Br. J. Surg. Vol. 62 (1975) 397-400
Bilateral extradural haematomas M. V. S U B R A H M A N I A N , G . B. R A J E N D R A P R A S A D A N D B. D I B B A L A R A O * SUMMARY
Eleven cases of bilateral extradural haematomas were encountered in a total of 49 cases of extradural haematoma during a period o f 4 years among I000 consecutive cases of acute head injury, Assault was held responsible .for 60 per cent of the total head injuries. Most of the paiienis were seen late; 8 were already unconscious and 5 had dilated fixed pupils, All 1 I patients died, 4 soon afrer admission. Nine cases were found to have associated brain damage at autopsy. In 2 cases bilateral extradural haematomas with compression of the brain were the only intracranial abnormalities. In 4 cases a clot was missed on conventional exploration.
BILATERAL extradural haematomas are rare. The previously reported cases are tabulated in Table I. Table I: NUMBER OF CASES OF EXTRADURAL HAEMATOMA REPORTED IN THE LITERATURE No. of cases of bilateral Period of No. of cases of extradural extradural study Author haematoma haematomas (vr)
Hooper (1959) 83 Cabraal and 53 Weinman (1964) Dayananda Rao 31 et al. (1967) 167 Gallagher and Browder (1968) Jamieson and 167 Yelland (1968) Jain and Kankandy 8 (1969) Kalyanaraman 51 et al. (1970) Sambasivan and 32 Ramachandran (1973) Soni (1973) Present series (1975) 49
5 2
11
2
Cause of head injury Assault was the main cause of head injury in 7 out of 11 cases. Two patients fell from a moving vehicle, another fell 20 feet from a tree and in one case the nature of the accident was not documented. It is obvious from Table ZZ that 60 per cent of the head injuries were the result of assault, which probably accounts for the high incidence of extradural haematoma in this region. Sticks, iron rods and axes were used for assault. In the series reported by Cabraal and Weinman (1964) of 53 cases of extradural haematoma, assault was the main cause in 43.4 per cent. All our patients were males aged between 12 and 60 years. Nine of them were over 25 years of age. The 2 younger patients (Cases 8 and 9) sustained head injuries by falling from moving vehicles. All the patients were admitted to hospital 4-44 hours after sustaining the injury, and their survival ranged from a few minutes to 8 days. Clinical features (Table ZV) Eight patients were unconscious, 2 were semiconscious and one was conscious. Signs of localization by way of aphasia and hemiparesis were noted in 3 cases. No lucid interval was found in any case.
7
25
10
It 20 5 1
-
11
4
Patients Among 1000 consecutive cases of acute head injury admitted to the Government General Hospital, Guntur, from February 1970 to January 1974, 49 cases of extradural haematoma were encountered either at surgery or at post-mortem examination. Of these, 1 1 cases were bilateral. It is our practice to admit all cases of acute head injury under the care of general surgeons whence they can later be referred to the neurological department if necessary. This may involve avoidable delay in an emergency neurosurgical intervention. We have analysed these 11 cases of bilateral extradural haematomas regarding their cause, clinical manifestations and radiological features in relation to the operative and autopsy findings.
Radiological features Plain X-rays of the head were taken in 9 patients, of whom 5 had fractures on both sides of the skull. In 3 cases unilateral fractures were found of which one was a depressed fracture. In Case 6 no obvious fracture was noticed on radiological examination but prominent venous channels were present, and a linear fracture in the frontal bone was found at autopsy. Operative findings The operative and autopsy findings are given in Table ZZZ. Seven patients were operated upon. In 3 cases it was possible to evacuate the extradural clots on both sides. In Case 1 biparietal craniectomy was done, a parietal extradural haematoma was removed and an associated left-sided subdural haematoma was drained, yet the parieto-occipital extension of the extradural haematoma was missed. In Case 2 bilateral extradural clots were evacuated; the brain was markedly compressed and the patient died 11 hours after surgery. The parieto-temporal extension was missed. In Case 7 a left parietal extradural haematoma was evacuated and on the right side only a small parietal clot was found. The brain did not expand. A parasagittal haematoma was missed. This patient had
* Department of N ~ covernment ~ cenera1 H~ ~ pital, Guntur, Andhra Pradesh, India. 397
