Spontaneous acute epidural hematoma associated with chronic subdural hematoma due to dural metastasis of gastric carcinoma: a case report and literature review.

Background: Non-traumatic spontaneous acute epidural hematoma (EDH) happening to chronic subdural hematoma (SDH) caused by dural metastases is a rare entity. Pathogenesis can be derived from infection, coagulopathy, and inflammation. Malignant tumors metastasize to dura mater is one of the most infrequent causes. The exact mechanism remains elusive in spite of several possible speculations. The clinical manifestations, management and outcomes vary among reported cases.Case Description: A 45-year-old woman without history of trauma presented with headache, vomiting and disturbance of consciousness and developed brain hernia rapidly. On arival, she has lost into coma with Glasgow coma scale (GCS) score 5, bilateral pupils were not equal, with disappeared reflectance. Emergency imaging prompted large acute EDH, combined with SDH, arising from dural granular neoplasm confirmed intraoperatively. Four days after surgery, the bilateral pupils were equal in size and sensitive to light reflection.Conclusion: Dural metastases can cause EDH, chronic SDH can also be resulted from metastatic tumors of dura mater. When dealing with spontaneous non-traumatic hematoma around the dura mater, to make the precise diagnosis is sometimes doubtful and confusing. The stream of diagnostic thinking should be opened, including medical diseases such as liver and kidney disease, drug history, history of cancer and other possible clues. Thus, a detailed and purposeful systematic medical history review and physical examination is important in order to make more appropriate strategies for the clinic.

Acute-on-Chronic Vertex Epidural Hematoma with Diastasis of the Sagittal Suture in an Adult.

BACKGROUND: Vertex epidural hematoma (VEDH) is a rare intracranial mass constituting roughly 2.5% of all epidural hematomas. Bleeding usually derives from the superior sagittal sinus, and presentation is often acute-seldom chronic. Fractures are common, but diastasis of the sagittal suture in adults is unique. We hereby present a case combining these rare features along with diagnostic pitfalls and management. CASE DESCRIPTION: A 43-year-old male with a history of hitting his head against the roll cage of the racing car 3 weeks before admission presented with unbearable headache of 9 Numeric Rating Scale intensity and decreased muscular strength in the right upper limb down to 4/5 of the Lovett scale. The initial Glasgow Outcome Scale was 4. His axial computed tomography scan mimicked convexity hyperostosis, meningioma, or lymphoma. Coronal reconstruction revealed a 102-mL large biconcave mass of mixed hyperdensity and hypodensity at the vertex. Bone window showed sagittal suture diastasis. Contrast-enhanced magnetic resonance imaging gave evidence of superior sagittal sinus detachment. Parietofrontal craniotomy crossing the midline was performed in order to evacuate the hematoma. On 2-week follow-up his pain decreased, his right arm strength recovered, and he had a Glasgow Outcome Scale score of 5. CONCLUSIONS: VEDH can present as an intensifying headache even weeks after purported trauma. Axial computed tomography scans can be tricky because of the blind spot. Even large VEDH may be seen only in the very last few axial slices and may mimic other entities. Coronal reconstructions or additional magnetic resonance imaging come in handy. One-piece parietofrontal craniotomy is an option to approach this hematoma.

Management of epidural hematomas in pediatric patients presenting with a GCS of 14 or better.

OBJECT: Guidelines for the management of pediatric epidural hematoma (PEDH) remain poorly defined. Here we seek to characterize the disease course of PEDH in patients with presenting Glasgow Coma Scale (GCS) of 14+, and suggest high-risk characteristics for progression to surgery. METHODS: A prospectively maintained, single-institution, level-1 trauma hospital admission database was queried to identify patients ages 6 months to 18 years presenting with PEDH between 2006 and 2016. Selected charts were reviewed for clinical information and treatment. Head imaging was reviewed for hematoma size, location, fractures, and midline shift. RESULTS: Of 210 cases reviewed, 117 presented with a GCS of 14+. Of these, 24 required surgery while 93 were managed conservatively. Factors leading to surgery included decline in GCS (40%), size alone (21%), localizing neurological deficit (20%), progression on repeat imaging (12%), and other (7%). Hematomas involving the temporal lobe plus an adjacent lobe were more likely to proceed to surgery than those involving the temporal lobe alone (OR: 24.8, 95% CI (4.74, 129.26)). Hematomas in proximity to the superior sagittal and transverse sinuses proceeded to surgery in 33.3% and 37.5% of cases, respectively. Of the 93 patients with a thickness:biparietal skull diameter ratio of ≤0.15, 89 (95.7%) were managed conservatively. CONCLUSION: In this single-institution experience, 21% of pediatric patients presenting with a GCS of 14+ proceeded to surgery. High-risk features include large hematoma thickness, proximity to the transverse sinus, and multilobar location. A thickness:biparietal skull diameter ratio less than 0.15 was highly unlikely to proceed to surgery.

