Bilateral occipital epidural hematomas

Bilateral occipital epidural hematomas

Bilateral Occipital Epidural J~,n H It~,ber~.~on, M.I:,," \tL Craig C:ak, Ph.D.." and Jame~ I), A~kv), M,D/: ~ , ~ ,a-c~ d bilateral ~)c~ipilal g~idu...

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Bilateral Occipital Epidural J~,n H It~,ber~.~on, M.I:,," \tL Craig C:ak, Ph.D.." and Jame~ I), A~kv), M,D/:

~ , ~ ,a-c~ d bilateral ~)c~ipilal g~idur,d hvmaloma arc rrescnied. Clinical findmgs, re~utln o# ~)nlgiographv and c,miptllvd tomograp|B, and opcraiis¢ managcm~'rli are db.-

"~*hc ]~)crat~;)c ), ~cplelc ~v)dl rcvwx~. ~i exlradllr d h c m a t,,m.~., lh~')t v,trv.n; ,~mwaJ t.l~>enl~tums, and v,¢i~.)s pni'*)wd ,]i,~no-~,. a)~,:~~v,,)mcnl mcth,,d-{7+ ] | ~ , 14, ]'}- ~ ~, J~ r~\ct~| )cvl{~ ~]!thl~ hf+crattllc )excalvd l}]at appn,x :ma~ Iv 7% ,,1 ~hc,~. heT)t |{,~]la**~Kt ~ttteJ i|) the ~a**,;Ipt),)I a~ca : 12 l, vulh ¢|w ,aHv ~,p.)rwd ~aws ~ bila)era] ex~ ~iadt~ra] hct))i|~)ma vlt]wr i~)I 111 the' ~.'~iI, ltal area t | 7 j or ~he ~eporr hawn; l~,'cn made lwli)rc die aJvcnt ~ff¢tmalvated ~,ml, i i | p a t i e n t s with .,t,o:c,,,,ii~|lr Ilt%ale~J bdiwr,d ~'cltmal epidmal helltalollla, al{l~ With a disCti~iOl: Ol ¢limcal l'-rcscmati, m, )he Iltlr~lrGtllC¢ (~|" ,ll',iil'~Til),~)|~il~i~ ~'D,',f'¢ll arlerial and venous, r.t)t.)r~,'t',, ot hem,,~fl~e. ~c-u!t~ ,~t m~i.graphv and (:T %arming, and t

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Case Rep.orls Pa:)o t * A ~5.vearoold man. a kru~wn dm~nic alcoh~)lic, was rrans)c:rcd ~r~n~ am ~mlyiB~ h~-pmd fig neur~urgica| cvaluaturn d~rcc days after he 1}I1 and injured his head ~hite d r m k m c N~ records of previous hi~orv w c r c available at the time ~ff uansDr clarifying the nature of lhe injury. Pby~cat examinati, m P..vea|ed an t~.'¢irilal contusion ofd~e ,-.;dp, m)ch;d rigidiB, intermittent dvsc~m~ugale gaze. and a sluggi~h, plIw~)~efu{ r¢ff.on~a.' to pain m all exil~mifics, F,~em'gcno-grams ,4 the skull shmved a bilateral, commi. nutted, tran~ver,e ~:¢ipital ~kuI! ~acture, A {_~ scan &me without ¢omrast aKem demonstrated a locali:ed, biconvex or lemicu|ar epidural hematfnua ,dhowiug a iJnifi~nn high

dcn.i~v ;md ~r,~sing the midtmc in 0~e ~ug¢ipilal region, w~d~ an as.-,~iqa~ed mtraDarenchvmal hcma~oma in d~c ~cmr~m~l area tl:ie~ 1), An~:l~,graphv c~,mrmed dlesc ~indm~ (Fi~ 2L C)pcratBc management involved two nepa~atc surl~ical exD)su,cs, ]niliallv, a n g h t lempora] crame~lbtemD,ral sub. dural hemamma was idemi)icd and ret:u~ved along wifl/a larger p,>ieti~)r ~emDmd inlraceR.bra| hemat~m, ao F,)lh)w)ng ¢lmure ~f the {em~)rad exp,~>ure, am:mion wa~ directed I,) )he large, Blh{cr.d ,~:cipiral cpiduraJ [aetmm,ma. A midhBc iB~Isum m the ~.:cipital r¢~um was carried a}~x'v flw lambda and b.,h)w t|~e external ~vcipi)ai pr~m|wrat~ce. A bi~,ccipital cram()wmB; f~ee Nine flap wa> fashioned by Dla(emenr ~4 burr h~)lm bilaterally ak~)ve the lamb&~idat sutures and ~mnsvcrsc sinus~:~ (Fie. }A). A Iarec, bloccipilal epiduial hemaroma was carefi~llv removed from the dura .~ater ro the level of d)e Iransver>~: silutse~ and t~rcular Her~}plnli, No active s,)ur¢c ,g bkx.din~ could be idemifit-d, An oreanized hema~oma overlyi)g the malor sinu~s was DarfiaIb¢ rcm~wcd+ leaving a d~m laver {ff hematoma d~a~ pn}vi&x] excdlent hcln~)stasis. Milu)r cpidtttal bleedilg was managed m a standard fashion witl; primary hemostasis provided by dural t~ckmg ~umres O~at obliterat~-d the cpidural :.pace. Po~uT-vralivclv die patiem showed sk~" neurological recovery But withou~ comphcatio~s. ~ r c e ~ecks after the {T~-ration, he was ambulat~B ~ with minimal assistance, e.pcaking gifla mitd dysphasia, and .qaowed no fivca] weakhess. Further lone-term recoveB' was uneventful.

