B ritish Jour nal of Neurosurgery 1999;13(1):77± 78 S HORT REPO RT B ilateral frontal extradural haem atom as caused by rupture of the superior sagittal sinus: case report Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/29/14 For personal use only. R. K ETT-W HITE & J. L. M ARTIN D epartment of N eurosurger y, M or riston Hospital, Swansea, UK Abstract A 26-year-old male sustained simultaneous massive bilateral frontal extradural haematomas following a head injury as a result of a large tear of the superior sagittal sinus, without fracturing of the skull vault. Key words: B ilateral extradural haematom as, CT, head injur y, seizure, superior sagittal sinus. Introduction Although bilateral extradural haem atom as (ED H s) are u nco m m on, there are several repor ts in the li te ra tu r e. 1 ± 1 2 W h e n co m p ar ed w ith u n ilater a l haem atom as, it has been reported that the y m ay d e ve lo p s lo w l y, o fte n a ft er a tra u m ati c fo r c e orien tated in the an teroposterio r direction , have fewer overlying fractures and com m o nly con tain 1 ven ous bloo d. A case of m assive, acute bilateral frontal extradural haem atom as due to rupture of the superior sagittal sinus in the absence of a skull fracture is reported. T he sources of haem orrhage in bilateral extradural haem atom as are discussed. C ase report A 26-year-old m an collapsed at hom e, striking his head. H e im m ediately had a tonic-clonic seizure, lasting 5 m in. H e awoke, com plained of a headache and vom ited. Apart from an episode of acute alcohol intoxication a year earlier there was no prior history of epilepsy or other illness. O n arrival at hospital he was alert, orientated and obeying com m ands. T he forehead was bruised. Blood and coagulation tests, EC G and chest radiographs were norm al, apart from som e m ildly raised liver function test levels and a new rib fracture. A skull radiograph was not taken. Soon after adm ission he becam e confused. Over the next 12 h, he had a further six ® ts, treated with a total of 30 m g of d iazepam rectally. D uring this tim e he d eteriorated u ntil both pu pils becam e ® xed and dilated. C T of the brain (Fig. 1) showed m assive F IG . 1. Axial CT scan showing very large bilateral frontal extradural haem atomas. bifrontal extradural haem atom as. O n referral to our neurosurgical department he was im m ediately intubated and ventilated, and given 300 m l of 20% m annitol intravenously. A bicoronal skin ¯ ap was turned and the extradural haem atom as Correspondence: Mr J. L. Martin, Departm ent of Neurosurgery, M orriston Hospital, Swansea SA6 6N L, U K. Received for publication 17th June 1997. Accepted 5th November 1997 . 0268-869 7/99/010077 ± 02 $9.50 ½ The Neurosurgical Foundation Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 10/29/14 For personal use only. 78 R. Kett-W hite & J. L. M artin were evacuated via separate bilateral frontal craniotom ies. N o fractures were found, but active bleeding was seen from the anterior third of the sagittal sinus into the extradural space. T his was controlled by hitching the surrounding dura up against the rem aining m idline skull vault. The dura had to be opened in order to do this. Postoperative serial CT showed gradual reexpansion of both cerebral hem ispheres, but w ith som e atrophy of both frontal lobes. Three m onths postoperatively, he rem ained com pletely dependent on nursing care with a tracheostomy and feeding gastrostrom y. He obeyed sim ple com m ands, but had bilateral com plete oculom otor ner ve palsies and a severe spastic tetraparesis. Discussion In an attem pt to identify the source of haem orrhage in cases of bilateral E D Hs, the literature of the last 30 years w as reviewed . T here appear to be two separate groups: patients with bilateral separate ED Hs 2± 9 over the frontal/tem poral/parietal lobes and those 1 0 ,1 1 with single m idline E D Hs spreading bilaterally. In the ® rst (lateral) group, separation of dura from bone independently on both sides of the head causes a m ixture of arterial and venous bleeding into the extradural spaces bilaterally, either sim ultaneously or sequentially. 1 Barlow 5 suggested that if both clots were largely arterial, they would be present soon after injury, but if one or both haem atom as are delayed, then they are venous in origin. In the second and rarer (m idline) group, of w hich our case is an exam ple, the bleeding source would appear to be m ore exclusively venous, from a rupture of the sagittal sinus itself rather than from smaller extradural vessels nearby. In the two other cases in this group, Agb i’s patient 1 0 was seen to have bleeding from the sagittal sinus just above the torcula causing a m idline E D H extending from vertex to foram en 11 magnum , but in Kissel’s case the source for a smaller m idline bifrontal ED H was not identi® ed because of initial conservative m anagem ent. In order to initiate a m idline ED H a tear of the strong dural attachm ent over the sagittal sinus is needed. Ford & M cLaurin, 1 2 following experim entation in anaesthetized dogs, doubted that venous pressure is sufficient to cause a unilateral extradural haem atom a, except when there is decreased intracranial pressure secondary to cerebrospinal ¯ uid leakage. H owever, they did ® nd that the force required was less if it was pulsatile rather than static. In our patient, the initial force was in an anteroposterior direction. This, we suspect detached the sinus from bone, creating a defect in the sinus. T his defect subsequently m ay have acted as a one-way valve. T he vom iting during the lucid interval, as well as the sequence of seizures would both have increased the central venous pressure transm itted to the sinus in a pulsatile fashion. T his com bination, we suggest, was sufficient to cause enlargem ent of the extradural haem atom as to a substantial size. R eferences 1 F ran k E , B erger T S, Tew JM . B ilateral ep idu ral hem atomas. Surg Neurol 1982;17:218± 22. 2 Subrahm anian M V, R ajend raprasad GB , R ao BD. Bilateral extradural haematomas. B r J Surg 1975;62 : 397± 400. 3 M aurer JJ, M ay® eld FH. A cute bilateral extradural hem atomas. J Neurosurg 1965;23 :63. 4 Soni SR. Bilateral asymm etrical extradural hem atomas. J N eurosurg 1973;38 :647± 9. 5 Barlow P, KohiYM . Acute sim ultaneous bilateral extradural hematom a. Surg Neurol 1985;23 :411± 13. 6 Reale F, Biancotti R. Acute bilateral epidural hematoma. Surg N eurol 1985;24 :260± 2. 7 Arienta C, Baiguini M, Granta G, Villani R. Acute bilateral epidural hematom as. J Neurosurg Sci 1986;30 : 139± 42. 8 Gelabert M , Prieto A, Rumbo RM , Bollar A, Allut AG. Sim ultaneous bilateral extradural hematom a. B r J Neurosurg 1993;7:95± 8. 9 Perera S, Keogh AJ. Chronic sim ultaneous bilateral extradural haematom as. B r J Neurosurg 1995;9:533± 5. 10 Agbi CB, Victoratos G, Turnbull IW. Bilateral extradural hematom a extending from the foramen m agnum to the vertex. Surg N eurol 1987;28 :123± 8. 11 Kissel P, Boggan JE, Wagner FC. CT evolution of an acute epidural hematoma. J E m erg M ed 1989;7:365± 8. 12 Ford LE, M cLaurin RL. M echanisms of extradural hem atomas. J Neurosurg 1963;20 :760± 5.