American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Rapid spontaneous redistribution of acute epidural hematoma☆
Abstract Acute epidural hematoma is a neurosurgical emergency that requires early recognition and urgent operation. Radiologically significant or symptomatic acute traumatic epidural hematomas (AEDHs) are typically treated by rapid surgical decompression. Various authors have reported the resolution of AEDHs managed conservatively with perfect clinical and radiologic outcome. The rapid spontaneous resolution of EDH is an extremely rare phenomenon. Herein, we report on a case of AEDH that rapidly disappeared without surgical intervention and discuss possible mechanisms in review of the literature. Acute traumatic epidural hematoma (AEDH) is one of the most critical emergencies. The rapid spontaneous resolution of EDH is an extremely rare phenomenon, and to our knowledge, there are only 12 cases in the English medical literature that show the rapid disappearance of AEDH without surgical intervention [1–4]. Herein, we report on a case of AEDH that rapidly disappeared without surgical intervention and discuss possible mechanisms in review of the literature. A 26-year-old man was admitted to the emergency department after a fall from 7 m on his head an hour before the admission. Upon arrival, he complained of severe headache. Witnesses reported that he lost consciousness right after the fall for a brief period, but then he regained consciousness before the ambulance has arrived. On neurologic examination, he had mild confusion, with the Glasgow Coma Scale (GCS) score being 13 (eye 3, motor 6, verbal 4), and he had equal and reactive pupils. There was no disturbance in motor or sensory function; there was no cranial nerve paresis. Physical examination was unremarkable, except the swelling on his left temporal area, a probable hematoma. A computed tomographic (CT) scan of the head was performed an hour after the injury, and it revealed an AEDH of 8.5 mm at its maximum thickness with an overlying fracture in the left temporal bone and pneumocephalus. There was also an oblique fracture line in mastoid and squamous piece of the temporal bone. There was no midline shift (Fig. 1). The patient's blood test results were within the normal limits with no evidence of coagulopathy. During emergency follow-up, the patient vomited 4 times in an hour, and his confusion has gradually recovered to being fully alert. A second nonenhanced cranial tomography that was performed just 2 hours after the initial tomography revealed total disappearance of the epidural hemorrhage and pneumocephalus that had been seen on the previous CT scan (Fig. 2). The patient was managed conservatively in the intensive care unit for 2 days with ☆ This paper is written in US English.
provision to proceed to surgical decompression in the event of neurologic change. On the 3rd day, he was discharged with instructions to return in case of emergency, and on his 7th and 30th days of follow-up, there were no complications. Epidural hematoma is a type of intracranial hemorrhage wherein a buildup of blood occurs between the duramater and the skull. Accumulation of blood increases pressure in the intracranial space, compresses brain tissue, and may cause brain shift. Most epidural bleedings originate from meningeal arteries, 10% of them may be venous. Particularly in the temporal region, epidural hematomas originate from the middle meningeal artery [2,3]. In our patient, the AEDH was also probably of arterial origin because the blood accumulation was fast and it occurred in the temporal region after a trauma. Acute traumatic epidural hematoma is a neurosurgical emergency that requires early recognition and urgent operation. Radiologically significant or symptomatic AEDHs are typically treated by rapid surgical decompression [1–4]. Smaller, asymptomatic AEDH can be treated conservatively with close clinical observation. Various authors have reported the resolution of AEDHs managed conservatively with perfect clinical and radiologic outcome. The use of CT has allowed the
Fig. 1. Computed tomographic scan illustrating acute epidural hematoma and pneumocephalus.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Coskun S, et al, Rapid spontaneous redistribution of acute epidural hematoma, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.02.029
2
S. Coskun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 2. Total disappearance of the epidural hemorrhage and pneumocephalus that had been seen on the previous CT scan.