Paii<))t 2 A $2~year-old male aIcoh{)lie reD~rtedly felI backv:ard from his &~,)rstep tm t|ae day of admi.~¢.ion and struck the {+zcipi+ tal region of his ~alp+ He had a transient toss of con~ious~ hess with confusion and was taken to a I{Kal hospital by his ihmily, Initial evaluation indicated an alert, di~arientexL agitated man with no focal weakne~ After he was trans~ termed m our medical center, ~}~ica| examination revealed a stuwamm individual who a~kened m verbal and painful N~u~,~u)gx,t),. I mve~)v¢~ffTem~e~,~.{k~te) f,n the Hea|di ~tet)>ce~, stimuli, ]F~at la~.ed into mmndemce in the absence of '156 t2~lwt Ave, T;'-¢JSI6L stimulation A bilate~a| ~:alp c~nm~on with swelling was pre~nt, Clotted bl~.a~d,*:as not~d in ~ e left external audiKeS ~'(~*d~:epiduralhema¢~; hemalt~ma;~*a,gipiu|hmau~nna.

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xk~d| {mc~.~re<'×lending m |he R}ramen maR~um t,~ ~°an. hcmamma. The ini~iai } ~ 4 da~,',~gho~pitaIi:a~i~n dmwoed n~ imp~,vement in I]w pa~icn~'~ ~g om~'i~mmex.-, d~>pi~e a ~g ~a~a|i:ing neund~lca~ d~qugiL |~\~au~v dini~a| cvi&.n~e ~g ~he d¢~'d~men~ ~4 ¢or~icaI bhndne~, fiarIhe~ diaRl~o~lic~Iudiea wel¢ ul~d~,~Iak~'I~ A ¢etehFa| al~-

emg~am de~uu~wated a ma~,.re, biparivIal ~veipita~ q~i and c~nlI~em~m~.> mvay ~;,m~~he mn~.r ~abl~ ~d ~l~e,-k.ll O;~g, 4).

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1he *:pid~a~ ,~pa~:ewi~h app|~a{utn ,ddura| {a kin~ ~u{~m~,, Pmmp~-rgmw,ly, lh~"pa~en* expe~ie~'ea n~pid]yimpn~v~ng aeumh~gi~a~ *b~'~i~m ~i{h ~u~ e~mpikali~ms By ~he ~hi~d De,~**%'m~iveday, he wa~ aul,~a|a~{~-4, ud,:ra{in,4 a


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diet well a~d functkming without assistance. Recovery was complete and uneventful

lm~:h. (B) [email protected] ~M;4uevWw~ffthe'skull ~,,uq~ dyerdation~hq, bclwec, the ~,we fl.q~, du~d ~i~use~. m~l l,*swncn"fi~s~ sm~cmre~

