Case Report Pediatr Neurosurg 2003;38:156–159 DOI: 10.1159/000068813 Received: April 11, 2002 Accepted: July 8, 2002 Transient Anton’s Syndrome: A Presenting Feature of Acute Epidural Hematoma at the Confluens sinuum Selcuk Yilmazlar Ozgur Taskapilioglu Kaya Aksoy Department of Neurosurgery, School of Medicine, Uludag University, Bursa, Turkey Abstract Although unilateral epidural hematomas are well known, bilateral presentation, especially at the confluens sinuum, is uncommon, and its diagnosis may be delayed, thus causing morbidity. We report a case of acute posttraumatic cortical blindness due to epidural hematoma at the confluens sinuum caused by venous sinus tearing. The epidural hematoma was evacuated and the dural tear was repaired. The patient remained alert throughout the hospitalization. Examination of the visual field revealed recovery postoperatively, and the patient was discharged. We discuss the pathological mechanisms of transient blindness. The importance of anopsia as an early sign of epidural hematoma is emphasized. Copyright © 2003 S. Karger AG, Basel ABC © 2003 S. Karger AG, Basel 1016–2291/03/0383–0156$19.50/0 Fax + 41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/pne Introduction The early recognition of visual disturbance can be the only sign of epidural hematoma without any other neurological abnormality. Tearing of the confluens sinuum causing epidural hematoma is not a well-known entity. Because of its different clinical presentation, the diagnosis may be delayed. We present a case of acute posttraumatic cortical blindness caused by a bilateral occipital-suboccipital epidural hematoma, the evacuation of which led to reversal of the blindness. There are several reports of epidural hematomas causing hemianopia [1, 2], but transient bilateral cortical blindness as a presenting symptom of epidural hematoma is a very rare situation. Case Report A 13-year-old boy was admitted to our emergency department with the complaint of blindness after a traffic accident. His medical history did not reveal any visual problem prior to the accident. His initial physical examination was uninformative. A neurological examination was unremarkable except for his blindness. Ophthalmologic examination proved blindness, but the patient denied his deficit. Eye movements in all directions were normal, with the pupils reactive to light. Fundoscopy was normal. The examination by the consulting neurosurgeon revealed a contusion in the extracranial soft tissues of the occipital region. A cranial CT scan Dr. Selcuk Yilmazlar Uludag University, School of Medicine Department of Neurosurgery, Gorukle TR–16059 Bursa (Turkey) Tel. +90 224 4428081, Fax +90 224 4429263, E-Mail selsus@uludag.edu.tr Downloaded by: King's College London 137.73.144.138 - 9/27/2018 12:15:51 PM Key Words Epidural hematoma W Cortical blindness W Anton’s syndrome W Visual field abnormality W Skull fracture W Head injury Fig. 1. Preoperative cranial CT showed bilateral occipital hyperdensity representing epidural hematoma at the confluens sinuum. Fig. 2. Postoperative cranial CT showed a partial craniectomy defect and craniotomy flap after evacuation of the epidural hematoma. revealed bilateral occipital epidural hematoma at the confluens sinuum between the inferior occipital and superior cerebellar hemispheres compressing the occipital lobes bilaterally (fig. 1). Midline occipital fracture with minimal depression of the confluens sinuum was also apparent in the bone windows of the CT scan. With a combined midline occipital and partial suboccipital craniotomy, a partially organized epidural hematoma was totally evacuated, as can be seen in the early postoperative CT scans (fig. 2). The dural tear over the confluens sinuum was repaired. Postoperatively, examination of visual fields with Goldmann perimeter revealed bilateral right inferior quadrantanopia (fig. 3). Cranial MRI showed a patchy hyperintensity signal consistent with a localized contusion on the calcarine cortex on T2-weighted images, which was believed to be the reason for the quadrantanopia (fig. 4). associated with epidural hematoma from injury of the confluens sinuum. Homonymous hemianopia in association with epidural hematoma has been reported in some series, but only Matwijecky and Steinbok [1] and McKissock et al. [2] mentioned cases of cortical blindness. In our case, blindness was the sole and vague deficit that led the emergency physician to consult with an ophthalmologist, since the patient was alert and had no complaint of headache, nausea or vomiting. Even in the absence of accompanying motor or sensorial disturbances, head trauma may be accompanied by visual problems. Symptoms and signs may be elusive in children with minor head trauma. Therefore, a detailed history and physical and neurological examination should be performed in a meticulous manner to avoid treatable intracranial pathology. Cortical blindness can occur after bilateral lesions of the calcarine cortex. There may be bilateral homonymous hemianopsia due to optic tract, radiation or occipital lobe involvement and bilateral central scotomas due to bilateral occipital lobe lesions. Cortical blindness may be traumatic in origin. Injuries to the posterior parts of both occipital poles and compression and obliteration of both cerebral arteries may cause cortical blindness. Cortical blind- Transient bilateral cortical blindness is a well-recognized clinical entity as a sign of head injury, especially in children. Although cerebral vasospasm is a suspected cause, the real underlying mechanism is elusive [3–5]. While there are several reports of hemianopia due to subdural hematoma, epidural hematoma has been implicated twice [6, 7]. To the best of our knowledge, the present case is the first reported case of transient cortical blindness Acute Cortical Blindness due to Epidural Hematoma Pediatr Neurosurg 2003;38:156–159 157 Downloaded by: King's College London 137.73.144.138 - 9/27/2018 12:15:51 PM Discussion Fig. 3. Examination of visual fields with Goldmann perimeter. Bilateral right inferior quadrantanopia indicates that the epidural hematoma affected the left occipital pole more than the right side. Fig. 4. Postoperative axial T2-weighted MRI. There was a hyperintensity signal (arrowhead) on the left calcarine cortex that was consistent with the localized contusion. 158 Pediatr Neurosurg 2003;38:156–159 hematoma [14]. Compression of the supplying arteries may cause visual problems, as we observed in this case. Lesions of one occipital lobe will cause a contralateral hemianopic defect. In our case, the occipital lobes were affected bilaterally due to epidural hematoma over the confluens sinuum, creating a very rare clinical situation in which the patient presented with cortical blindness. The finding of blindness in a conscious patient suspected of having a head trauma can suggest evaluation in an occipital location preoperatively. Yilmazlar/Taskapilioglu/Aksoy Downloaded by: King's College London 137.73.144.138 - 9/27/2018 12:15:51 PM ness is sometimes difficult to differentiate from hysterical blindness since the pupils may still react to light. Transient cortical blindness due to epidural hematoma is a rare complication of head trauma. Mechanisms involved may be occlusion of the posterior cerebral arteries caused by downward or upward transtentorial herniation and direct compression of the calcarine cortices bilaterally by the hematoma [8–10]. Homonymous hemianopia and other visual field defects are more common presenting symptoms after trauma than cortical blindness. Few patients have evidence of damage bilaterally due to epidural hematoma [11–13]. A review of the literature revealed one reported case of blindness after epidural References Acute Cortical Blindness due to Epidural Hematoma 5 Eldridge PR, Punt JA: Transient traumatic cortical blindness in children. Lancet 1988;i:815– 816. 6 Soza M, Tagle P, Kirkham T, Court J: Bilateral homonymous hemianopia with sparing of central vision after subdural hematoma. 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