PAJT

CASE REPORT

10.5005/jp-journals-10030-1093 Spontaneous Decompression of Extradural Hematoma Through Skull Fracture

Spontaneous Decompression of Extradural Hematoma Through Skull Fracture Amit Agrawal

ABSTRACT It has been increasingly recognized that there is a subgroup of patients, the extradural hematoma can disappear rapidly without surgical evacuation. In present, we report a case of 65-year-old gentleman whose follow-up computed tomography scan, showed reduction in the size of acute epidural hematoma and review the relevant literature. However, we need to remember if there is no improvement in the neurological status of the patient, a follow-up scan still is needed to assess the size of the hematoma.

been increasingly recognized that there is a subgroup of patients, where the EDH disappeared rapidly without surgical evacuation.1,4,5,8-13 In present article, we report a case of an elderly gentleman whose follow-up computed tomography (CT) scan showed reduction in the size of acute EDH and review the relevant literature. CASE REPORT

Se ha reconocido cada vez más que hay un subgrupo de los pacientes, el hematoma extradural puede desaparecer rápidamente sin evacuación quirúrgica. En la actualidad, se presenta un caso de 65 años de edad, caballero cuyo seguimiento tomografía computarizada exploración, mostraron una reducción en el tamaño del hematoma epidural aguda y revisar la bibliografía pertinente. Sin embargo, tenemos que recuerde que si no hay una mejora en el estado neurológico del paciente, scan queda por realizar un seguimiento para evaluar la tamaño del hematoma.

A 65-year-old gentleman presented with a history of fall from 20'. height at 1.30 A.M. He had multiple episodes of vomiting and loss of consciousness for 1 hour. A scan done after 4 hours of injury showed extradural hematoma left parietal region (volume: 40 ml, Fig. 1). He presented to the emergency department of our hospital about 16 hours after the injury. At that time, the patient was irritable. Glasgow coma scale was E3V3M6. He had cataract in left eye. Right pupil was normal and reacting to light. He had fracture in right femur. In view of nonimprovement in his condition and early first scan, a repeat CT scan was performed that showed decrease in the size of hematoma (20 ml, Figs 2A and D). There was overlying fracture of the parietal bone (Figs 3A and B). His blood investigations including coagulation profile were normal. The patient was managed conservatively for EDH and underwent internal fixation of the femur fracture. The patient made an uneventful recovery from the operation.

Palabras claves: Hematoma extradural, Epidural hematoma, La resolución espontánea, Fractura de cráneo.

DISCUSSION

Keywords: Extradural hematoma, Epidural hematoma, Spontaneous resolution, Skull fracture. How to cite this article: Agrawal A. Spontaneous Decompression of Extradural Hematoma Through Skull Fracture. Panam J Trauma Crit Care Emerg Surg 2014;3(2):79-81. Source of support: Nil Conflict of interest: None

RESUMEN

INTRODUCTION It has been estimated that acute epidural hematoma (EDH) accounts for 1.5% of patients treated for traumatic brain injury and the lesion can be potentially fatal, and urgent surgical intervention is recommended.1-7 However, it has

Professor Department of Neurosurgery, Narayana Medical College and Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, India Corresponding Author: Amit Agrawal, Professor, Department of Neurosurgery, Narayana Medical College and Hospital Chinthareddypalem, Nellore 524003, Andhra Pradesh, India Phone: 91-8096410032, e-mail: [email protected]

Spontaneous resolution of EDH has been reported in all age groups.5,9,14 Usually, the spontaneous resolution takes place in weeks and rarely in days,2-4,9,14-16 but in rare circumstances the EDH can resolve within hours after trauma.5,8-10,14,17,18 The mechanisms responsible for the spontaneous resolution of the EDH in acute stage are entirely different than that of chronic resolution.5,9,14,17-19 The mechanism behind chronic resolution of EDH is that there is formation of fibrovascular neomembrane and granulation tissue, acting as a semipermeable membrane like absorbing structure through which there is transfer of the clot into diploic bone or extracranial space through the fractures.2,3,6,8-10,14,20,21 In acute, the reduction in size of the EDH occurs though overlying skull fracture causing transfer of collection to the subgaleal space.8,14,18,22 It is further facilitated by increase

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2014;3(2):79-81

79

Amit Agrawal

Fig. 1: Computed tomography scan performed at 4 hours after injury, showing a large epidural hematoma in the left parietal region (volume: 40 ml)

A

B

C

D

Figs 2A to D: Computed tomography scan brain performed 18 hours after the injury, showing reduction in the size of hematoma (volume: 20 ml) with increase in the size of subgaleal hematoma

in intracranial pressure that creates a pressure gradient and forcing out the clot from epidural space to the subgaleal space through the fracture. 3-5,8-10,18,19,21,23 The most appropriate management modality for the management of EDH is determined by the size and neurological status of the patient.1-4 However for smaller lesions, careful followup, monitoring, and nonoperative management have been recommended.3,4,6,8-10,14,17-19,21,23 In view of smaller size and further reduction in clot volume, a nonoperative management

80

was offered to the patient. The learning points in present case include that not all extradural hematomas will increase in size over a period of time and although rare in contrast to this, in a subgroup of patients the size and volume of the hematoma can further decrease. We need to remember if there is no improvement in the neurological status of the patient, a follow-up scan is still needed to assess the size of the hematoma even an early CT scan was showing a significant size of extradural hematoma.