Discussion Epidnral hematonm may be arterial or venous in origin. A disrupd~m of the meningeal arteries or veins, major dural sinuses, or diploic channels pro,rides a umrce for the epidural accumulation of b l ~ L The rote of accumulation and the kx:ation of the hematoma arc major factors in the developing clinical picture. The m¢~t common bleeding site for arterial eptdutal hematoma is the posterior branch d the middle meningeal artery 191. The classic course that ~bllows disruption of the middle meningeal attee; involves rapidly accumuIating hemamma with early" medial uncal displacement. (_~m~nsation t;or the enl~ging rna~ is prohibit~J by the rapid functional aqueductal c~:clusion thac occurs, which prevents the lateral ventqcl¢~ from colla~ing. Progre~ive &mndation occurs ~hether or not a lucid interval has ~een pre~nL and a high mortality, rate is coramon [ 12]. In contrast, when epidural hematom~s cx:cur as a r e . i t of venous bleeding ~om the diploic veins of the calvarium or dural sinu~s, the brain and cerebrospinal fluid c ~ a n e t s have mote time to a c c o m ~ d a t e d~e int~craniaI ma~ and herniation is less likely"[18, 201. ~cause comi:~nsation for the enlarging ma~ ma~"~ c u r , the neumlogi~l symptoms Fig. 4. The ~ e t ~ c ~ l p i ~ tx~don ~¢ i~_.~#ttal s ~ is ~splca:ed and si~s may' ~ vague and of late onset [4]. ~ i s com- &m* {armw~).in~4dcagng~n c3~duratfm,~s~. F~r~tion ~ ~rticula,-ly c o m ~ n in ChiMren ~ a u ~ their dura mater is easily s~ipped from the inner table of the skull

Robe+~+~m¢~ aL ~.X++pmd EpM~md Hcma+,,m+++ 471

t lO|+ This di+pk+zement d a du+at +i~u++mhieh irvdiea~e+-an @idu~a| |~+atkm+ is ..+man~mior the identification iff a ski+|| rearm+ and its characteristics+ If a t~ctme |i~e exfel~ds acl'o~.;the middle meningea| gr~.we or a maB+t v¢ncm+ sinus+ this mag in-|is care a developing epidum| hematonu~ ~+e absence ~ff a visible l%acmre on plain x+m+"films +af the +~kulIwii[ met+ ht+wevet+ eliminate the g>+ibi|ity ~ffan cpidum| hemat~mm in a traumatized g~tiem+ ~ t h Of the patienes d.e~ril:~+.~demo++++r.ated mtahip}e bilateral fn+cmres of d~e ~i+u+~'++a ++",+taNned venm+ and anmial ++.~mmeof Needing is a ~s+ib+llty+ Angi i¢ signs that have ~er+ rcr~rl~ with eNdund hematoma include amputation of the migdie meningeal a~te~++extravamtkm of the meningeal aIte~++stdural sinus+ 6aunation of a ~:u&+a~ag+m on the middle meningeal artery++and s~ipping ~gth¢ dural si,+m++.s(as a|~+ memioned in g-+iS~ } isle pIW i+ eu>w¢~+~id+ et~J the prefe+ed mdiokgica| didies+tie p it+ a t m u + t i : e d ~+ient with a head inju~" | |+ 2+ 6, 16} Get+ d o ~ and a + g i a t + [31 concluded that the improved re~lts in the ~reatment ~+f+epid~nd hemammas ~ere .~:ordary to the rapid and accurate definttkm ~ff }vemat+.~as and a~.o*=iated lesion+ provided by CT ~c;m+ ning+ Akhough a ven~m epi&mI hemator~m may be 2 m 3 weeks a~er injur~"a~d ~%+ b.,: i,~*Jen~ t+r h}+p,>Jen~+ nearly a|| epidum| hemamma~ a~e deter:ted during die acute a~d are {he.fore | m on C ~ examination+ Since the eNdura| hemau+ma is limi+o3 b~' dura| attachments and ~utuPes+ the |eio+~ is &~:a| in h~a+ lion and thetefo~e biconvex ot [entieu|~ in ~ap:+ Ektct+ minati~n d ¢onti~aity d the hematoma re+ the adjacene ~ n y calvafium, with the ab~nee of + u ~ n d i n g low at+ tenuadon in the brain ~renehyma+ differentiaes the epidum| h e c t o r e d ~ m in~apa~enehymN h e ~ h a g e ~ ~ e non|c
b,me +|ape bul m~+r+imf~++tamlv+rec~+~t++iti,+++of +he m+¢ce ~ffbl~ding m+that it ran lw ¢~mm+|k:d+ Us+liket|+e ¢pi&+a| ht:matonla ,c+af|e+ial ori~i+Lthe vv+~ol+sepldt~ta| |+,etnaIolt+a midst N: app~md~ed with a lh~r,m~:h +mde~andm~: ~+|+{he int+a¢+a+~ia| re+urn+ anahm+y+ ~+e m+alomic.d rc|ati,m+l++p +ffdie external toDmt +r}w +4 the ,.ku|| t~+the mail+ vc+m~+ +inu.~ a~d ~up++al,~'~totialat}d |nf~atel++t~|a|,maeturc~ ~m,l he dated C,<+eF+g+ 3BL ;am imI'+++l++N,++e +lap ++m|d mean ~+p:mtived~+~++tst+ k~,~+ratixx+¢×p~k.+tca+ro+, the silt,|+ li++ ~4 ~he epidural s[uce i+ ~eed,c~Jfor a hemaroma o++g+ inatin~ from the sa+:it~;d mt~+ ++ ttwcu|ar Here,phi|i+ ~+hereas a unilateral fn+¢mrc ~+vetlv+ngan i++j~r++ + to the lint+rePro, sinu,~may require ontC a limil~x||'~me flap+ In the two pa+iem.xd~-.+.'+d~ed, a bilateral ~m¢,pilal |xme limp wax used to ptovi& a~¢¢.~s t~+ the m+dliue ,~a~itta| sinus and to easily vbtmli=e the t~an+ve++e sinu>v+ and t~+r+uh++ Her~+phili A fi+l| ~md++++~ta++dmg+ff rile sop+d+ of vote+ms +i,~us hi+t+++ a+ d+~~ ~f the ~+r~:a++i:ed hematm++a +l~m|d N: remov~-d with a I+e+ ~4 ~+~:ai+i:ed hematoma leh m+e~{he YCmm+simls to l~,Wide tt~mm~asi~ 7lie us: ~,f heInmtaI{+ re+duels in=++ &,t+:iee| Gelfi++m+} hel~, i+ c~*ntu+lhn~ ~mci,++:~+f bhm+d +hem the epidura| s[m+ce+Nit t i e r+mm+ mcdu~ ~ffhem,r,~a++ +h,mld alway+ corr,/~t rlm+eme+~+~ffdum| tack/rig m+t~m+t~* t+b|i+crate +he epidum| ~paee meg preside a mmDmade effc~++ C~d~iun Bilate~l ~:cipita| epiduml hemat,m~a *~T+e~:n*~~m ,mo~ual and i~hcquent p~emntation of ~iduml henu+nhlg¢+ ~ e imF~ant features~ffthis ¢~mditkm Milch d~mld be e m ph~i:ed inch®de: ( I} ~e¢,~nilkm ~ff ,hc r.~lentml for a~,~te a~d delayed cpiduml he+n++t+hag+and its di+,ical preach|a+ ti~m +he+ fracture li++~+invoNx+the maj;+ dural si+u++; {2) ~ 0 ~ ¢ +|ilia+Ibm {+f diagn~+li~: an+de+, pa+tmula+[y G~+ ~a+ning i+ h+th the acu+e evalua+um ard ,a+he~ the+e b a p~*o~essi.on +>l+ neumke.:ieal d,:l{¢il. ++r fi+i|ute t~+ imp~wei a~d (3} ~ under+rending of the +++¢k+alanau+my and of (he imp,trance t+f i~iunc~ in the ~mcipita| te~:mn that ~ S +invdve the m:ajt~ v ~ + a ~ simi~:~