Sagittal craniosynostosis associated with midline cephalhematoma or vice versa, case report and a review of the literature.

INTRODUCTION: Sagittal craniosynostosis associated with midline cephalhematoma is a rare finding. Despite the controversy regarding its etiopathogenesis, this condition represents a clear indication for surgery. CASE REPORT: We present a case of a 10-week-old boy with an ossified midline vertex cephalhematoma and sagittal craniosynostosis. The child underwent a cephalhematoma excision and minimally invasive non-endoscopic narrow vertex craniectomy, with calvarial vault remodeling followed by 2 weeks use of a cranial orthosis. On 5-month follow-up, mesocephaly was achieved. CONCLUSION: Our case is well documented with native CT, 3D CT, intraoperative pictures, and 3D head scan imaging. We described our minimally invasive non-endoscopic technique that led to a rapid cranial vault remodeling with reduction of cranial orthosis need. A review of literature focused on surgical techniques is included.

Synchronous Diagnosis of Intradiploic Epidermoid Cyst and Anatomically Close Associated Chronic Epidural Hematoma.

BACKGROUND: Intradiploic epidermoid cyst (IEC) concurrent with chronic epidural hematoma (CEDH) has never been reported in the literature. We report a unique case of IEC concurrent with anatomically close associated CEDH. CASE DESCRIPTION: A 54-year-old man presented with a 1-week history of headache, confusion, and drowsiness. Computed tomography exposed large, extraaxial, mixed-density lesions with bone destruction and substantial mass effect in the left frontotemporal region. Magnetic resonance imaging revealed 2 adjacent extraaxial lesions. The frontal lesion was predominantly hyperintense on both T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI), with an enhancement rim of the thickened dura mater. The frontotemporal lesion was mainly hyperintense on both TlWI and T2WI, with some areas of hypointensity on both T1WI and T2WI. No enhancement in the lesion was found. The patient underwent left frontotemporal craniotomy for resection of the lesion. At the time of the craniotomy, a copious amount of yellow liquid outflowed. After the bone flap was removed, an irregular tumor was found epidurally located and composed of fragile and laminated yellow materials. The tumor was totally removed. Histologic examination revealed an epidermoid cyst. Postoperative computed tomography showed mild bleeding in the operation area. His symptoms improved significantly after surgery, and he was discharged 1 week later. At 2 weeks' follow-up, the patient was well without neurologic deficits. CONCLUSIONS: Intradiploic epidermoid cyst concurrent with chronic epidural hematoma is extremely rare. We present the first case of intradiploic epidermoid cyst concurrent with anatomically close associated chronic epidural hematoma.

Bilateral Temporal Extradural Hematoma on Top of Bilateral Temporal Arachnoid Cyst: First Case Report and Extensive Literature Review.

BACKGROUND: The traumatic complication of an arachnoid cyst (AC) with intracystic and subdural hematoma has been reported in many cases. However, a unilateral extradural hematoma (EDH) as a complication of AC is extremely rare. Most arachnoid cysts are unilateral and are located in the middle cranial fossa. Bilateral temporal AC alone is an extremely rare condition, and a bilateral EDH on top of a bilateral temporal AC has never been reported in the literature, to our knowledge. CASE DESCRIPTION: We report the case of a 25-year-old man with a known bilateral AC who was involved in a motor vehicle accident and developed a bilateral temporal EDH. The brain computed tomography scan also showed fractures in the skull on both temporal areas. The patient was treated conservatively. He was discharge with Glasgow Coma Scale score of 5. CONCLUSIONS: Bilateral temporal EDH in a bilateral temporal AC has never been reported in the literature. The presence of an AC may predispose a patient to complications because of the anatomic changes in the area. It is important to educate asymptomatic patients and their families about these cysts and the importance of avoiding head injury and not being involved in contact sports or military service.