serial imaging and the possibility of nonoperative management. The spontaneous resolution of AEDH begins in the second week after trauma [2]. Although various mechanisms of disappearance of hematoma have been suggested, the underlying mechanism is not yet clear. The cited mechanism of the resolution of an EDH differs; formation of a fibrovascular neomembrane, granulation tissue acting as an absorbing structure through sinusoid vessels, and transfer of the clot into diploic bone or extracranial space through the fractures are among the major hypotheses for spontaneous resolution. Rapid resolution of EDHs is rarely seen and reported. Herein we discuss a rapid spontaneous resolution of AEDH. The disappearance of an AEDH within hours after admission to the emergency department is very rare. To the best of our knowledge, there are only 12 cases in the English literature up to this day [2,4]. Similar to our case, all cases of AEDH that disappeared in 24 hours had an overlying linear skull fracture. The presence of skull fracture can allow communication between the epidural region and extracranial tissues. Transfer of collection to the subgaleal space can relieve compression caused by the hematoma [3]. Aoki [1] supports this finding, in a case report in which there was an increase in the volume of an epicranial hematoma, whereas a decrease in the size of the AEDH was detected. In this circumstance, if there is a linear fracture neighboring an epidural hematoma that can allow the drainage of blood, epidural hematomas can rapidly dissolve spontaneously [5,6]. In our case, the first CT revealed epidural hematoma and intracranial pneumocephalus adjacent to the fracture line; there was also an oblique fracture line in mastoid and squamous piece of the temporal bone. Because our patient had fractures involving the mastoid portion of the temporal bone, it is reasonable to consider that the air in the epidural hematoma originated from the mastoid air cells. The second CT that was performed 2 hours after the first CT revealed complete disappearance of the EDH and pneumocephalus. There was extracranial air and blood adjacent to the fracture line. In physical
examination, there was no scalp laceration that could cause air to penetrate under the scalp. We believe that the rapid disappearance of the AEDH and the presence of extracranial air under the scalp are due to the leakage of blood and air to epicranial area via an overlying linear fracture. Lack of pneumocephalus in the second CT also supports this proposal. Our case has vomited 4 times in an hour in the emergency department. We know that emesis is a result of increased intracranial pressure, and it also increases intracranial pressure. Emesis may have resulted in temporary raise in intracranial pressure by raising intra-abdominal pressure, and that may have forced the hematoma from the fracture to the extracranial space. During the emergency and intensive care unit follow-up, the patient did not deteriorate. We believe that the rapid redistribution of blood to extracranial space has protected our patient from second deterioration phase after he regained consciousness, and because of that, there was no lucid interval. However, unfortunately, there is no diagnostic tool at present to identify patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results. Conservative treatment should be prescribed only for those patients who exhibit improving neurologic signs early in the clinical course [7]. This report describes a mechanism for the rapid disappearance of an AEDH. The case is characterized by the rapid disappearance of an AEDH associated with an overlying skull fracture. We believe that it was possible due to the redistribution of hematoma rather than its resolution. In our case, AEDH seems to have redistributed from intracranial space to extracranial space through the overlying skull fracture. Selcuk Coskun MD Beliz Oztok MD Gul Pamukcu Gunaydın MD Gulhan Kurtoglu Celik MD Department of Emergency Medicine Ankara Ataturk Training and Research Hospital Ankara, Turkey E-mail addresses: [email protected], [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2014.02.029
References [1] Aoki N. Rapid resolution of acute epidural hematoma. Report of two cases. J Neurosurg 1988;68(1):149–51. [2] Tataryn Z, Botsford B, Riesenburger R, Kryzanski J, Hwang S. Spontaneous resolution of an acute epidural hematoma with normal intracranial pressure: case report and literature review. Childs Nerv Syst 2013;29(11):2127–30. [3] Deniz FE, Türk CC, Ismailoğlu O, Bozkurt G, Ozcan OE. Rapid spontaneous resolution of epidural hematoma: a case report. Ulus Travma Acil Cerrahi Derg 2010;16 (3):280–2. [4] Eom KS, Park JT, Kim TY, Kim JM. Rapid spontaneous redistribution of acute epidural hematoma: case report and literature review. J Korean Neurosurg Soc 2009;45 (2):96–8. [5] Celikoğlu E, Süsülü H, Delatioğlu M, Ceçen A, Hakan T, Bozbuğa M. Rapid spontaneous resolution of an acute epidural hematoma. Ulus Travma Derg 2002;8(2):126–8. [6] Malek AM, Barnett FH, Schwartz MS, Scott RM. Spontaneous rapid resolution of an epidural hematoma associated with an overlying skull fracture and subgaleal hematoma in a 17-month-old child. Pediatr Neurosurg 1997;26(3):160–5. [7] Aoki Y, Yamagata M, Shimizu K, Ikeda Y, Nakajima F, Ohtori S, Takahashi K. An unusually rapid spontaneous recovery in a patient with spinal epidural hematoma. J Emerg Med 2012;43(2):e75–9.
