CASE REPORTS

Vertex Epidural Hematoma: Surgical
versus Conservative Management:
Two Case Reports and Review of
the Literature
Daniel James Miller, M.D., Michael Steinmetz, M.D.,
Ian E. McCutcheon, M.D.
Department of Neurosurgery (DJM, MS), Texas Tech University Health Sciences Center,
El Paso, Texas, and Department of Neurosurgery (DJM, IEM), The University of Texas
M.D. Anderson Cancer Center, Houston, Texas

OBJECTIVE AND IMPORTANCE: Vertex epidural hematomas may be under­
estimated or overlooked altogether when computed tomographic scans
alone are used for diagnosis. Such hematomas can be resolved with active
intervention and sometimes with conservative treatment.
CLINICAL PRESENTATION: Two cases of successfully treated vertex epi­
dural hematomas, in a 33-year-old man who presented with seizures and
an 11-year-old girl who presented with headache and vomiting, are
described. Both hematomas were traumatic in origin and were associated
with cranial fractures. In each, coronal images (computed tomographic
or magnetic resonance imaging scans) showed the extent of the hema­
toma much more clearly than did axial images.
INTERVENTION: One case was treated surgically and the other conservatively.
CONCLUSION: Magnetic resonance imaging is not usually indicated for
trauma patients, but it is an appropriate diagnostic modality for these rare
lesions, to supplement standard axial computed tomographic scans. Be­
cause vertex epidural hematomas may resolve spontaneously with time,
conservative treatment should be considered on a case-by-case basis.
(Neurosurgery 4 5 : 6 2 1 - 6 2 5 , 1999)
Key words: Conservative treatment, Magnetic resonance imaging in head injury, Surgical indica­
tions, Vertex epidural hematoma

ases of vertex epidural hematoma
(V EH ) are rare. In large series of
epidural hematomas in all locations, the
incidence of the vertex location was 0 to
8% (5, 6, 8, 13, 25, 33, 34). When these
lesions occur, they frequently cause a
diagnostic dilemma, both clinically and
radiographically. Neurosurgeons, as well
as emergency physicians and radiologists,
must initially have a strong suspicion of
their presence and perform the appropri­
ate diagnostic testing. Fairly characteristic
of VEHs are clinical findings indicating

C

elevated intracranial pressure (headache,
nausea, and vomiting), which may not
contribute to the establishment of a spe­
cific diagnosis (5, 6, 13, 34). The onset can
be acute, subacute, or even chronic and
can be significantly delayed, as in one re­
ported case with an 1 1 -month history (5,
6,18, 26, 30, 31, 34). In general, the neuro­
logical examination results are both nonlocalizing and nonlateralizing (13). The
clinical findings have been related to in­
creased intracranial pressure resulting
from compression of the venous outflow

at the superior sagittal sinus (SSS) and
subsequently decreased absorption and
outflow of cerebrospinal fluid (3, 7, 8 ).
In conventional axial computed tomo­
graphic (C T) scans, the lesions may be
misinterpreted as artifacts or even over­
looked altogether (9, 13, 18, 26, 29). In
the past, these lesions have been diag­
nosed using radionuclide studies, cere­
bral angiography, and coronal CT scan­
ning (3-6, 8, 9, 13, 15, 19, 20, 22, 23, 26,
31, 32, 34). The true size of the lesion, as
w ell as the actual mass effects on the
underlying brain tissue, may be dram at­
ically underestimated in axial CT scans,
as is w ell illustrated in the following
two cases.

CASE REPORTS
Patient 1
A 33-year-old m entally retarded man
had fallen backward, striking his head,
during a generalized seizure on the day
of admission. In the emergency room,
the patient experienced a second gener­
alized seizure, which was witnessed.
The patient was treated w ith anticon­
vulsant agents and experienced no ad­
ditional episodes. On examination, the
patient was lethargic but easily roused.
Ophthalmoscopic examination results
were normal. The sister of the patient
claimed that the patient was at his base­
line level w ith respect to his overall
mental state. During further investiga­
tion, it was found that the patient had
suffered blunt head trauma on m ultiple
occasions; the most recent episode had
occurred 2 weeks before the onset of the
seizures, when he had been struck on
the head w ith a baseball bat. Unen­
hanced axial CT scans obtained at the
time of admission were significant for a
small hyperdense region along the right
frontal area; a large area of high density
w ith mixed low density in the upper left
frontoparietal area extended across the
SSS into the upper right frontal region
(Fig. 1). The patient was admitted to the
intensive care unit and treated w ith an­
ticonvulsant agents and mannitol. Coro­
nal reconstructions of the CT scans
showed a very large V E H , as did subse-