Computerized Tomography-Guided Stereotactic Biopsy of Intracranial Lesions: Report of 500 Consecutive Cases.

AIM: Computed tomography (CT)-guided stereotactic brain biopsy has been performed in our clinic since March 1998. In this prospective study, we examined the patient data undergoing stereotactic biopsy and the results of biopsies in 500 consecutive patients. MATERIAL AND METHODS: Between the dates of March 1998 and January 2015, CT-guided stereotactic biopsies were performed by using the Leksell stereotactic frame system (Elekta Instruments EU, Sweden) in 500 patients. A total of 512 procedures were performed in patients consisting of 184 females (36.8%) and 316 males (63.2%), ages ranging from 3 to 81 years (mean 50.40±16.67). RESULTS: Conclusive histopathological diagnosis was not achieved in 17(3.3%) of 512 procedures. Of the others, 173 (33.8%) were high-grade gliomas, 103 (20.1%) were low-grade gliomas, 36 (7%) were malignant lymphomas, 34 (6.6%) were other types of brain tumors, 82 (16%) were metastasis and 67 (13.1%) were non-tumoral lesions. Complications were occurred in ten cases: 3 tumoral bleedings, 2 hypertensive cerebral hematomas, 2 peroperative convulsions, 1 epidural hematoma, 1 myocardial infarction and 1 brain edema. The patients who developed myocardial infarction and hypertensive thalamic hematoma died. The mortality was 0.4% and morbidity was 1.6% in 512 procedures. CONCLUSION: CT-guided stereotactic biopsy is a reliable and a safe procedure in cases with intracranial lesions when histopathological diagnosis is required for the appropriate treatment.

Software output from semi-automated planimetry can underestimate intracerebral haemorrhage and peri-haematomal oedema volumes by up to 41.

INTRODUCTION: Haematoma and oedema size determines outcome after intracerebral haemorrhage (ICH), with each added 10 % volume increasing mortality by 5 %. We assessed the reliability of semi-automated computed tomography planimetry using Analyze and Osirix softwares. METHODS: We randomly selected 100 scans from 1329 ICH patients from two centres. We used Hounsfield Unit thresholds of 5-33 for oedema and 44-100 for ICH. Three raters segmented all scans using both softwares and 20 scans repeated for intra-rater reliability and segmentation timing. Volumes reported by Analyze and Osirix were compared to volume estimates calculated using the best practice method, taking effective individual slice thickness, i.e. voxel depth, into account. RESULTS: There was excellent overall inter-rater, intra-rater and inter-software reliability, all intraclass correlation coefficients >0.918. Analyze and Osirix produced similar haematoma (mean difference: Analyze - Osirix = 1.5 ± 5.2 mL, 6 %, p ≤ 0.001) and oedema volumes (-0.6 ± 12.6 mL, -3 %, p = 0.377). Compared to a best practice approach to volume calculation, the automated haematoma volume output was 2.6 mL (-11 %) too small with Analyze and 4.0 mL (-18 %) too small with Osirix, whilst the oedema volumes were 2.5 mL (-12 %) and 5.5 mL (-25 %) too small, correspondingly. In scans with variable slice thickness, the volume underestimations were larger, -29%/-36 % for ICH and -29 %/-41 % for oedema. Mean segmentation times were 6:53 ± 4:02 min with Analyze and 9:06 ± 5:24 min with Osirix (p < 0.001). CONCLUSION: Our results demonstrate that the method used to determine voxel depth can influence the final volume output markedly. Results of clinical and collaborative studies need to be considered in the context of these methodological differences.

Soft Membrane Sheath for Endoscopic Surgery of Intracerebral Hematomas.

