Spontaneous epidural haematoma in a paediatric patient with sickle cell disease.

Spontaneous epidural haematoma (SEDH) is a rare complication of sickle cell disease (SCD). To our knowledge, 38 cases of patients with SEDH associated with SCD have been reported in the literature. In this case report we describe the first Danish paediatric case with SCD and SEDH. The pathophysiology of this association is not fully understood, but skull bone infarction, haemopoietic marrow expansion or compromised blood flow due to hyper viscosity might contribute to this rare complication. In patients with SCD presenting with relevant symptoms, early imaging could be considered.

[Rare association of subperiosteal hematoma of the orbit with frontal extradural hematoma: a case report]. / Association rare d'un hématome sous-périosté de l'orbite et d'un hématome extradural frontal: à propos d'un cas.

Subperiosteal haematoma of the orbit associated with frontal extradural hematoma is very rare. We here report a case treated in our Department with a literature review. The study involved a 15-year-old boy, victim of head injury from white weapon, a week before his admission to the emergency room. He had inflammatory and painful exophthalmos on the left side, associated with left ophthalmoplegia and blindness. Brain scanner showed left frontal extradural hematoma associated with subperiosteal hematoma of the ipsilateral orbit. Frontal craniotomy associated with fracture orbitotomy allowed evacuation of the extradural hematoma, and then, of the subperiosteal hematoma. Patient´s outcome was favorable. Simultaneous occurrence of frontal extradural hematoma and subperiosteal hematoma of the orbit is extremely rare. Generally, attention is drawn by exophthalmos and visual disturbances. Emergency brain scan without contrast agent injection can be used to make a diagnosis. Prognosis depends on visual function, then adequate management helps to safeguard the eye and vision.

Contrecoup epidural hematoma: a rare case report.

Epidural hematoma (EDH) is defined as a traumatic accretion of blood separating the dural membrane and the internal table of the skull that caused from contact bending or skull fracture. The cases of contrecoup EDH are as not common, and there are just 10 recorded cases on this. As a result of its uncommonness, we disclose one subject of a 33-year-old man having countrecoup EDH who suffered from a head trauma caused by falling from 4 meters high. The main symptoms were decreasing consciousness and vomiting. Clinical findings showed a Glasgow Coma Scale score of 9, laceration in the left parietal region with stable hemodynamic. Head Computed tomography showed a large EDH in the right frontal and temporal region with coronal suture diastasis. The patient immediately underwent surgery, and craniotomy with evacuation of extradural hematoma were performed. This case presents that a force, which creates an angle, can propagates and causes opposite coronal suture diastasis and makes contrecoup EDH.

Aggressive primary scalp lymphoma mimicking an acute epidural hematoma: Case report and review of the literature.

BACKGROUND: Cutaneous Central Follicular Lymphoma (CCFL) is a type B cutaneous lymphoma with a usually indolent course. Scalp localization of CCFL is extremely rare, we report a new case mimicking an epidural hematoma, and showing a rapid progression with aggressive infiltration of skin, calvaria, dura and brain parenchyma. CASE REPORT: A 58-year-old patient with an unlabeled polymalformative syndrome was admitted to the Emergency department following a head injury secondary to a self-resolving tonic-clonic epileptic seizure. The initial CT-scan was interpreted as a minor subcutaneous and epidural hematoma initially deemed for conservative management. Within 4 days, the patient showed a progressive neurological deterioration culminating into a stuporous status which prompted a constrast-enhanced brain MRI. The scan revealed a multilayered solid lesion, extending from the subgaleal compartment to the subdural space, threatening the integrity of overlying skin and causing infiltration of the brain parenchyma. Following emergency neurosurgical excision a definitive histology diagnosis of central follicular lymphoma was made. A focused chemotherapy with high-dose Methotrexate with R-CHOP protocol led to disease control until the latest follow up at 2 years. CONCLUSION: To our knowledge, this case represents the first CCFL invading the brain parenchyma and the second extending to the dura. Although such tumor is usually indolent the aggressive behavior herein reported extend the differential diagnosis to high-grade meningiomas, sarcomas, and metastases. Prognostication and appropriate adjuvant treatment require prompt surgical excision and histological confirmation.