Neurosurgery, Vol. 45, No. 3, September 1999

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622

Miller et al.
mained normal. Ophthalmoscopic ex­
amination results were normal. The pa­
tient underwent unenhanced axial CT
scanning of the head, which showed a
cranial fracture at the vertex, as well as a
very small region of high density, which
was diagnosed as a V E H (Fig. 2). These
CT scans had been officially interpreted
by a radiologist and by the emergency
room physician as representing com­
pletely normal findings. M R I was per­
formed. This demonstrated an extraaxial collection at the vertex (more
sizable than initially observed in axial CT
scans) displacing the SSS, with associated
compression of the cerebral hemispheres
and corpus callosum. The patient began
to receive steroid therapy and experi­
enced no additional vomiting or head­
aches after 24 hours. She was monitored,
while continuing to receive steroid ther­
apy, for several days and was then dis­
charged home. She remained neurologi­
cally intact and asymptomatic. Repeat
M R I performed 6 weeks later showed
complete resolution of the hematoma.

DISCUSSIO N
FIG U R E 1. Patient 1. A, axial CT scan, without contrast medium. This shows an
area of hyperdensity crossing the midline and compressing both frontal lobes.
B, coronal reconstruction of the CT scan, without contrast medium. This allows
better appreciation of the size of the hyperdense lesion and brain compression.
C, coronal, T2-weighted M RI scan. The true severity of SSS depression and under­
lying mass effects can be fully appreciated. The size of the lesion and the signifi­
cance of its effects are more evident than in CT scans. D, sagittal, T1-weighted
M RI scan. This scan confirms the extra-axial location and size of the epidural
hematoma, in conjunction with the coronal image.

quent magnetic resonance imaging
(M R I) scans. This hematoma displaced
the sinus and compressed the underly­
ing brain tissue, with significant distor­
tion of the corpus callosum. The size of
the lesion was not well demonstrated in
axial CT scans. The patient underwent a
vertex craniotomy. A t the time of sur­
gery, diastasis of the coronal suture that
crossed the SSS was found; this had not
been appreciated in the CT scans. A
thick epidural hematoma compressing
the dura over both hemispheres and
over the SSS was found. The hematoma
was removed without incident. The
SSS was not intraoperatively exposed.
A ll clot was removed, except for a thin
layer left covering the sinus in the m id­
line; the dura was tacked up lateral to it

on each side. After surgery, the CT ap­
pearance returned to normal. The pa­
tient recovered to his neurological base­
line and remained well, as observed 6
months later in a follow-up examination.

Patient 2
An 11-year-old girl fell out of a sta­
tionary car and struck her head, with no
loss of consciousness. The patient was
im m ediately examined in the emer­
gency room, where she was judged to be
neurologically intact, without any prob­
lems from the fall, and so was released.
Two days later, the patient returned,
complaining of a severe frontal head­
ache and emesis. The fam ily denied any
significant change in her mental state.
The neurological examination results re­

Epidural hematomas usually result
from laceration of the m iddle meningeal
artery and thus most commonly occur
over the lateral convexities (16, 2 1 , 22).
Posterior fossa epidural hematomas can
also occur, but these are very rare ( 1 , 21 ).
Epidural hematomas occurring at the
vertex represent another distinct group
( 2 1 ). The incidence of V E H s has been
reported to be 0 to 8% , and V EH s were
associated w ith a reported mortality
rate of 18 to 50% in the pre-MRI period
(5, 6, 13, 25, 33, 34).
Cranial fractures have been associ­
ated w ith epidural hematomas in non­
specific locations in 60 to 91% of pa­
tients in large series ( 1 2 , 16, 21, 22 ). In
series specifically review ing VEH s, ver­
tex fractures were present in 100% of
cases (6, 34). Borzone et al. (6) reported
V EH s in 22 of 416 cases of epidural hema­
toma (5% ), w ith an associated fracture
at the vertex in each case. Zuccarello et
al. (34) reported V EH s in 14 of 478 cases
(3 % ); all involved vertex fractures.
Other cranial fractures can also be found
in these patients w ith V EH s and vertex
fractures (5, 34). The literature does in­
clude cases without a fracture at the

