New-onset contralateral delayed extradural haematoma in an operated case of extradural haematoma: life-threatening if not diagnosed early
- 1 Neurosurgery, All India Institute of Medical Sciences - Rishikesh, Dehradun, Uttarakhand, India
- 2 Neurosurgery, All India Institute of Medical Sciences - Mangalagiri, Vijayawada, Andhra Pradesh, India
- Correspondence to Dr Rajkumar Pannem; pannem16@gmail.com
Abstract
Head trauma is still a leading cause of mortality in neurosurgical practice. Among various post-traumatic pathologies, extradural haematoma (EDH) is an acute condition that has good neurological outcomes if intervened promptly. New contralateral delayed EDH (DEDH) in an operated case of ipsilateral EDH is a very rare entity, which if not diagnosed timely may lead to devastating outcomes, sometimes even death. We present a case of newly found contralateral DEDH with significant mass effect and midline shift in the immediate postoperative scan, in an operated case of right frontoparietal EDH, which was not found in the initial preoperative scan. A high index of suspicion is needed in cases of unilateral EDH with contralateral skull fracture along with tense dura after the evacuation of EDH, to diagnose rare but life-threatening contralateral DEDH. Routine immediate postoperative CT scan will prevent devastating complications in these kinds of patients.
Background
Acute epidural haematoma (EDH) is a common entity after trauma seen in routine neurosurgical practice. The definition of DEDH varies widely in various literature. It is a rare neuroradiological entity, an EDH that is not present in the initial neuroradiological examination after the trauma but appears in subsequential neuroradiological examinations.1 Incidence of DEDH varies from time to time and between various publications may be because of increased availability and frequency of CT head done in head injury cases. Also, because it is a relatively less known entity, there might be under-reporting of these cases. According to a review article in 1995 by Domenicucci et al, DEDH accounts for 6%–13% of all EDH, in their series it is 8% of all EDH.2 A recent review article cited the incidence of DEDH from 13% to 30%.3 Among the DEDH entity, contralateral DEDH after the evacuation of ipsilateral EDH is a very rare entity, with very few cases reported till now. The mechanism for its occurrence is not well established, few hypotheses are postulated in literature, and lack of initial tamponade effect by raised intracranial pressure (ICP) after surgical or medical treatment of intracranial hypertension is one of them.4–6 Contralateral DEDH after the initial evacuation of post-traumatic EDH is a very rare entity, only very few cases were reported in the literature till now. Here we present a case of post-traumatic contralateral frontoparietal EDH and frontoparietal thin subdural haematoma (SDH) after initial right frontoparietal EDH evacuation because it is rare and can be lifesaving if all treating neurosurgeons are aware of it.
Case presentation
A man in his 20s presented with an alleged history of road traffic accident, a pillion rider without wearing a helmet on a bike with a head-on collision with a car. He presented with a Glasgow Coma Scale (GCS) of E2V2M5 within 5 hours of injury. Non-contrast enhanced CT (NCCT) head (figure 1A,D) suggested a right frontoparietal EDH along with a left frontal bone fracture with small underlying contusions. The EDH was evacuated immediately. Tense underlying dura was noted after EDH evacuation. The patient was extubated immediately after surgery. He was occasionally following commands. In the immediate postoperative NCCT head (figure 1B,E), surprisingly a new left frontoparietal EDH, underlying SDH and frontoparietal contusion was noted. The patient was immediately taken for evacuation of newly formed haematoma. Left frontoparietal fracture, a large EDH was noted and evacuated. Dura was tense, on opening dura, left frontoparietal SDH was also noted and evacuated. The bone flap was kept in abdominal subcutaneous pouch.
(A and D) Axial and coronal preoperative non-contrast enhanced CT head showing right-sided frontoparietal extradural haematoma (EDH) with left frontal bone fracture with underlying minor contusion. (B and E) Immediate postoperative scan of axial and coronal CT images, showing newly noted contralateral frontoparietal EDH, underlying thin subdural haematoma (SDH) and frontoparietal contusions with mass effect and midline shift. (C and F) Axial and coronal CT images after the second surgery showing the absence of left frontotemporoparietal bone flap along with the post evacuation status of EDH and SDH.
Outcome and follow-up
The patient was weaned off from ventilator on second postoperative day. He was discharged with a GCS of E4V4M6. There were no residual neurological deficits. On a follow-up visit after 3 months, the patient was conscious and oriented without any neurological deficits.
Discussion
Contralateral DEDH after the initial evacuation of EDH is very rare and can lead to a quick death if not diagnosed properly. Before the invention of CT scan, most of the DEDH might have been missed. In the light of CT scans many cases of this entity were reported.7 Simultaneous bilateral EDH is more common compared with DEDH. The incidence of simultaneous bilateral EDH among all EDH cases in the case series by Gupta et al, Görgülü et al and Dharker et al are 4.8, 2.58 and 5.6%, respectively.8–10 In a three case series by Riesgo et al, three mild head injury patients did not show any evidence of EDH on the initial scan, but EDH was observed in CT scans done after clinical deterioration.1 Contralateral DEDH after the evacuation of EDH in a patient is very rare. Very few cases were published in the literature.