Post-traumatic cerebral venous sinus thrombosis associated with epidural hematoma: A challenging clinical situation.

Post-traumatic cerebral venous sinus thrombosis (ptCVST) is often associated with brain hemorrhage; consequently, the anticoagulation may be challenging. We report the case of a 42-year-old man who presented with post-traumatic epidural hematoma and rapidly developed transverse sinus thrombosis extending to the internal jugular vein. As the patient was asymptomatic, we decided not to use anticoagulants: close clinical and radiological monitoring was implemented. The hematoma resolved within 2 months, and the CVST diminished by the third month. Such a good outcome is not always the case in ptCVST. The present article also discusses pathophysiological mechanisms and treatment options when hematoma is associated with ptCVST.

Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data.

Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.

Calvarial diploic venous channels: delineation with maximal intensity projection technique.

PURPOSE: To date, very few studies have explored the three-dimensional architecture of calvarial diploic venous channels (CDVCs). This study aimed to characterize the three-dimensional architecture of CDVCs using maximum intensity projection (MIP) images based on contrast-enhanced magnetic resonance imaging (MRI). METHODS: A total of 77 patients with intact calvarial hemispheres and underlying dura mater and dural sinuses underwent contrast-enhanced MRI. Among them, we extracted the data of 49 with at least a part of the major CDVC pathways identified on the MIP images for analysis. RESULTS: On serial contrast-enhanced MRI images, the CDVCs were commonly detected as curvilinear structures with inhomogeneous diameters and tributaries, while the MIP images delineated the three-dimensional architecture of the developed CDVC pathways. More than such CDVC pathway was entirely delineated on the right in 67.3% and on the left in 71.4%, most frequently in the frontal and temporal regions, with their connecting sites to the sphenoparietal and superior sagittal sinuses. The morphology, distribution, and course of the identified CDVCs were highly variable. In 55.1%, the CDVCs formed fenestrations that were variable in size, shape, and number. CONCLUSIONS: The developed CDVC pathways may be characterized by morphological variability and fenestrations. Thin-sliced, contrast-enhanced MRI is useful to depict diploic veins, while MIP images allow for better appreciation of the entire course of the developed CDVC pathways. Traumatic and intraoperative disconnection between the dura mater overlying the dural sinuses and the adjacent inner table of the skull can cause epidural venous bleeding.

Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls.

BACKGROUND/PURPOSE: The purpose of this study was to review the initial clinical presentation of EDH, identify potential clinical markers and highlight diagnostic pitfalls. METHODS: Retrospective review of all pediatric patients admitted to a Level I Trauma Center diagnosed with blunt traumatic EDH from 2008 to 2018. RESULTS: A total of 699 pediatric patients were identified with blunt traumatic brain injury (TBI); 106 with EDH made up the study population. A skull fracture was present in 84%. Overall, the most common clinical finding was a scalp hematoma (86%), followed by loss of consciousness (66%), emesis (34%), headache (27%), amnesia (18%), and seizures (12%). Importantly, 40% of patients with EDH presented with GCS 15. Four children (4%) had GCS 15 and were completely asymptomatic on admission. In three children (3%) the only symptom was a scalp hematoma. 50% of all EDH required craniotomy, and this was not significantly different if GCS was 15 on presentation (45%, p = 0.192). Mortality was 2%. Fourteen patients (13%) were discharged with cognitive/motor deficits. CONCLUSIONS: Pediatric EDH frequently present with subtle clinical signs, including a normal GCS half the time. Irrespective of asymptomatic presentation, threshold for CT scan or an observation period should be low after head injuries in children. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II/III.