Neurosurgery, Vol. 45, No. 3, September 1999

Vertex Epidural Hematomas

62 5

combination in our second case (Fig.
2B). There is rarely a diastatic fracture of
the coronal suture, as in our first case (4,
33).
The clinical presentation has been fre­
quently described as being both nonspe­
cific and nonlocalizing, thus giving few
indications of the presence of the V E H
(13). This may lead to delays in treat­
ment and even death (18, 29). In contrast
to convexity epidural hematomas,
V E H s are not alw ays acute in presenta­
tion (11). Chronic cases of V E H have
been reported (26, 31). Patients m ay
demonstrate a more rapid evolution,
w ith or without a lucid interval (5). The
most prominent symptom is headache,
which is usually severe and unrelenting
(5, 6, 9, 13, 34). Upper motor neuron
signs may also be present because of
unilateral or bilateral compression of
the parasagittal motor cortex (5, 9, 14,
33, 34). Im pairm ent of flow through the
SSS, w ith obstruction of cerebrospinal
fluid outflow, has also been suggested
as a cause of increased intracranial pres­
sure in this condition (3, 8 ). Patients can
present w ith dramatic findings, such as
paraplegia, papilledema, anisocoria, and
even coma, but rarely seizures; more com­
monly, they present with severe head­
ache, possibly resulting from intracranial
hypertension (5, 6, 9, 13, 14, 27, 33, 34).
Associated cranial fractures at the vertex
are extraordinarily common (5, 34). The
diagnosis of V E H may be delayed be­
cause of the nonspecific clinical findings.
Conventional axial CT scans m ay be
misleading, as in our two cases, in which
the size of the lesion was initially under­
estimated (2, 17, 18, 29). The axial slices
parallel the hematoma, close to the border
JRE 2. Patient 2. A, axial CT scan, without
medium^ 1 5 sh^
between brain tissue and bone. This bor­
I area of hyperdensity at the vertex, C
' " 8Sh0tv"?he vertex fracture line,
der between two structures of grossly dif­
i windows, without contrast medium. T
midline as a bilateral
fering densities can be difficult to differ­
Iving a portion of the sagittal suture and cro
g
shows depression of
entiate, and the lesion may be interpreted
ir fracture. C, coronal, T 1 -weighted M R I scam T h s an
p ^
as an artifact (9,13,18, 26,29). Coronal CT
SSS and underlying mass effects resulting from an p
sss and
scans may better delineate the lesion (5, 9,
, Tl-weighted M R. scan. The size of the lesion and its effect^. ^ ^
^
13, 26). These hematomas may also be
n tissue can be much more fully apprecia e
resolution of the extraindicated by inferior displacement of the
»nal, T1 -weighted M R I scan. T h is scan s
h
o
w
s
^
^
^
^
SSS from the inner table of the cranium in
il collection after 6 weeks. F, sagittal, T
g
conservative
the venous phase of cerebral angiography
r residual henralnnra —
rema.ns after conserva
(5, 6, 34). M R I has been found to clearly
treatment.
delineate these lesions as V EH s (27, 29).
31, 33). A linear fracture line crosses
Whenever there is strong clinical suspi­
vertex and cases in w hich no mention
(usually horizontally) the sagittal suture
cion that significant pathological features
made of the presence or absence o
overlying the hematoma, or there is d i­
are present and axial CT scans of the ver­
fracture, but the majority of indiv it ua
astasis of the sagittal suture (5, 6, 10, 16,
tex show either possible artifacts or quesreported cases have an associated ver e
18, 28, 33, 34). These features occurred in
fracture (1 ,3 , 4 , 8,9,13,15,19, 23,
c

o

n

t

r

a

s

t

N e u ro su rg e ry, Vol. 45, No. 3, September 1999

624

Miller et al.

tionable pathological features, M RJ should
be performed to search for a possible VEH ,
especially if a vertex fracture is present.
Unlike standard epidural hematomas,
those at the vertex do not necessarily
require surgery (8, 9, 13, 19, 25). V EH s
may have a chronic and favorable
course, with some resolving spontane­
ously (8, 9, 13, 19, 25). As our second
case demonstrates, there may eventu­
ally be complete resolution of the clot
and the compression (25). Colum ella et
al. (7) reported that 6 of 32 cases (19%)
showed spontaneous resolution without
surgical intervention. Other cases re­
quire simple twist-drill drainage but not
a craniotomy (4). However, the majority
of these hematomas do receive aggres­
sive surgical treatment (5, 6, 9,15, 26, 27,
33, 34). It must be recognized that SSS
tears may be exposed during surgery
and may significantly complicate the
surgical removal of these lesions (5, 6,
18, 24, 25). Strict criteria for surgical in­
tervention have not been established,
but significant m orbidity rates have
been observed for patients who develop
neurological signs of deterioration (5, 6,
25, 33, 34). Patients with progressive
clinical improvement and fairly small
hematomas require only observation, as
in our second case, with complete reso­
lution of the pathological findings in 6
weeks (8). Patients w ith severe sym p­
toms of clinical deterioration or with
clearly ominous neurological examina­
tion findings require prompt surgical in­
tervention (5, 8, 13).