Please cite this article as: Coskun S, et al, Rapid spontaneous redistribution of acute epidural hematoma, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.02.029
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Rapid spontaneous redistribution of acute epidural hematoma☆
Abstract Acute epidural hematoma is a neurosurgical emergency that requires early recognition and urgent operation. Radiologically significant or symptomatic acute traumatic epidural hematomas (AEDHs) are typically treated by rapid surgical decompression. Various authors have reported the resolution of AEDHs managed conservatively with perfect clinical and radiologic outcome. The rapid spontaneous resolution of EDH is an extremely rare phenomenon. Herein, we report on a case of AEDH that rapidly disappeared without surgical intervention and discuss possible mechanisms in review of the literature. Acute traumatic epidural hematoma (AEDH) is one of the most critical emergencies. The rapid spontaneous resolution of EDH is an extremely rare phenomenon, and to our knowledge, there are only 12 cases in the English medical literature that show the rapid disappearance of AEDH without surgical intervention [1–4]. Herein, we report on a case of AEDH that rapidly disappeared without surgical intervention and discuss possible mechanisms in review of the literature. A 26-year-old man was admitted to the emergency department after a fall from 7 m on his head an hour before the admission. Upon arrival, he complained of severe headache. Witnesses reported that he lost consciousness right after the fall for a brief period, but then he regained consciousness before the ambulance has arrived. On neurologic examination, he had mild confusion, with the Glasgow Coma Scale (GCS) score being 13 (eye 3, motor 6, verbal 4), and he had equal and reactive pupils. There was no disturbance in motor or sensory function; there was no cranial nerve paresis. Physical examination was unremarkable, except the swelling on his left temporal area, a probable hematoma. A computed tomographic (CT) scan of the head was performed an hour after the injury, and it revealed an AEDH of 8.5 mm at its maximum thickness with an overlying fracture in the left temporal bone and pneumocephalus. There was also an oblique fracture line in mastoid and squamous piece of the temporal bone. There was no midline shift (Fig. 1). The patient's blood test results were within the normal limits with no evidence of coagulopathy. During emergency follow-up, the patient vomited 4 times in an hour, and his confusion has gradually recovered to being fully alert. A second nonenhanced cranial tomography that was performed just 2 hours after the initial tomography revealed total disappearance of the epidural hemorrhage and pneumocephalus that had been seen on the previous CT scan (Fig. 2). The patient was managed conservatively in the intensive care unit for 2 days with ☆ This paper is written in US English.
provision to proceed to surgical decompression in the event of neurologic change. On the 3rd day, he was discharged with instructions to return in case of emergency, and on his 7th and 30th days of follow-up, there were no complications. Epidural hematoma is a type of intracranial hemorrhage wherein a buildup of blood occurs between the duramater and the skull. Accumulation of blood increases pressure in the intracranial space, compresses brain tissue, and may cause brain shift. Most epidural bleedings originate from meningeal arteries, 10% of them may be venous. Particularly in the temporal region, epidural hematomas originate from the middle meningeal artery [2,3]. In our patient, the AEDH was also probably of arterial origin because the blood accumulation was fast and it occurred in the temporal region after a trauma. Acute traumatic epidural hematoma is a neurosurgical emergency that requires early recognition and urgent operation. Radiologically significant or symptomatic AEDHs are typically treated by rapid surgical decompression [1–4]. Smaller, asymptomatic AEDH can be treated conservatively with close clinical observation. Various authors have reported the resolution of AEDHs managed conservatively with perfect clinical and radiologic outcome. The use of CT has allowed the
Fig. 1. Computed tomographic scan illustrating acute epidural hematoma and pneumocephalus.
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Coskun S, et al, Rapid spontaneous redistribution of acute epidural hematoma, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.02.029
2
S. Coskun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
Fig. 2. Total disappearance of the epidural hemorrhage and pneumocephalus that had been seen on the previous CT scan.