BACKGROUND: Although the functional efficacy of surgical evacuation of an intracerebral hematoma (ICH) remains controversial, it has a valuable role for managing ICHs. Endoscopic surgery is increasingly used to evacuate ICHs; however, the narrow rigid sheath may be limiting. We report the usefulness of a soft plastic membrane sheath for endoscopic evacuation of ICHs. METHODS: The 20 × 100-mm flat membrane sheath was made of polyester film. Before introducing the sheath into the ICH cavity under navigation, one side was tucked into the opposite side to make a narrow four-layered tube. After inserting it in the brain, the tucked-in leaf was pulled out, and the slit-like tube was ready to remove the hematoma. A rigid endoscope and various instruments were introduced into the sheath. Large ICHs in the putamen and thalamus were evacuated under endoscopic visualization using the same microsurgical instruments. RESULTS: This technique was applied to 41 patients. Nearly complete evacuation of all hematomas was achieved. No surgical complication or rebleeding occurred. The new membrane sheath allowed more room for accommodating and handling the instruments, including bipolar forceps. CONCLUSIONS: This flat membrane sheath is disposable and easy to prepare, which could overcome the limitation of the instruments to allow for efficient evacuation of an ICH using the same microsurgical techniques.

Traumatic acute extradural haematoma - Indications for surgery revisited.

Extradural haematomas (EDH) occur in approximately 2% of all head injuries but account for a significant proportion of fatal head injuries with mortality rates ranging from 1.2 to 33%. The expeditious surgical evacuation of EDH is associated with an excellent prognosis and is considered the most cost-effective operation performed by neurosurgeons. The Brain Trauma Foundation (BTF) has produced informative guidance on the management of EDH. The criteria laid out for conservative management comprises non-comatose patients with EDH less than 30 cm in volume, less than 15 mm thick and causing less than 5 mm midline shift. The BTF recommends that all patients with an EDH volume of greater than 30 cm(3) should undergo surgical evacuation regardless of Glasgow Coma Scale. This recommendation was based upon early case series and cohort studies from two decades. Within an ageing population, we now see many older patients who may accommodate greater extra-axial blood volumes. With this in mind, we believe the indications for surgical evacuation of EDH merit renewed consideration.

[A case of acute intracranial epidural hematoma caused by chronic nasal sinusitis].

Non-traumatic intracranial acute epidural hematoma(EDH)is rare. It is mostly caused by coagulation disorders, dural metastasis, or vascular malformations of the dura. We report a case of non-traumatic acute EDH caused by chronic nasal sinusitis and review the literature comprising 10 cases of acute EDH caused by chronic nasal sinusitis. A 16-year-old boy visited our outpatient clinic with a 2-day history of severe headache. He did not have fever or neurological abnormalities and showed no evidence of head trauma. Cranial computed tomography(CT)revealed sphenoid sinusitis and a small amount of epidural air in the middle fossa, but no other intracranial abnormalities. After eight days with no subsequent history of trauma, radiological exams showed a massive acute epidural hematoma in the left middle fossa and temporal convexity without any vascular lesion or skull fracture. The patient underwent a hematoma evacuation that revealed neither a skull fracture nor a vascular abnormality. In this adolescent, chronic nasal sinusitis caused fragility of the meningeal artery wall, an air collection in the epidural space, and the detachment of the dura mater from the inner surface of the skull, thereby resulting in a non-traumatic acute EDH.

Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery.

OBJECTIVE: Post-operative extradural hematoma (EDH) is a relatively common complication in patients undergoing intracranial operations. The risk factors associated with the occurrence of EDH are not well described in the literature. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy or the craniectomy site. METHOD: This was a retrospective study of 24 (2.6% of total) patients who underwent extradural hematoma evacuation after primary intracranial supratentorial surgery between January 2005 and December 2011. During this period, 941 intracranial operations were performed. The control group (72 patients) was selected on the basis of having undergone the same pre-operative diagnosis and treatment within 2 months of the operations for the 24 hematoma patients. The Glasgow Coma Scale score and operation character (emergency or elective) of the hematoma and control group were individually matched to minimize pre-operative conditional bias. The ages of both groups were individually matched with similar ages within 10 years of each other to minimize age bias. RESULT: Univariate analysis showed that the significant pre-operative and intra-operative factors associated with post-operative EDH were an intra-operative blood loss of greater than 800 mL (p=0.007), maximal craniotomy length of greater than or equal to 100 mm (p=0.001), and craniotomy area of greater than or equal to 71.53 cm2 (p=0.018). In multivariate analysis, intra-operative blood loss exceeding 800 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH. CONCLUSION: The data did not examine established risk factors for post-operative hematoma, such as thrombocytopenia, anti-coagulant and anti-platelet therapy, and a history of heavy alcohol consumption and/or tobacco intake. Recognizing the limitations of the study, large intra-operative blood loss and wide craniotomy area are implicated with an increased risk of post-operative EDH after intracranial surgery.