CONCLUSION
The clinical presentation of V EH s is
not straightforward. The symptoms
have been described as nonlocalizing
and nonspecific. Axial CT scans may
completely miss the lesion. A high index
of clinical suspicion is required for the
detection of these distinct lesions, so
that the appropriate study (M R I) can be
performed. If M R I is unavailable, coro­
nal CT scans can be obtained. Cranial
fractures at the vertex are almost univer­
sally present in these cases.
Because some cases exhibit spontane­
ous resolution with a conservative ap­
proach, surgery is not required in all
cases. The choice of surgical versus con­
servative management should be based

on the size of the V E H , the amount of
SSS displacement, the degree of under­
lying mass effects and brain distortion,
the overall severity of symptoms, the
presence or absence of specific neuro­
logical examination findings, and w ors­
ening or improvement w ith conserva­
tive treatment.
Received, March 30, 1999.
Accepted, May 7, 1999.
Reprint requests: Ian E. McCutcheon, M.D.,
Department of Neurosurgery, The University
of Texas M.D. Anderson Cancer Center, 1515
Holcombe Boulevard, Box 064, Houston, TX
77030.

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extradural hem atom a extending from the fora­
men m agnum to the vertex. Surg N eurol 28:
123-128, 1987.
2. A kim oto H, Maki Y, Nose T, O no Y, Egashira T:
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M: Vertex epidural hem atom as. Surg N eurol
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T: Acute traum atic vertex epidural haem atom as
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signs in a patient with an acute vertex epidural
hem atom a. Am J Em erg M ed 1:288-291, 1983.
10. Da Pian R, Benati A, Bricolo A, Tom asi A,
Perbellini D, Dalle Ore G: Em atom i extradurali
traumatici del terzo medio del seno longitudinale
superiore. O sp Ital Chir 8:667-676, 1963.
11. Faw az A, Lozes G, M escola P, Plouvier B,
Deocster B, Duham el P, Jom in M: Subacute ex­
tradural hem atom a of the vertex: A case [in
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14. H ooper R: O bservations on extradural h em or­
rhage. Br J Surg 47:71-87, 1959.

15. Jackson FE, Heinz W , Blum berg N: Operative
technic of rem oval of epidural hem atom a of the
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16. Jam ieson KG, Yelland JD N : Extradural hema­
toma: Report of 167 cases. J N eurosurg 29:1323, 1968.
17. Kobayashi S, N akazaw a S, Yokota H, Yajima K,
Yano M, O tsuka T: C om puterized tomography
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18. Kunz U, M auer U M , W ald bau r H, Dietz H:
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W
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22. M cK issock W , Taylor JC, Bloom W H, Till K:
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23. M ilbouw G, Born JD , Flandroy P, Bonnal J:
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24. N akam ura K, H ayashi H, Takeuchi T: Vertex
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28:261-272, 1966.
25. Plotkin FR, Burke TF: Vertex epidural hema­
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26. Pom eranz S, W ald U, Z agzag D, Gomori M,
Shalit M: C hronic epidural hem atom a of the
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27. Ram esh VG, Sivakum ar S: Extradural hema­
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Cabrera A, G om ez P: Extradural hematoma:
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K h ir 106:1138-1139, 1971.
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Neurosurgery, Vol. 45, No. 3, September 1999

