|Year : 2016 | Volume
| Issue : 3 | Page : 400-402
Ipsilateral double extradural hematoma in a child: An uncommon case
Sharad Pandey, Kulwant Singh, Vivek Sharma, Deepak Bhanudas Patil
Department of Neuro Surgery, Sir Sunder Lal Hospital, IMS, BHU, Varanasi, Uttar Pradesh, India
|Date of Web Publication||17-May-2016|
Department of Neuro Surgery, Sir Sunder Lal Hospital, IMS, BHU, Varanasi - 221 005, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Double extradural hematomas (DEDH) comprise 2-10% of all extradural hematomas (EDH). The ipsilateral occurrence of more than one EDH is quite uncommon. We are reporting a case of ipsilateral DEDH in a 10-year-old child following a head injury. Though DEDH is extremely lethal and a rare diagnosis, ipsilateral DEDH is still uncommon. Furthermore, the occurrence of EDH in the pediatric age group is quite unusual. As compared to single EDHs, DEDH should be considered more urgently for neurosurgical intervention.
Keywords: Double extradural hematomas, ipsilateral, pediatric
|How to cite this article:|
Pandey S, Singh K, Sharma V, Patil DB. Ipsilateral double extradural hematoma in a child: An uncommon case. Med J DY Patil Univ 2016;9:400-2
|How to cite this URL:|
Pandey S, Singh K, Sharma V, Patil DB. Ipsilateral double extradural hematoma in a child: An uncommon case. Med J DY Patil Univ [serial online] 2016 [cited 2020 May 26];9:400-2. Available from: http://www.mjdrdypu.org/text.asp?2016/9/3/400/182523
| Introduction|| |
Double extradural hematomas (DEDH) have an overall incidence of 2-10% of all extradural hematomas (EDHs).  The ipsilateral occurrence of more than one EDH is uncommon. This injury has a mortality rate of >30%.  We reported a case of ipsilateral DEDH in a child secondary to fall from height. This case report intends to discuss the presentation, diagnosis, and management of this injury.
| Case Report|| |
A 10-year-old female child was referred from district hospital to our Emergency Department with a history of fall from the roof. She was managed conservatively at district hospital where her condition deteriorated progressively within 6 h. On clinical examination, the patient was not oriented to time, place, and person, Glasgow Coma Score (GCS) was E3V4M5. Features of raised intracranial tension were present. Pupillary reflex in the right eye was absent and the pupil was semi-dilated. Routine laboratory tests were within normal limits. X-ray cervical spine showed no abnormality. Noncontrast computed tomography (NCCT) head showed evidence of well-defined blood attenuation (CT attenuation value 66 HU) biconvex extra-axial collection in right frontal region with maximum width 14 mm and another extra-axial collection in right temporal region with maximum width 10 mm [Figure 1]. The mass effect with midline shift measuring approximately 5 mm toward the left was reported with evidence of a linear undisplaced fracture of squamous part of right temporal bone with superior extension into frontal bone [Figure 2]. An emergency right frontal and right temporal trephine craniotomy were done. Intraoperatively, gentle evacuation of EDH with irrigation and suction was done [Figure 3]. Adequate hemostasis was achieved with placement of dural hitch sutures at margins of the craniotomy thus allowing brain expansion, preventing extradural dead space formation and possible blood re-accumulation [Figure 4]. Postoperative period was uneventful. The patient was discharged on the eight postoperative days with improved neurological status.
|Figure 1: Noncontrast computed tomography showing right frontal and temporal extradural hematoma with mid line shift|
Click here to view
|Figure 2: Noncontrast computed tomography showing a linear fracture of squamous part of right temporal bone with extension into frontal bone|
Click here to view
|Figure 3: Intraoperative photograph showing right frontal and right temporal trephine craniotomy with hematoma|
Click here to view
|Figure 4: Intraoperative photograph showing adequate hemostasis with dural hitch sutures at the margin of the craniotomy|
Click here to view
| Discussion|| |
DEDH is an uncommon diagnosis and a neurosurgical emergency. The mortality rate of DEDH exceeds 30%. DEDH may be unilateral or bilateral and accounts for 2-25% of all EDHs.  The frontal lobe is the most common site. The reported incidence in most series is 2-10% of EDH, with the unilateral variant comprising only 8.6% of that subgroup.  Most often DEDH occurs bilaterally due to the coup and countercoup injury but the occurrence of two or more EDH on one side is also witnessed and is quite rare. Dawar et al. reported a similar case of same side double chronic calcified EDH in an 18-year-old boy as a result of coup injury on right frontal aspect and the countercoup injury at right fronto-parietal region.  In our case, there was DEDH as a result of linear contact injury causing separation of periosteal dura from bone and disruption of interposed vessels due to shearing stress. Baugh et al. reported a similar case of complex polytrauma causing DEDHs in 20-year-old female.  The hematoma arises from injury to the middle meningeal artery (MMA) in over half of the patients, from the middle meningeal vein in one-third and from diploic veins or a torn dural venous sinus in the remaining. 