Alagille syndrome case report: implications for forensic pathology and anthropology.

This case report offers a multidisciplinary interpretation of the violent death of a 4-year-old girl suffering from Alagille syndrome who died after a low-height fall that resulted in temporal bone fracture and a large epidural hematoma. The article evidences the macroscopical and microscopical characteristics of the syndrome, focusing especially on the skeletal findings that emerged during autopsy. In the case report, distinction is made between a possible accidental or non-accidental nature of the injuries and the characteristics of the injury have been interpreted in the light of the existing data on Alagille syndrome. In conclusion, the death was documented as accidental since abnormalities in the skeletal system evidenced during autopsy have predisposed the death of the child albeit through a very mild head trauma. The case report evidences the importance of studying features of skull macro- and microstructure in patients with Alagille syndrome, which have been, until now, underreported in literature and which might contribute to fracture vulnerability in these patients. Although rare, Alagille syndrome is a condition that should be known to forensic medicine practitioners and whose features and peculiarities must be taken into consideration in pediatric autopsy and suspected child abuse cases.

Surgical treatment of supra- and infratentorial epidural hematoma.

Supra- and infratentorial acute epidural hematoma (SIEDH) is a common type of posterior fossa epidural hematoma (PFEDH), representing 11- 64% of all PFEDHs. Although SIEDH is associated with typical characteristics, it might be difficult to diagnose when presenting as infratentorial acute epidural hematoma, which is clinically silent and has nonspecific symptoms. However, this type of hematoma can often be rapidly deteriorating, causing a sharp rise in intracranial pressure that leads to a life-threatening foramen magnum herniation. Early diagnosis and management of SIEDH are imperative. Traditional surgical management has always required relatively large craniotomies, larger than the hematoma itself, to expose its edge, and then tack up the dura matter). It usually opens the window and emphasizes retention of the bone bridge outside the transverse sinus. This method can effectively eliminate the hematoma, but it is associated with larger postoperative wound, longer operation time, larger skull defect, and more complications. Hence, exploration into a better surgical method is direly needed.

Retroclival subdural haematoma secondary to pituitary apoplexy.

Retroclival haematomas are rare entity and they are mostly caused by trauma. There has been only one case published to have a retroclival haematoma following pituitary apoplexy. We present a patient diagnosed with pituitary apoplexy who was found to have acute subdural retroclival haematoma on the MRI.

Traumatic hematoma of the posterior fossa.

Posterior fossa injury is rare, occurring in less than 3 % of head injuries. We retrospectively reviewed patients' clinical and radiological findings, management, and outcomes. The aim of the present study was to investigate the features of posterior fossa hematoma, including posterior fossa epidural hematoma (EDH), posterior fossa subdural hematoma (SDH), and intracerebellar hematoma. From January 1995 to January 2009, 4,315 patients with head trauma were hospitalized at our institution. The -present study focused on 41 patients (1.0 %) with traumatic hematomas of the posterior fossa. Eighteen patients had EDH, 10 patients had SDH, and 17 patients had intracerebellar hematomas. In each type of injury, occipital bone fractures were seen in many patients, and hematoma enlargement was often observed within a few days of the injury. In addition, a high frequency of associated lesions and a high poor outcome rate were features of intracerebellar hematomas and -posterior fossa SDH. The present study suggests that repeat CT imaging and careful management are necessary until the lesion is stabilized, and patients showing lesions with mass effects should therefore be immediately treated with surgery.