serial imaging and the possibility of nonoperative management. The spontaneous resolution of AEDH begins in the second week after trauma [2]. Although various mechanisms of disappearance of hematoma have been suggested, the underlying mechanism is not yet clear. The cited mechanism of the resolution of an EDH differs; formation of a fibrovascular neomembrane, granulation tissue acting as an absorbing structure through sinusoid vessels, and transfer of the clot into diploic bone or extracranial space through the fractures are among the major hypotheses for spontaneous resolution. Rapid resolution of EDHs is rarely seen and reported. Herein we discuss a rapid spontaneous resolution of AEDH. The disappearance of an AEDH within hours after admission to the emergency department is very rare. To the best of our knowledge, there are only 12 cases in the English literature up to this day [2,4]. Similar to our case, all cases of AEDH that disappeared in 24 hours had an overlying linear skull fracture. The presence of skull fracture can allow communication between the epidural region and extracranial tissues. Transfer of collection to the subgaleal space can relieve compression caused by the hematoma [3]. Aoki [1] supports this finding, in a case report in which there was an increase in the volume of an epicranial hematoma, whereas a decrease in the size of the AEDH was detected. In this circumstance, if there is a linear fracture neighboring an epidural hematoma that can allow the drainage of blood, epidural hematomas can rapidly dissolve spontaneously [5,6]. In our case, the first CT revealed epidural hematoma and intracranial pneumocephalus adjacent to the fracture line; there was also an oblique fracture line in mastoid and squamous piece of the temporal bone. Because our patient had fractures involving the mastoid portion of the temporal bone, it is reasonable to consider that the air in the epidural hematoma originated from the mastoid air cells. The second CT that was performed 2 hours after the first CT revealed complete disappearance of the EDH and pneumocephalus. There was extracranial air and blood adjacent to the fracture line. In physical
examination, there was no scalp laceration that could cause air to penetrate under the scalp. We believe that the rapid disappearance of the AEDH and the presence of extracranial air under the scalp are due to the leakage of blood and air to epicranial area via an overlying linear fracture. Lack of pneumocephalus in the second CT also supports this proposal. Our case has vomited 4 times in an hour in the emergency department. We know that emesis is a result of increased intracranial pressure, and it also increases intracranial pressure. Emesis may have resulted in temporary raise in intracranial pressure by raising intra-abdominal pressure, and that may have forced the hematoma from the fracture to the extracranial space. During the emergency and intensive care unit follow-up, the patient did not deteriorate. We believe that the rapid redistribution of blood to extracranial space has protected our patient from second deterioration phase after he regained consciousness, and because of that, there was no lucid interval. However, unfortunately, there is no diagnostic tool at present to identify patients who recover spontaneously, and the interval between onset and surgery is correlated with clinical results. Conservative treatment should be prescribed only for those patients who exhibit improving neurologic signs early in the clinical course [7]. This report describes a mechanism for the rapid disappearance of an AEDH. The case is characterized by the rapid disappearance of an AEDH associated with an overlying skull fracture. We believe that it was possible due to the redistribution of hematoma rather than its resolution. In our case, AEDH seems to have redistributed from intracranial space to extracranial space through the overlying skull fracture. Selcuk Coskun MD Beliz Oztok MD Gul Pamukcu Gunaydın MD Gulhan Kurtoglu Celik MD Department of Emergency Medicine Ankara Ataturk Training and Research Hospital Ankara, Turkey E-mail addresses: [email protected], [email protected], [email protected] http://dx.doi.org/10.1016/j.ajem.2014.02.029
References [1] Aoki N. Rapid resolution of acute epidural hematoma. Report of two cases. J Neurosurg 1988;68(1):149–51. [2] Tataryn Z, Botsford B, Riesenburger R, Kryzanski J, Hwang S. Spontaneous resolution of an acute epidural hematoma with normal intracranial pressure: case report and literature review. Childs Nerv Syst 2013;29(11):2127–30. [3] Deniz FE, Türk CC, Ismailoğlu O, Bozkurt G, Ozcan OE. Rapid spontaneous resolution of epidural hematoma: a case report. Ulus Travma Acil Cerrahi Derg 2010;16 (3):280–2. [4] Eom KS, Park JT, Kim TY, Kim JM. Rapid spontaneous redistribution of acute epidural hematoma: case report and literature review. J Korean Neurosurg Soc 2009;45 (2):96–8. [5] Celikoğlu E, Süsülü H, Delatioğlu M, Ceçen A, Hakan T, Bozbuğa M. Rapid spontaneous resolution of an acute epidural hematoma. Ulus Travma Derg 2002;8(2):126–8. [6] Malek AM, Barnett FH, Schwartz MS, Scott RM. Spontaneous rapid resolution of an epidural hematoma associated with an overlying skull fracture and subgaleal hematoma in a 17-month-old child. Pediatr Neurosurg 1997;26(3):160–5. [7] Aoki Y, Yamagata M, Shimizu K, Ikeda Y, Nakajima F, Ohtori S, Takahashi K. An unusually rapid spontaneous recovery in a patient with spinal epidural hematoma. J Emerg Med 2012;43(2):e75–9.
Please cite this article as: Coskun S, et al, Rapid spontaneous redistribution of acute epidural hematoma, Am J Emerg Med (2014), http://dx.doi.org/ 10.1016/j.ajem.2014.02.029