Vertex Epidural Hematomas
COMMENTS
In this interesting case presentation,
the authors make the point that, even with
modem computed tomographic (CT) scan­
ning techniques, vertex epidural hemato­
mas (VEHs) may be overlooked or diag­
nosed late unless specific measures are
used to detect them in trauma patients for
whom these lesions are suspected. Such
patients should include all those with
fractures that cross the vertex and also
those with significant external subgaleal
hematomas, indicating a vertex impact.
We do not, however, agree with the au­
thors that magnetic resonance imaging
(MRI) is necessarily an appropriate imag­
ing method for initial diagnosis of these
lesions. In most hospitals, M RI is difficult
to schedule on an emergency basis, and it
is much more difficult to perform for neu­
rotrauma patients who are restless or in
unstable condition. W e contend that it is
greatly preferable to obtain either coronal
CT scans, as recommended by the au­
thors, or coronal reconstructions of stan­
dard axial CT images; both techniques are
appropriate for rapidly and safely dem­
onstrating VEHs in trauma patients.
The authors do not review the im por­
tant issue of V E H volum e; this may be a
critical determinant of whether these le­
sions are safe to treat conservatively or
should be surgically treated. In the im ­
portant series of Pang et al. (2) and in
our previous work ( 1 ), a 'Volum e break­
point" of approximately 40 to 50 ml was
found, above which almost all patients ex­
perienced deterioration and below which
the majority of conscious patients satisfac­
torily tolerated an epidural hematoma.
Surgical intervention planning for
this group of patients may be challeng­
ing because of the problems of the sag1ttal sinus. Fortunately, for most such

patients, the presentation is less acute
and the sagittal sinus lesion that led to
generation of the hematoma can be
treated w ith appropriate positioning of
the operating table and with tamponade
using Surgicel (Ethicon, Inc., Som erville,
N J), Avitene (Davol, Inc., Cranston, RI),
or other hemostatic agents.
Scott Huneycutt
M. Ross Bullock
Richmond, Virginia

625

Finally, I com pletely agree with the
recommendation of the authors that sur­
geons be careful in exposing the supe­
rior sagittal sinus (SSS) and conserva­
tive in removing blood clots adjacent to
the sinus. M any of these hematomas are
likely the result of laceration of the SSS,
and life-threatening hemorrhage may
occur if the laceration is opened during
surgery without adequate control of the
sinus.
Donald W. Marion
Pittsburgh, Pennsylvania

1. Bullock R, Smith RM, van Dellen JR:
Nonoperative management of extradural
hematoma. Neurosurgery 16:602-606,
1985.
2. Pang D, Horton JA, Herron JM, Wilberger
JE Jr, Vries JK: Nonsurgical management
of extradural hem atom as in children.
J N eu rosu rg 59:958-971, 1983.

In this article, M iller et al. have de­
scribed the difficulties of V E H diagno­
sis. In two case reports, they remind us
of the sometimes relatively subtle and
nonspecific symptoms with which these
patients present, and they clearly docu­
ment the under-representation of the
size of these clots in conventional axial
CT images obtained at 10 -mm intervals.
One of the most important findings of
this report is that, although there are
very few instances in which M R I is su­
perior to CT scanning in the emergency
evaluation of cranial trauma, patients
suspected of having V EH s seem to rep­
resent such cases. When emergency
M R I is not readily available, sagittal or
coronal reconstruction of fine-cut axial
CT images through the cranial vertex
can provide better assessment of the
size of these hematomas.

M iller et al., in this article on V EH s,
remind us of lesions that have been
w idely described in the neurotrauma lit­
erature and that certainly deserve occa­
sional reconsideration. As the authors
rightly point out, hematomas in this
area can be overlooked and their signif­
icance minimized on the basis of CT
scans alone.
I think it is important to point out that,
in both of the cases described, there were
significant bony (cranial) pathological fea­
tures crossing the SSS. Whenev er we are
confronted with such a situation, we must
bear in mind the possibility7 of a signifi­
cant underlying injury to the SSS or, as in
the cases described, a clinically significant
epidural hematoma. Therefore, it is al­
ways prudent to perform additional test­
ing, including M RI, for patients with head
injuries for whom associated injuries may
indicate the development of significant
morbidity (i.e., SSS thrombosis resulting
from diastatic fractures) or for whom the
clinical findings cannot be explained on
the basis of CT results alone.
Jack E. Wilberger
Pittsburgh, Pennsylvania

WANTED
Your Help to Preserve Neurosurgical History
contact me with any information to help identify the names of those general surgeons
selected by the Surgeon General of the Army to train in neurosurgery during World War II. The
training consisted of short 6-week courses in Chicago, New York, I hiladtlphia, and possibly other
locations The surgeons then served for 3 to 6 months in neurosurgical centers, such as Walter
Reed, before being sent overseas. Also, 1 would appreciate any information concerning how this
program began. E-mail to ealexand@wfubmc.edu or fax to 336/777-3029. Eben Alexander, Jr.,
M.D., Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC
27157, phone 336/777-3980.

N e u ro su rg e ry ; Vol. 45, No. 3, September 1999