PAJT Spontaneous Decompression of Extradural Hematoma Through Skull Fracture

A

B

Figs 3A and B: Computed tomography scan bone window and three-dimensional reconstruction, showing extensive fracture of left parietal bone

REFERENCES 1. Deniz FE, Turk CC, Ismailoglu O, Bozkurt G, Ozcan OE. Rapid spontaneous resolution of epidural hematoma: a case report. Ulus Travma Acil Cerrahi Derg 2010 May;16(3):280-282. 2. Pang D, Horton JA, Herron JM, Wilberger JE Jr, Vries JK. Nonsurgical management of extradural hematomas in children. J Neurosurg 1983 Dec;59(6):958-971. 3. Pozzati E, Tognetti F. Spontaneous healing of acute extradural hematomas: study of twenty-two cases. Neurosurgery 1986 Jun;18(6):696-700. 4. Weaver D, Pobereskin L, Jane JA. Spontaneous resolution of epidural hematomas. Report of two cases. J Neurosurg 1981 Feb;54(2):248-251. 5. Dolgun H, Turkoglu E, Kertmen H, Yilmaz ER, Ergun BR, Sekerci Z. Rapid resolution of acute epidural hematoma: case report and review of the literature. Ulus Travma Acil Cerrahi Derg 2011 May;17(3):283-285. 6. Wagner A, Freudenstein D, Friese S, Duffner F. Possible mechanisms for rapid spontaneous resolution of acute epidural hematomas. Klinische Neuroradiolgie 2002;12:45-50. 7. Taussky P, Widmer HR, Takala J, Fandino J. Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience. Swiss Med Wkly 2008 May 3;138(19-20): 281-285. 8. Aoki N. Rapid resolution of acute epidural hematoma. Report of two cases. J Neurosurg 1988 Jan;68(1):149-151. 9. Kang SH, Chung YG, Lee HK. Rapid disappearance of acute posterior fossa epidural hematoma. Neurol Med Chir (Tokyo) 2005 Sep;45(9):462-463. 10. Kuroiwa T, Tanabe H, Takatsuka H, Arai M, Sakai N, Nagasawa S, Ohta T. Rapid spontaneous resolution of acute extradural and subdural hematomas. Case report. J Neurosurg 1993 Jan;78(1):126-128. 11. Sinha AK, Parmar C, Ahmed S, May P, O’Brien DF, Buxton N. Spontaneous resolution of a small extradural haematoma in a child. Cent Eur Neurosurg 2009 Feb;70(1):52-54. 12. Neely JC 2nd, Jones BV, Crone KR. Spontaneous extracranial decompression of epidural hematoma. Pediatr Radiol 2008 Mar;38(3):316-318.

13. Onal MB, Civelek E, Kircelli A, Yakupoglu H, Albayrak T. Reformation of acute parietal epidural hematoma following rapid spontaneous resolution in a multitraumatic child: a case report. Ulusal travma ve acil cerrahi dergisi = Turkish journal of trauma and emergency surgery. TJTES 2012 Nov;18:524-526. 14. Servadei F, Staffa G, Pozzati E, Piazza G. Rapid spontaneous disappearance of an acute extradural hematoma: case report. J Trauma 1989 Jun;29(6):880-882. 15. Chen TY, Wong CW, Chang CN, Lui TN, Cheng WC, Tsai MD, Lin TK. The expectant treatment of ‘asymptomatic’ supratentorial epidural hematomas. Neurosurgery 1993 Feb;32(2):176-179. 16. Sakai H, Takagi H, Ohtaka H, Tanabe T, Ohwada T, Yada K. Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 1988 Apr;68(4):566-570. 17. Akagami R, Cochrane DD. Does it leak in or does it leak out. Concerning the article by Malek, et al. Pediatr Neurosurg 1997;26:160-165. Pediatr Neurosurg 1999 Feb;30(2):109-110. 18. Malek AM, Barnett FH, Schwartz MS, Scott RM. Spontaneous rapid resolution of an epidural hematoma associated with an overlying skull fracture and subgaleal hematoma in a 17-monthold child. Pediatr Neurosurg 1997 Mar;26(3):160-165. 19. Celikoğlu E, Süsülü H, Delatioğlu M, Ceçen A, Hakan T, Bozbuğa M. Rapid spontaneous resolution of an acute epidural hematoma. Ulus Travma Derg 2002 Apr;8(2):126-128. 20. Sato S, Suzuki J. Ultrastructural observations of the capsule of chronic subdural hematoma in various clinical stages. J Neurosurg 1975 Nov;43(5):569-578. 21. Ugarriza LF, Cabezudo JM, Fernandez-Portales I. Rapid spontaneous resolution of an acute extradural haematoma: case report. Br J Neurosurg 1999 Dec;13(6):604-605. 22. Chan KH, Mann KS, Yue CP, Fan YW, Cheung M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990 Feb;72(2):189-194. 23. Tataryn Z, Botsford B, Riesenburger R, Kryzanski J, Hwang S. Spontaneous resolution of an acute epidural hematoma with normal intracranial pressure: case report and literature review. Child’s nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. Childs Nerv Syst 2013 Nov;29(11):2127-2130.

Panamerican Journal of Trauma, Critical Care & Emergency Surgery, May-August 2014;3(2):79-81

81