Intravenous Tranexamic Acid for Subdural and Epidural Intracranial Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Recovery of patients with traumatic brain injury largely depends on the reduction in secondary brain damage. The present study aims at investigating the effect of Tranexamic Acid (TXA) administration within the first hours of brain trauma in the emergency department (ED). METHODS: This randomized, double-blind, placebo-controlled clinical trial was carried out in patients with subdural and epidural hemorrhage. Patients with any type of bleeding were assigned into two groups of TXA and 0.9% normal saline as placebo. The rate of intracranial hemorrhage after surgery was assessed by CT-scan and amount of hemoglobin (Hb) was measured immediately before surgery and after 6 hours of surgery. RESULTS: A total of 80 participants were randomly assigned into four groups of 20 people. There was a significant difference in the mean of intraoperative bleeding during surgery in patients receiving TXA and placebo in both SDH (Subdural hematoma) and EDH (Epidural Hemorrhage) groups (P= 0.012). The Hb drop amount had no significant difference with placebo (P< 0.0001). No complications were observed in any of the intervention and control groups during the study as well. CONCLUSION: The use of TXA may reduce bleeding, however, based on the results of this study, such effect was not statistically significant in controlling the epidural and subdural hemorrhage, but clinical trials with a higher sample size are suggested for further investigation in this regard.

Plasmacytoma of the skull mimicking an epidural hematoma: A case report.

RATIONALE: Plasmacytoma as the 1st presentation of skull tumors is a rare disorder. When it is combined with brain trauma or dramatic changes in intracranial pressure, patients are more prone to misdiagnosis. PATIENT CONCERNS: A 67-year-old woman complaining of a headache presented with a history of head trauma for the past 1 hour. Emergency head computed tomography initially suggested an epidural hematoma. DIAGNOSIS: Emergency surgery was performed to remove the intracranial hematoma, but a tumor-like mass was found during surgery, and pathologic assessment confirmed plasmacytoma. Surgery was difficult because of bleeding. The tumor was radically removed. INTERVENTIONS AND OUTCOMES: The patient underwent whole-brain radiotherapy and chemotherapy. She died 40 months after the surgery. LESSONS: Epidural lesions found after a head injury may be assumed to be an epidural hematoma, leading to unnecessary surgery. Diseases such as hematomas, meningiomas, eosinophilic granulomas, bone metastases, and osteosarcomas must be considered.

Early diagnosis of traumatic intracranial hematomas.

Timing of the intervention for intracranial hematomas is critical for its success, specifically since expansion of the hemorrhage can result in debilitating and sometimes fatal outcomes. Led by Britton Chance, we and an extended team from University of Pennsylvania, Baylor and Drexel universities developed a handheld brain hematoma detector for early triage and diagnosis of head trauma victims. After obtaining de novo Food and Drug Administration clearance, over 200 systems are deployed in all Marine battalion aid stations around the world. Infrascanner, a handheld brain hematoma detection system, is based on the differential near-infrared light absorption of the injured versus the noninjured part of brain. About 12 independent studies have been conducted in the USA, Canada, Spain, Italy, the Netherlands, Germany, Russia, Poland, Afghanistan, India, China, and Turkey. Here, we outline the background and design of the device as well as clinical studies with a total of 1293 patients and 203 hematomas. Infrascanner demonstrates high sensitivity (adults: 92.5% and children: 93%) and specificity (adults: 82.9% and children: 86.5%) in detecting intracranial hematomas >3.5 mL in volume and <2.5 cm from the surface of the brain. Infrascanner is a clinically effective screening solution for head trauma patients in prehospital settings where timely triage is critical.

Spontaneous resolution and complete recovery of spontaneous cervical epidural hematoma: Report of two cases and literature review.