Showing details of previous delayed extradural haematoma (DEDH) case reports
| S. no age/sex | Author | Primary EDH details | Delayed EDH details | The duration between primary evacuation and DEDH | Outcome | Mode of injury |
| 1 40/M |
Koga et al 23 | Right FP EDH + right FP # OF: bleed source right MMA |
Left F EDH OF: dural venous bleed |
7 hours | Discharged after 5 months with mild gait disturbance | Road traffic accident (RTA) |
| 2 45/M |
Reale et al 21 24 | Left TP EDH + linear fracture extending bilaterally from both temporal bones OF: bleed source MMA |
Right TP EDH OF: superior sagittal sinus |
Immediately | Discharged home after 40 days of Intensive care unit (ICU) stay and 10 days of ward stay | Fall from the stairway |
| 3 21/M |
Balasubramaniyam et al 25 | Right P EDH OF: bleed source dural arterial branch |
Left F EDH OF: dural arterial branch |
20 hours | Within hours conscious oriented | Fell from a moving bus |
| 4 31 /M |
Burbridge et al 26 | Right FP EDH + fracture OT: bleed source not mentioned |
Left TP EDH + fracture OF: bleed source not mentioned |
10 hours | Not mentioned | RTA |
| 5 31/M |
Rochat et al 27 | Right T EDH + right petrous # OF: bleed source MMA |
Left TO EDH OF: bleed source MMA |
4 hours | After 2 weeks, transferred to rehabilitation | Assault |
| 6 44/M |
Rochat et al 27 | Left F EDH + right PO linear # with underlying thin bleed + b/l diffuse Subarachnoid hemorrhage (SAH) OF: bleed source not mentioned |
Right O EDH OF: arterial bleed |
4 hours | Transferred to the rehabilitation after 4 days | RTA |
| 7 18/M |
Eftekhar et al 19 | Right FT EDH + left temporal contusion OF: bleed source MMS, brain bulge |
Left TP EDH OF: bleed source not mentioned |
Immediately | Not mentioned | Fall from 3 m in height |
| 8 25/M |
Wani et al 20 | Right FT EDH + multiple linear fractures OF: bleed source not mentioned, brain bulge present |
Left TP EDH | Next day | Discharged in a conscious oriented state | Assault(table 1) |
| 9 28/M |
Sharma et al 21 | Right FP EDH + left temporal contusion, left FT linear fracture OF: bleed source MMA, dura was tense |
Left FP EDH + left FT linear fracture | Immediately after the first surgery | The patient remained severely disabled | Assault |
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#, Fracture; F, Frontal; MMA, Middle meningeal artery; O, Occipital; OF, Operative finding; P, Parietal; T, Temporal.
One of the well-accepted hypotheses for DEDH is the sudden loss of tamponade effect after treatment of intracranial hypertension seen after the evacuation of EDH, SDH, or decompressive craniectomy or medical management with cerebral decongestant medication.3 5 11 12 In a case series by Talbott et al, among 203 post-traumatic decompressive craniectomies following Traumatic brain injury (TBI), 12 have developed DEDH after decompressive surgery.13 Spontaneous EDH is also a well-known complication of CSF drainage, so can be a cause of DEDH in post-traumatic Cerebrospinal fluid (CSF) leak patients.14–16 This explains that sudden loss of intracranial pressure can lead to the formation of EDH due to extra space available in the calvarium. Another hypothesis explaining the cause of DEDH is mechanical ventilation leading to increased venous pressure causing venous bleeding and DEDH.17 But according to Ford and McLaurin, venous bleeding alone is less likely to cause dural stripping unless it is previously stripped.18
In most cases, contralateral DEDH after the initial evacuation of EDH was associated with a skull fracture around the DEDH location. In a review article by Gregori et al, skull fracture was observed at the DEDH site in two-thirds of cases.3 Among the 12 DEDH cases in Talbott et al series who developed DEDH after decompressive craniectomy, all of them have a skull fracture at the site of DEDH.13 This finding is consistent with the right frontal bone fracture observed in our case.
Another interesting intraoperative finding that we have noticed in our case is, that the dura was tense after the initial evacuation of right frontoparietal EDH. Which suggests that there is some underlying pathology leading to raised ICP. Similar findings were noted by Eftekhar et al, Wani et al and Sharma et al.19–21
In the immediate postoperative period, close clinical, radiological and intracranial pressure monitoring will guide us towards this DEDH entity early, so that we can act on this promptly. There are various modalities direct or indirect to monitor ICP in ICU settings. Among the recent and non-invasive, near-infrared spectroscopy will be very useful in this kind of clinical situation.22
Learning points
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Delayed contralateral extradural haematoma (EDH) is a rare but known complication, especially if there is a skull fracture contralateral to first EDH or if tense dura was noted beneath EDH during initial surgical evacuation.
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If not diagnosed timely with caution, may lead to severe morbidity and mortality.
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So high index suspicion is needed in EDH cases, especially in cases with associated contralateral skull fractures and tense underlying dura during the initial evacuation of EDH.
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Immediate postoperative scan or urgent scan in an operated EDH patient if neurological condition deteriorates is key to diagnosing contralateral DEDH timely.
Ethics statements
Patient consent for publication
Footnotes
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Contributors RP: acquisition of data, assisting surgeon and reporting. RR: operating surgeon and planning. GB: assisting surgeon and planning. RA: conception and design.
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Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
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Competing interests None declared.
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Provenance and peer review Not commissioned; externally peer reviewed.
- © BMJ Publishing Group Limited 2022. No commercial re-use. See rights and permissions. Published by BMJ.
References
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