~
-
~
M. V. Subrahmanian et al.
Table 11: CAUSES OF HEAD INJURY IN REPORTED SERIES
Cause of injury (% of cases) Author Rowbotham et al. (1954) Dayananda Rao et al. (1967) Jain and Kankandy (1969) Kalyanaraman et al. (1970) Sambasivan and Ramachandran (1973) Present series (1975)
Hospital Newcastle Hospital, U K Osmania General Hospital, Hyderabad, India lrvin Hospital, Delhi, India Government General Hospital, Madras, India Government General Hospital, Trivendrum, India Government General Hospital, Guntur. India
Table Ill: OPERATION AND AUTOPSY FINDINGS Case no. ODeration Extrddural haematoma Parieto-occipito-temporal 1 Biparietal craniectomy; parietal extradural haematomas removed ; haematomas left-sided subdural haematoma Right: 15 x 9 x 2 crn Left: 1 0 x 9 ~ cm 1 drained 2
Bioarietal craniectomv: evacuation of parietal clots
3
Not operated
4
Conventional exoloratorv burr holes; depressed fracture removed. Laceration of the brain on left parietal lobe noticed Left parietal craniectomy and evacuation of clot; left subdural haematoma drained. Right temporal burr hole revealed no clot Not operated
5
6
7
Left temporal craniectomy and evacuation of the clot; small right temporal clot present. Brain did not expand
Road accident
Fall
Assault
34 34
22 31
19
43 47
55
38
5 4
37
32
18
25
7
60
Autopsy findings Associated iniuries
1. Laceration of tip of left temporal lobe 2. Contusion of right cortex 3. Pontine haemorrhage 4. Fracture of right parieto-occipital and left parietal bones Parieto-temporal haematomas Compression of brain Right: 4X2X 1 cm Left: 3 x 2 1~cm 1. Left subdural haematoma of 6 x 4 x 3 cm Bitemporal extradural haematomas 2. Laceration, 3 x 1 x 1 cm, of the left Right: 3 x 2 ~ cm 1 temporal lobe and base of the frontal lobe Left: 6 x 6 ~ cm 3 3. Fractures of right parieto-temporal, left parietal and occipital bones. Faciomaxillary fractures on the left side Left fronto-Darieto-temooral 1. Laceration of left parietal lobe haematoma of 14 >' 7\
Bilateral extradural haematomas M. V. S U B R A H M A N I A N , G . B. R A J E N D R A P R A S A D A N D B. D I B B A L A R A O * SUMMARY
Eleven cases of bilateral extradural haematomas were encountered in a total of 49 cases of extradural haematoma during a period o f 4 years among I000 consecutive cases of acute head injury, Assault was held responsible .for 60 per cent of the total head injuries. Most of the paiienis were seen late; 8 were already unconscious and 5 had dilated fixed pupils, All 1 I patients died, 4 soon afrer admission. Nine cases were found to have associated brain damage at autopsy. In 2 cases bilateral extradural haematomas with compression of the brain were the only intracranial abnormalities. In 4 cases a clot was missed on conventional exploration.
BILATERAL extradural haematomas are rare. The previously reported cases are tabulated in Table I. Table I: NUMBER OF CASES OF EXTRADURAL HAEMATOMA REPORTED IN THE LITERATURE No. of cases of bilateral Period of No. of cases of extradural extradural study Author haematoma haematomas (vr)
Hooper (1959) 83 Cabraal and 53 Weinman (1964) Dayananda Rao 31 et al. (1967) 167 Gallagher and Browder (1968) Jamieson and 167 Yelland (1968) Jain and Kankandy 8 (1969) Kalyanaraman 51 et al. (1970) Sambasivan and 32 Ramachandran (1973) Soni (1973) Present series (1975) 49
5 2
11
2
Cause of head injury Assault was the main cause of head injury in 7 out of 11 cases. Two patients fell from a moving vehicle, another fell 20 feet from a tree and in one case the nature of the accident was not documented. It is obvious from Table ZZ that 60 per cent of the head injuries were the result of assault, which probably accounts for the high incidence of extradural haematoma in this region. Sticks, iron rods and axes were used for assault. In the series reported by Cabraal and Weinman (1964) of 53 cases of extradural haematoma, assault was the main cause in 43.4 per cent. All our patients were males aged between 12 and 60 years. Nine of them were over 25 years of age. The 2 younger patients (Cases 8 and 9) sustained head injuries by falling from moving vehicles. All the patients were admitted to hospital 4-44 hours after sustaining the injury, and their survival ranged from a few minutes to 8 days. Clinical features (Table ZV) Eight patients were unconscious, 2 were semiconscious and one was conscious. Signs of localization by way of aphasia and hemiparesis were noted in 3 cases. No lucid interval was found in any case.
