Bilateral occipital extradural hematoma in a child.

Extradural hematoma (EDH) occurs in approximately 2% of all patients with head injuries. Bilateral EDHs account for 2-10% of all acute EDHs in adults but are exceedingly rare in children. Posterior fossa EDHs occurs in 5% of all cases of EDHs. EDHs in children are more frequently venous (from tears of a dural sinus or diploic veins) and consequently have a better prognosis than EDHs in adults. Once the diagnosis of BEH is confirmed, urgent surgical treatment should be considered. We are reporting such rare form of injury as bilateral occipital EDH with supratentorial extension in 12 years child following road traffic accident.

Introduction

Extradural hematoma (EDH) occurs in approximately 2% of all patients with head injuries and 5–15% of patients with fatal head injuries. Bilateral EDHs accounts for 2–10% of all acute EDHs in adults but are exceedingly rare in children. Posterior fossa EDHs occurs in 5% of all cases of EDHs.[1] In cases of EDH of nonarterial origin, the bleeding is from rupture of arachnoid granulations, diploic emissary veins, and dural sinuses. They have been described as bifrontal, biparietal or vertex and bioccipital EDH.[2] Acute infratentorial EDH with supratentorial extension is an infrequent lesion, and only a few articles are published in the literature. The presence of infratentorial EDH leads to sudden death and quick deterioration, and its complication is more significant than supratentorial EDH as it masks the features of supratentorial EDH. We reported a rare case of bilateral occipital EDH with supratentorial extension in a child.

Case Report

A 12-year-old male child presented to our Emergency Department with a history of road traffic accident. At the time of admission the child was conscious, his vitals were stable and routine investigations were within normal limits. X-ray neck was done to exclude any type of cervical injury. Noncontrast computed tomography (CT) scan showed two well-defined, biconvex, extra-axial hyperdense blood attenuating (CT attenuation value + 62 HU) collections noted in occipital region, one on each side (maximum thickness on left side is 2.2 cm and on right side 1.4 cm) with few internal hyperdense areas s/o acute extradural hemorrhage with active bleed (“swirl sign”) [Figure 1]. Scalp hematoma was noted in bilateral parieto-occipital regions. Evidence of an undisplaced fracture was noted in occipital bone extending superiorly up to lambda with posterior sagittal sutural diastasis [Figure 2].

Figure 1

Noncontrast computed tomography head showing two extra-axial hyperdense blood attenuating collections in occipital region with “swirl sign” (axial, sagittal and coronal view)

Figure 2

Noncontrast computed tomography head showing undisplaced fracture of occipital bone with posterior sagittal sutural diastasis

Within hours, the child became irritable with respiratory distress, and there was also visual agnosia in the left eye. Left paramedian suboccipital craniectomy was done in an emergency using high speed 8 mm burr and Kerrison punch forceps. The EDH was then gently removed with the help of cup forceps and suction [Figure 3]. The bleeding source was from the emissary diploic veins. The clot on the right side was also removed with suction via same craniectomy site. However, the supratentorial portion was left unoperated. After hemostasis dural hitch sutures were placed [Figure 4]. The wound was closed in layers. Postoperative recovery was uneventful, and the child was discharged on the eighth postoperative day.

Figure 3

Intraoperative photograph showing hematoma during posterior fossa decompression

Figure 4

Intraoperative photograph showing hemostasis with placement of dural hitch sutures

Discussion

Cases of bilateral EDHs are rare in the literature.[23] There have been sporadic reports of bilateral EDHs with an incidence ranging from 0.5% to 2% of all EDHs.[4] In clinical practice, such cases are rarely seen.[4] EDHs are less common in infants and young children than in adults. The pediatric dura is more firmly adherent to the inner table of the skull.[5] EDHs in children are more frequently venous (from tears of a dural sinus or diploic veins) than arterial and consequently have a better prognosis than EDHs in adults.[678] In a present case report, infratentorial EDH occurred because of damage to the diploic veins, and supratentorial component was due to stripping of the dural sinuses. Pediatric EDH is more frequently seen in the posterior fossa or simultaneously above and below the tentorium.[7] EDH does not cross-cranial sutures because the periosteal layer of the dura is tightly adherent to the sutures. Huisman and Tschirch studied 57 children with proven EDH and showed that 11% of EDHs (seven patients) extended across cranial sutures.[9] Associated fractures are somewhat less frequent.[8] However, in this case, a fracture in occipital bone had extended superiorly with posterior sagittal sutural diastasis.

Noncontrast CT scan is diagnostic in such cases. In CT scan, low-density areas within the hyperdense collection (“swirl sign”) are thought to represent active bleed within the hematoma.[10] In this case “swirl sign“ was present in CT finding. Once bilateral infratentorial EDH is diagnosed, urgent surgical treatment should be considered. With the widespread use of CT scan, early diagnosis has changed the surgical results and prognosis.

Acute infratentorial bilateral EDH can be initially asymptomatic. Deterioration can, however, be quick and life-threatening.

Acute infratentorial EDH with the supratentorial extension should be strongly suspected in the presence of fracture of occipital bone with sagital suture diastasis. To conclude, early surgical intervention in the bilateral occipital (infratentorial) EDH confers better prognosis and lesser mortality.

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Conflicts of interest

There are no conflicts of interest.