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Bilateral epidural hematoma

Article  in  Neurosurgical Review · April 2000

DOI: 10.1007/s101430050028 · Source: PubMed

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Neurosurg Rev (2000) 23:30–33 © Springer-Verlag 2000

O R I G I N A L A RT I C L E

A. Görgülü · S. Çobanoǧlu · S. Armaǧan

H. Karabaǧlı · M. Tevrüz

Bilateral epidural hematoma

Received: 2 June 1998 / Accepted: 15 April 1999

Abstract Bilateral epidural hematomas are very rare creased the number of cases diagnosed as bilateral epidu-
and are associated with high mortality. The purpose of ral hematoma [1-3, 8, 10-16]. In this study, we present
this study is to identify the clinical features, mecha- our experience with 19 patients thus diagnosed.
nisms, and outcomes of bilateral epidural hematomas.
This report considers 19 cases of bilateral epidural he-
matoma hospitalized between 1987 and 1997. All of the Materials and methods
cases, with the exception of three, were diagnosed within
the first 6 h. The neurologic evaluations on admission and This study examines 19 bilateral epidural hematoma cases hospital-
during hospital stay were based on the Glasgow ized between 1987–1997 at the Neurosurgery Clinics of Hay-
Coma Scale. Hematomas were determined by CT scans in darpas‚a Numune Hospital and Trakya University Hospital, which
are main centers serving the Marmara and Trakya regions of Tur-
all cases. The patients were evaluated using the Glasgow key, respectively. First examination findings and clinical follow-up
Outcome Scale after 6 months. In 13 patients, the bilateral were based on the Glasgow Coma Scale (GCS). Hematomas were
epidural hematoma was in the midline. In six patients, he- determined by CT scans in all cases. In total, 18 of the patients
matomas were at different locations on either side. Surgical were treated surgically. Surgical approaches were made via bilater-
al craniotomies. Priority was given to hematomas on the dominant
approach was chosen as the primary treatment modality in side, as long as their volumes were equal, or to those with greater
18 patients. One was treated conservatively. The mortality volume. Only one case was treated conservatively, since his GCS
rate was 15.7% in this series. With the widespread use of showed 15 with no neurological deficit. The patients were evaluat-
CT scan, diagnosis before deterioration of the neurological ed by the Glasgow Outcome Score (GOS) after 6 months.
status affects the results of surgery and prognosis or even
presents the possibility of a conservative treatment.
Results
Key words Bilateral epidural hematoma · Head injury
Bilateral epidural hematoma comprised 2.58% of all our
cases with epidural hematoma (n=736). A total of 13
Introduction cases were brought to the emergency unit after traffic ac-
cidents and 6 after falls. Of these, 15 patients were male
Epidural hematomas are one of the most common com- (78.9%) and 4 female (21.1%), with ages ranging from
plications of closed head injuries. They rarely show bi- 11 to 52 years (mean 34.2 years).
lateral localization. A case with bilateral epidural hema- Acute bilateral epidural hematomas were diagnosed in
toma was first reported by Roy in 1884 [17]. The wide- 16 cases. The GCS was between 13–15 in 5, 8–12 in 6
spread use of computed tomographic (CT) scan has in- and 3–7 in 5. The skull X-rays showed a sagittal suture
separation in 1 patient, linear skull fractures with two dif-
ferent localization in 5, and crossing fracture over the sag-
A. Görgülü (✉)
Trakya Üniversitesi Tıp Fakültesi, Nöros‚rürji Anabilim Dali, ittal sinus in the others. The localization of epidural he-
22030 Edirne, Turkey matomas in CT scan were bifrontal in 7, and were bioc-
S. Çobanoǧlu
cipital in 3 patients. In another case, there were bilateral
Trakya University School of Medicine, occipital fractures crossing the transverse sinus, bilateral
Department of Neurosurgery, Edirne, Turkey epidural hematoma could be seen from the foramen mag-
S. Armaǧan · H. Karabaǧlı · M. Tevrüz num to the vertex(Fig. 1). Main clinical features of acute
Haydarpas‚a Numune Hospital, Department of Neurosurgery, bilateral epidural hematoma either in middline were sum-
Istanbul, Turkey marized in Table 1. The localization’s of epidural hemato-
 31
Fig. 1 Bilateral epidural hema-
toma extending from the poste-
rior fossa to the vertex

