Midline Epidural Hematoma Patient Characteristics

Midline Epidural Hematoma

• Midline epidural hematoma is a rare type of epidural hematoma that occurs in the midline of the brain.
• It is associated with both supratentorial hemispheric surface and superior sagittal sinus, one of the most vital drainage structures of the brain.
• Increased ICP (intracranial pressure) is a common finding in midline epidural hematoma, which can cause visual impairment, papilledema, and other symptoms.

Patient Characteristics

• 9 patients with midline epidural hematoma were treated at the neurosurgery department of Bakirkoy Sadi Konuk Research and Training Hospital, University of Health Sciences between 2013 and 2018.
• 7 male and 2 female patients, with ages ranging from 11 to 64 years (mean: 32.9±18.3).
• 2 patients were under 18 years old.
• All patients were admitted to the emergency room shortly after trauma (40-120 minutes).

Symptoms and Signs

• Symptoms and signs had acute onset and were found on initial examination, except for one patient who had a lucid interval.
• Common symptoms include headache, nausea/vomiting, disorientation, altered level of consciousness, and paraparesis.
• Cranial nerve involvement is unusual but reported in some cases.

Radiological Features

• Multiplanar CT scan was performed at admission to elicit intracranial injury.
• Radiological features included midline epidural hematoma, fracture line, and increased ICP findings.

Surgical Technique

• Emergency surgery was performed using separate craniotomies.
• Patients' heads were fixed in a three-pin holder in a supine position, elevated for 30° to prevent air embolism.
• A bicoronal incision was made, and the fracture line was identified.

Outcome

• All patients were discharged with a Glasgow Outcome Score (GOS) of 5.
• No complications were observed during the post-operative period.
• The authors suggest that midline epidural hematoma can be safely operated on by experienced surgeons, and preserving the bone strip in the midline can facilitate easier bleeding control.

Midline Epidural Hematoma

• Between 2013 and 2018, 9 patients with midline epidural hematoma underwent emergency surgery at the neurosurgery department of Bakirkoy Sadi Konuk Research and Training Hospital, University of Health Sciences.

Patient Characteristics

• There were 7 male and 2 female patients, with ages ranging from 11 to 64 years (average: 32.9±18.3 years).
• Two patients were under 18 years old.
• All patients were admitted to the emergency room shortly after trauma (40-120 minutes).

Causes of Injury

• Two patients were admitted to the emergency room with a history of falling from height.
• Four patients were involved in road traffic accidents.
• Three patients were assaulted.

Symptoms

• All signs and symptoms had acute onset, except for one patient who had a lucid interval.
• Severe headache should be regarded as a major symptom for midline epidural hematomas.

Surgical Technique

• Patients' heads were fixed in a three-pin holder in a supine position, elevated for 30°, to prevent air embolism.
• A bicoronal incision was made, and the fracture line was identified.
• In three patients, post-operative cranial MR imaging and MR venography showed venous flow was intact in the superior sagittal sinus.

Outcome

• The neurological status of the patients at discharge was assessed using the Glasgow Outcome Score (GOS).

Literature Review

• There are reports of successful results using separated craniotomy techniques without unplanned further interventions.
• Some surgeons advocate for complete exposure of the sinus, while others prefer to leave a thin layer of clot to avoid bleeding.
• Preserving a midline bone strip provides a back-up for dural tenting sutures, both to provide hemostasis preoperatively and to prevent post-operative reaccumulation of blood, especially in cases with thick epidural hematomas.