CC BY-NC-ND 4.0 · Arquivos Brasileiros de Neurocirurgia: Brazilian Neurosurgery 2019; 38(04): 324-327
DOI: 10.1055/s-0039-1695760
Case Report | Relato de Caso
Thieme Revinter Publicações Ltda Rio de Janeiro, Brazil

Large Vertex Epidural Hematoma: Case Report and Review of Surgical Approaches

Volumoso hematoma epidural do vértex: relato de caso e revisão de estratégias cirúrgicas
1   Departament of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
,
Luana Medeiros
1   Departament of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
,
Fábio B. Silva
1   Departament of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
,
Renata N. Velloso
1   Departament of Integrative Medicine, Hospital Universitário Onofre Lopes, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
› Author Affiliations
Further Information

Publication History

13 December 2018

01 July 2019

Publication Date:
03 September 2019 (online)

Abstract

Vertex epidural hematomas (VEHs) are a special clinical entity due to their clinical presentation, vascular etiology and options of surgical approach. The clinical suspicion involves recognizing the mechanism of the injury and the correct visualization of the hematoma in computed tomography (CT) coronal sequences. In the present article, we describe a case of a very large (146 mL) VEH with central brain herniation, and provide a technical note on the surgical planning and treatment. A 34-year-old male patient was admitted to the hospital after an injury on the left superior parietal region. The Glasgow coma scale score was 6, and the left pupil of the patient was dilated. The CT scan showed a large epidural hematoma on the vertex between the coronal e lambdoid sutures, and a fracture over the sagittal suture. During the surgery, multiple burr holes were made laterally to the sagittal suture, and after inspection and no visualization of bleeding in the superior sagittal sinus (SSS), we performed a standard biparietal craniotomy. The patient was discharged three days after the surgery without any deficits. Currently, with the improvement in imaging modalities, more cases of VEH are being identified. Identifying the etiology prior to the craniotomy is challenging in severe cases. Tears in the SSS can bleed profusely, and they demand strategies during the craniotomy. With multiple burr holes parallel to the sagittal suture, we can visualize whether there is bleeding in the SSS and design a craniotomy with or without a central osseous bridge to anchor the dura. Neurosurgeons must be prepared to plan a surgical strategy in cases of large VEHs. Due to its rare frequency and bleeding risks, VEHs are considered challenging.

Resumo

O hematoma epidural do vértex (HEV) é uma entidade clínica especial particularmente por sua sintomatologia, etiologia vascular e tratamento. A suspeita clínica envolve o reconhecimento do mecanismo do trauma e a correta visualização de sequências coronais na tomografia. Descrevemos no presente artigo um paciente com volumoso HEV (146 mL) com herniação central e detalhes do planejamento cirúrgico. Paciente de 34 anos, do sexo masculino, deu entrada no hospital após agressão na região parietal esquerda superior. A escala de coma de Glasgow foi de 6 pontos, com dilatação pupilar esquerda. A tomografia demonstrou grande HEV entre as suturas coronal e sagital associado a fratura. Na cirurgia, realizamos múltiplas trepanações lateralmente à sutura sagital e, após inspeção do seio sagital superior (SSS), fizemos uma ampla craniotomia biparietal. Após 3 dias, o paciente recebeu alta sem déficits. Atualmente, mais casos de HEV são identificados radiologicamente por conta de melhoras nas modalidades de exames radiológicos. Identificar a etiologia antes de realizar a craniotomia é desafiador em casos graves. Lesões no SSS podem apresentar sangramento volumoso, o que exige o uso de estratégias durante a craniotomia. Com múltiplas trepanações paralelas à sutura sagital, podemos antecipar se há ou não sangramento ativo do SSS e desenhar uma craniotomia com ou sem ponte óssea central de ancoramento dural. Neurocirurgiões devem estar preparados para planejar uma estratégia cirúrgica em casos de HEV. Por sua raridade e potencial de sangramento, os HEVs são considerados desafiadores.

 
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