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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| #, Fracture; F, Frontal; MMA, Middle meningeal artery; O, Occipital; OF, Operative finding; P, Parietal; T, Temporal. | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 1 40/M |
Koga et al23 | 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 al21 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 al25 | 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 al26 | 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 al27 | 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 al27 | 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 al19 | 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 al20 | 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 al21 | 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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