7
25
10
It 20 5 1
-
11
4
Patients Among 1000 consecutive cases of acute head injury admitted to the Government General Hospital, Guntur, from February 1970 to January 1974, 49 cases of extradural haematoma were encountered either at surgery or at post-mortem examination. Of these, 1 1 cases were bilateral. It is our practice to admit all cases of acute head injury under the care of general surgeons whence they can later be referred to the neurological department if necessary. This may involve avoidable delay in an emergency neurosurgical intervention. We have analysed these 11 cases of bilateral extradural haematomas regarding their cause, clinical manifestations and radiological features in relation to the operative and autopsy findings.
Radiological features Plain X-rays of the head were taken in 9 patients, of whom 5 had fractures on both sides of the skull. In 3 cases unilateral fractures were found of which one was a depressed fracture. In Case 6 no obvious fracture was noticed on radiological examination but prominent venous channels were present, and a linear fracture in the frontal bone was found at autopsy. Operative findings The operative and autopsy findings are given in Table ZZZ. Seven patients were operated upon. In 3 cases it was possible to evacuate the extradural clots on both sides. In Case 1 biparietal craniectomy was done, a parietal extradural haematoma was removed and an associated left-sided subdural haematoma was drained, yet the parieto-occipital extension of the extradural haematoma was missed. In Case 2 bilateral extradural clots were evacuated; the brain was markedly compressed and the patient died 11 hours after surgery. The parieto-temporal extension was missed. In Case 7 a left parietal extradural haematoma was evacuated and on the right side only a small parietal clot was found. The brain did not expand. A parasagittal haematoma was missed. This patient had
* Department of N ~ covernment ~ cenera1 H~ ~ pital, Guntur, Andhra Pradesh, India. 397
~
-
~
M. V. Subrahmanian et al.
Table 11: CAUSES OF HEAD INJURY IN REPORTED SERIES
Cause of injury (% of cases) Author Rowbotham et al. (1954) Dayananda Rao et al. (1967) Jain and Kankandy (1969) Kalyanaraman et al. (1970) Sambasivan and Ramachandran (1973) Present series (1975)
Hospital Newcastle Hospital, U K Osmania General Hospital, Hyderabad, India lrvin Hospital, Delhi, India Government General Hospital, Madras, India Government General Hospital, Trivendrum, India Government General Hospital, Guntur. India
Table Ill: OPERATION AND AUTOPSY FINDINGS Case no. ODeration Extrddural haematoma Parieto-occipito-temporal 1 Biparietal craniectomy; parietal extradural haematomas removed ; haematomas left-sided subdural haematoma Right: 15 x 9 x 2 crn Left: 1 0 x 9 ~ cm 1 drained 2
Bioarietal craniectomv: evacuation of parietal clots
3
Not operated
4
Conventional exoloratorv burr holes; depressed fracture removed. Laceration of the brain on left parietal lobe noticed Left parietal craniectomy and evacuation of clot; left subdural haematoma drained. Right temporal burr hole revealed no clot Not operated
5
6
7
Left temporal craniectomy and evacuation of the clot; small right temporal clot present. Brain did not expand
Road accident
Fall
Assault
34 34
22 31
19
43 47
55
38
5 4
37
32
18
25
7
60
Autopsy findings Associated iniuries
1. Laceration of tip of left temporal lobe 2. Contusion of right cortex 3. Pontine haemorrhage 4. Fracture of right parieto-occipital and left parietal bones Parieto-temporal haematomas Compression of brain Right: 4X2X 1 cm Left: 3 x 2 1~cm 1. Left subdural haematoma of 6 x 4 x 3 cm Bitemporal extradural haematomas 2. Laceration, 3 x 1 x 1 cm, of the left Right: 3 x 2 ~ cm 1 temporal lobe and base of the frontal lobe Left: 6 x 6 ~ cm 3 3. Fractures of right parieto-temporal, left parietal and occipital bones. Faciomaxillary fractures on the left side Left fronto-Darieto-temooral 1. Laceration of left parietal lobe haematoma of 14 >' 7\