Table 1 Main clinical features of acute bilateral epidural hematoma in either side of midline

Case Trauma GCS Fracture Fracture Hematoma Treatment GOS

diagnosis Right Left
interval
(hours)

1 6 10 Occipital Occipital Bioccipital Surgical 5

2 1 14 Frontoparietal Frontal Bifrontal Surgical 5
3 1 14 Occipital Parieto-occipital Bioccipital Surgical 5
4 6.5 15 Frontal Frontal Bifrontal Conservative 5
5 2 14 Frontal Frontoparietal Bifrontal Surgical 5
6 5 6 Frontal Frontal Bifrontal Surgical 1
7 6 9 Frontoparietal Frontal Bifrontal Surgical 5
8 3 6 Frontoparietal Frontal Bifrontal Surgical 5
9 2 5 Occipital Occipital From foramen Surgical 1
magnum to the vertex
10 2 14 Frontal Frontal Bioccipital Surgical 5
11 2 9 Sagittal suture separation Bifrontal Surgical 5

Table 2 Main clinical features of acute bilateral epidural hematoma at different sides of midline

Case Trauma GCS Fracture Fracture Hematoma Treatment GOS

diagnosis Right Left
interval

1 30 min 11 Parieto-temporal Temporal Right parietal–left temporal Surgical 5

2 5h 9 Temporal Parietal Right temporal–left parietal Surgical 5
3 1h 7 Temporal Frontoparietal Right temporal–left parietal Surgical 3
4 4h 4 Temporal Parieto-temporal Right temporal–left temporal Surgical 1
5 4h 8 Parieto-temporal Temporal Right parietal–left temporal Surgical 5

Table 3 Main clinical features of late term bilateral epidural hematoma

Case First Trauma First CT findings First treatment Second Trauma Second CT findings Second GOS
GCS First CT GCS diagnosis treatment
interval interval
(hours) (hours)

1 12 2 Bilateral frontal Dexametasone 8 6 Bifrontal epidural Surgical 5

fracture, cerebral hematoma, bilateral
edema frontal fracture,
cerebral edema

2 12 3 Bilateral frontal Dexametasone 9 8 Bifrontal epidural Surgical 5

fracture, cerebral hematoma, bilateral
edema frontal fracture,
cerebral edema

3 10 5 Left temporal, Dexametasone 15 7 Left frontoparietal Surgical 5

right frontoparietal (11 mm), right parietal
fractures, (27 mm) epidural
left frontoparietal hematoma,
EDH (11 mm), left fronto parietal,
cerebral edema right parietal fractures
32

