EDH is road traffic injury. The most common age of presentation is 20 to 40 years. This is less common in old age due to the formation of dense adhesions. The other causes of EDH are coagulopathy, infection, tumors, etc. As per the location, 75% of the EDH is seen in the temporal region. The EDH rarely crosses the sutures due to the strong adherence of the dura with the sutures. The EDH can cross the midline, unlike the subdural hematomas. The source of EDH is mostly arterial. It can bleed from the venous source like the midline sinus as well as from the fractured bones. The EDH presents with lucid interval which is seen in 20% of the patients. EDH is mostly present below the fractured bony segment. Presentation of a bifrontal mirror image-like EDH is quite a rare occurrence.[1]

 

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Case Presentation

We present to you a 24-year-old male with an alleged history of road traffic accident followed by altered sensorium with three episodes of vomiting. The Glasgow Coma Scale (GCS) at arrival was E3V4M5. The patient was managed as per the Advanced Trauma Life Support guidelines followed by a head-to-toe examination. FAST (focused assessment with sonography for trauma) was negative. Computed tomography (CT) imaging of the brain was done which was suggestive of a bifrontal mirror-like EDH ([Fig. 1A]) with a depressed fracture in the midline ([Fig. 1B]). He was planned for surgery on an emergency basis. A bicoronal flap was done followed by a bifrontal craniotomy plus EDH evacuation ([Fig. 2A]). Postoperative brain imaging was done which was suggestive of postoperative CT changes with no residual blood ([Fig. 2B]). The postoperative recovery was uneventful with the patient discharged on postop day 5.

Fig. 1 (A) Noncontrast imaging of the brain suggestive of bifrontal mirror-like extradural hematoma (EDH). (B) Depressed fracture in the midline of the calvarium.

Fig. 2 (A) Intraoperative picture of bifrontal craniotomy plus extradural hematoma (EDH) evacuation. (B) Postoperative computed tomography (CT) brain is suggestive of postoperative changes with no residual blood.

 

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Discussion

EDHs are acute emergencies that should be managed with utmost care and prompt decision of surgery. The decision of early surgery can save the patient from prolonged mortality or morbidity. The indications of surgery are a large volume of EDH which is more than 30 mL, a posterior fossa EDH, and GCS of less than 9 with pupillary abnormalities like anisocoria. The most common location of EDH is a temporal region which is supratentorial and unilateral. Posterior fossa hematomas are less common. Midline EDH is quite rare. Bilateral separate EDH is quite a rare phenomenon and not many cases have been reported in the literature. The rarity of our case is the mirror-like bifrontal EDH, and the location of the EDH is away from the depressed fracture segment of the bone.[2]

 

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Conflict of Interest

None declared.

Acknowledgment

We acknowledge SOA University for the unconditional support.

• References

• 1 Senapati SB, Acharya A, Puppala S, Mahapatra AK. Book craniotomy: modified craniotomy for midline extradural hematoma. Patient series. J Neurosurg Case Lessons 2025; 9 (17) CASE2518
• 2 Dhilsha P, Gupta P, Pandey S. et al. Post traumatic mirror image basi-frontal extradural hematoma – An unknown enigma and review of literature. Interdiscip Neurosurg 2022; 27: 101334

Publication History

Article published online:
27 August 2025