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~:¢a~h,m: k }~re}iminan*g ~ m " by O } D~.hnnann ;rod j~ M Rubh~ { 16:362,-36G 198D, w~th interact The~e hax nev¢~ ~ e n any d, mbl in mg mind d~aI trm~dora} uh~a,~md has ~*eat h~a|iaim~ vahu2 inmu~.mmx4y The mt~h~ ~*iG:~:r~o b~b|h~graphg }~e~their" i~ vae-I|i~eraIu~¢~m this l~mic. ~ e tq,md&~&~gC&~icdUl~.~.und edited by M, de* \qie~Ie~ {New Y~k: Wi|(~*. 1979, pp 7~9-778). i'- a mind tef~.

Reply ~ t ~eh~ m ~he t¢~hnique~ men~i~rux~ in his h~ter, c~,.~en. ~i~IIy ehe ~mb; ~h~fi~ariW F , v ~ r ~ o~r ~e
J ~he wh~,| wi~h their s~a~emen~, "h Iub di~lay ¢apldly b~th m ~ l and abnorma| anatomy h~ any ~rienm~mnd] has ~or b,.en klcntificd as havin~ a n4e in the neem,m~- lati~+n he or she ehtm¢~*:s+Fu~her. ~he images a+e dilaitaL all,~wln~ gka[ ~,pcm~ing u~,m." ~ e slatement i~ not ¢r~e and ~Rncaespt,:. the myri:~l manipula~i~ms one ca,~ Fed~tm in d~ism~-di~ v i ~ pub|ishers o~ this mpie~ Gemge 3~ D~km~m;~, M D ~ Ph.D.~ "There ~s n~thin~ new under ~he ~n" (Eerie/~

a~lJ,~a~han M. M D ~ P£D. K~¢r P>& M D

FoA C S.