ma in five patients were various (Table 2). All cases ex- epidural hematoma 11 mm. in diameter at left frontotem-
cept one were treated surgically. One patient with a GCS poral localization. There was no midline shift (Fig. 3A).
of 15 was managed conservatively; he had epidural hema- It showed no other hematoma on the right side (Fig. 3B).
toma bifrontally with a thickness of 15 mm. This case was A conservative management and follow up with serial
managed with observation and intermittent CT scans. CT CT scans was decided upon. Although his GCS on day 3
scan revealed resorption of hematomas within 17 days. increased to 15, we were unable get a CT scan due to socio-
In three cases, bilateral epidural hematoma developed economic problems of the family. A control CT scan could
during follow-up (Table 3). Two of these, with a frontal be obtained on day 7, although no change was observed in
linear fracture crossing the superior sagittal sinus, were left frontoparietal epidural hematoma (Fig. 3C), an addi-
brought to the hospital 2 and 3 h after their trauma and tional right parietal EDH of 27 mm in diameter was seen
cerebral edema was determined in their first CT scans (Fig. 3D). On seeing the development of epidural hemato-
(Fig. 2A). They were managed conservatively. The con- ma at late stages, it was decided that these three cases
trol CT scans revealed that bilateral frontal epidural he- should be treated surgically. GOS of three cases were 5
matoma developed 6 h after admission (Fig. 2B). A lin- when they were discharged from the hospital. The mortality
ear fracture extending from left temporal to the right pa- rate was 15.7% in this series.
rietal bone was identified in the third case, brought to
hospital 5 h after the trauma with GCS of 10. CT scan of
this case showed moderate diffuse cerebral edema and Discussion
Epidural hematoma usually occurs unilaterally. Bilateral
epidural hematomas are very rare. They consist of 2–10%
of all acute epidural hematomas in adults [6, 8–10]. The
ratio was 2.21 in this study. In the pediatric age group, it
is exceedingly rare [8]. However, Dharker et al. [6] found
a very high incidence of up to 20% in the pediatric age
group. Our ratio in the same group was 5.2%.
Bilateral epidural hematomas are accompanied by
loss of consciousness at higher rates. Frank et al. [8] re-
ported that there was no loss of consciousness in 2% of
64 bilateral epidural hematoma cases examined by him.
However, GCS in 45% of Dharker’s [6] series were 14
Fig. 2 A First CT scan on admission, showing a diffuse brain ede- and 15 and less than 8 in only 30% of his cases. Feuer-
ma. B Second CT scan 6 h after first CT scan, showing the presence man et al. [7] reported asymptomatic acute bilateral epi-
of bilateral epidural hematoma which was absent on the first CT scan dural hematoma in a case with minor head trauma. In

Fig. 3 A Initial CT scan

showed the presence of a left
frontoparietal small epidural
hematoma. B Initial CT scan
showed no other hematoma on
the right side. C Repeated CT
scan carried out 7 days after the
initial scan, showed the same
epidural hematoma which was
present in (A). D Second CT
scan showed an additional right
parietal epidural hematoma
 33

this study, one patient had 15 points of GCS and another the other 17 cases with acute or late bilateral epidural he-
four patients had 14 points on the GCS. In the case with matoma, the origin of the bleeding was venous.
a GCS of 15 the diagnosis was made by CT scan on the Barlow and Kohi [2] reported that dominant-sided
patient’s complaint of headache and a linear fracture epidural hematoma should predominantly be evacuated
crossing the vertex seen on skull X-ray examination. On- in order to prevent serious neurological sequels. All of
ly five cases had GCS 7 or less (26.3%). Identification of our cases except one was treated surgically. In the case
the higher number of cases with bilateral epidural hema- of bilateral epidural hematoma with different volumes
toma without any loss of consciousness as in Dharker’s the side with a larger volume of hemorrhage had to be
[6] and our series may have been due to the result of evacuated primarily, followed by the opposite side.
widespread use of cranial CT scan in head injury cases. When the volumes of the hematomas were equal, the
Bilateral epidural hematoma are produced when dura dominant-sided hematoma was first evacuated.
mater is separated into two locations by a single directed High mortality rates (42–100%) have been reported in
impact. A lateral force can strip the dura mater at the old series on bilateral epidural hematoma [8, 18]. This
side of impact by the inward and outward bending of the rate was 20% in Dharker’s [6] series and 15.7% in our
skull as described by Bell [8]. Guardjian [9] has reported series. With the widespread use of CT scan, diagnosis
that the dural stripping on the opposite side may occur before deterioration of the neurological status affects the
due to motion of the skull, further aggravated by the de- results of surgery and prognosis and even presents the
crease in intracranial pressure found at the antipode of possibility of a conservative treatment.
the compression forces. Frank et al. [8] thought that the
more common directions of the force of impact in the pa-
tients who developed bilateral epidural hematoma tend References
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