In the present case, the right temporal EDH occurred due to bleeding from the branch of MMA and the frontal EDH occurred due to dural stripping following trauma. MMA most commonly arises from the maxillary artery and supplies blood to cranial dura mater. Through numerous perforating branches, it nourishes the periosteum on the inner aspect of cranial bones. It enters the middle cranial fossa through the foramen spinosum, and courses between the dura mater and the inner aspect of the vault of the skull and then divides into two strong terminal branches anterior and posterior MMA.  The anterior MMA (frontal) supplies blood to bones forming anterior cranial fossa and the anterior part of the middle cranial fossa and the posterior MMA (parietal branch) runs more horizontally toward the back and supplies posterior part of the middle cranial fossa and supratentorial part of the posterior cranial fossa. 
There may be variations in its origin and MMA may arise from the inferior posterior cerebellar artery, basilar artery, lateral aspect of the internal carotid artery, maxillary artery from the third portion (pterygopalatine), the ascending pharyngeal artery, completely, or partially from the ophthalmic artery. 
Unlike the classic EDH, DEDH is most often venous in origin.  Expansion of an EDH may also result from repeated bleeding from the inner table of the skull  or due to oozing from the dural surface veins.
NCCT head is diagnostic in this clinical condition. Magnetic resonance imaging is time-consuming and no way superior to CT. Another diagnostic modality now under development is near infrared spectroscopy which can be used with reasonable sensitivity and specificity for detection of intracranial lesions in a short span of time.  Cervical spine evaluation usually is necessary to rule out neck injury associated with EDH. Simultaneous evacuation of both hematomas is the preferred management for DEDH.
The occurrence of EDH in the pediatric age group is unusual as the dura mater is relatively firmly adhered to the inner table and suture line. In children, EDH is of venous origin, and it takes longer time for the blood to accumulate inadequate volume to cause significant mass effect. Thus, most children and infants with EDH do not deteriorate rapidly and present later.  We reviewed literature and found no case of ipsilateral DEDH has been reported in a child so far.
Extradural hematoma is considered to be the most serious complication of a head injury. As compared to single EDHs, DEDH is characterized by lower GCS at presentation and rapid neurological deterioration. An ipsilateral DEDH is a rare entity and even rarer in children and should be considered an emergency necessitating transfer to a nearest trauma center for neurosurgical treatment leading to excellent results.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baugh AD, Baugh RF, Atallah JN, Gaudin D, Williams M. Craniofacial trauma and double epidural hematomas from horse training. Int J Surg Case Rep 2013;4:1149-52.
Huda MF, Mohanty S, Sharma V, Tiwari Y, Choudhary A, Singh VP. Double extradural hematoma: An analysis of 46 cases. Neurol India 2004;52:450-2.
Dawar P, Phalak M, Sinha S, Sharma BS. Same side double chronic calcified epidural hematoma: Case report and review of literature. Neurol India 2013;61:195-7.
Miller JD, Murray LS, Teasdale GM. Development of a traumatic intracranial hematoma after a "minor" head injury. Neurosurgery 1990;27:669-73.
Chmielewski P, Skrzat J, Walocha J. Clinical importance of the middle meningeal artery. Folia Med Cracov 2013;53:41-6.
Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surg Neurol 1982;17:218-22.
Francis SV, Ravindran G, Visvanathan K, Ganapathy K. Screening for unilateral intracranial abnormalities using near infrared spectroscopy: A preliminary report. J Clin Neurosci 2005;12:291-5.
Kaye EM, Cass PR, Dooling E, Rosman NP. Chronic epidural hematomas in childhood: Increased recognition and non-surgical management. Pediatr Neurol 1985;1:255-9.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]