OBJECTIVE: To present the natural course and treatment modalities of spontaneous cervical epidural hematoma (SCEH), by reporting two rare cases with spontaneous resolution in both clinical and radiologic findings without surgery. MATERIAL AND METHODS: One patient presenting with acute right side hemiparesis and another showing pure cervical radiculopathy were diagnosed with SCEH on magnetic resonance imaging (MRI). Both were both treated non-operatively. We also conducted a literature review of 19 cases of spontaneous spinal epidural hematoma (SSEH). RESULTS: These two patients achieved complete resolution in terms of both neurologic function and radiologic findings within 21 days after onset. In the literature review, 63.2% of cases experienced neurologic improvement in the first 24h, 78.9% achieved complete neurologic recovery within 1 month, and radiological images showed complete resolution of hematoma in the first month for 73.7% of patients. CONCLUSIONS: Atypical cervical SSEH can mimic cerebral stroke or a ruptured cervical disc. A high index of clinical suspicion followed by MRI examination is critical for diagnosis. Prompt surgical decompression and evacuation of the hematoma is generally regarded as first-line treatment. However, for patients without or with only slight neurologic symptoms, or showing early and sustained neurologic improvement, non-surgical therapy with close observation is a viable alternative. Both neurologic and radiologic resolution can be expected within the first month following onset in most cases of spontaneous resolution of SSEH.

Rare occurrence of a huge traumatic extradural haematoma in a patient with an ipsilateral sylvian arachnoid cyst.

A man, a teenage victim of an assault to the head, presented to the emergency department, in Baghdad, with a Glasgow Coma Score of 4/15 (E1 M2 V1) and total right-sided paralysis. CT of the brain revealed a large-left sided frontotemporoparietal extradural haematoma with the presence of an ipsilateral sylvian arachnoid cyst deep to the haematoma. Urgent surgical evacuation of the haematoma was performed, leaving the arachnoid cyst intact. The patient improved and gained full consciousness within 4 days.Three years after the initial trauma, the patient has remained well. This case required a thorough discussion of the surgical options, in particular whether to intervene with the associated cyst, and whether any intervention with the cyst should be performed in the same or future operations. This dilemma forms the basis of the discussion in the following report.

[Traumatic homonymous hemianopsia and ganglion cell complex changes: Report of 3 cases]. / Hémianopsie latérale homonyme post-traumatique et atteinte des cellules ganglionnaires : à propos de 3 cas.

Homonymous lateral hemianopia follows an attack on the contralateral retrochiasmal visual pathways. In three patients with post-traumatic homonymous hemianopia, optical coherence tomographic (OCT) study of the ganglion cell layer thickness showed hemiretinal thinning contralateral to the visual field defect. This involvement could be explained by trans-synaptic degeneration of the pre-geniculate visual pathways, whose cell nuclei correspond to ganglion cells, which synapse with the damaged retrogeniculate visual pathways.

A rare case of deep cerebral venous thrombosis secondary to traumatic epidural hematoma: Case report.

RATIONALE: Deep cerebral venous thrombosis (DCVT) is a rare disease, but always results in poor prognosis. PATIENT CONCERNS: We reported a 79-year-old female with coma after traumatic brain injury (TBI). DIAGNOSIS: The epidural hematoma was first diagnosed on non-contrast computerized tomography (CT). The hypodense areas in bilateral thalami and basal ganglia on reexamination CT highly indicated the suspicion of DCVT. Finally, the appearance of thrombosis of the vein of Galen on the computed tomography venography (CTA) and digital subtraction angiography (DSA) confirmed the diagnosis. INTERVENTIONS: The patients received surgery to remove the epidural hematoma. After that, she was treated with oral anticoagulation agent (low molecular weight heparin (LMWH), 180 Axal U/kg 24 h) for 4 weeks, shifted by oral warfarin (2.5 mg qd) for 4 weeks. OUTCOMES: The hypodense areas in bilateral thalami and basal ganglia have been largely reversed. At the time of 6 months after surgery, the patient could take care of herself. LESSONS: If the CT shows hypodense areas in bilateral thalami and basal ganglia, a diagnosis of DCVT should be suspected once the patients could not recover from the treatment of primary diseases.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient.

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures.

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ±â€Š3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ±â€Š1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.