Vertex epidural hematoma: Diagnosis, therapeutic consideration and outcome. Issue 1 (January 2023) - Su, Tsung-Ming
Highlights: Vertex epidural hematoma is a relatively rare intracranial hematoma. Diagnosis and management of vertex epidural hematoma can be challenging. Massive blood loss is a potential risk during the evacuation of vertex epidural hematoma. Strip craniotomy may be a safer surgical method for vertex epidural hematoma. GCS score is the most important prognostic factor in patients with VEDH. Abstract: Objective: Vertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging. Materials and methods: A retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome. Results: Patients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively ( p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional "simple craniotomy". No patients undergoing "strip craniotomy" experienced massive bleeding. Thrombocytopenia ( p = 0.008), headache ( p = 0.015), consciousness disturbance ( p = 0.043), pupil reactivity ( p = 0.010), GCS score ( p < 0.0001) and the relationship between skull fracture and the SSS ( p = 0.037) were significant prognostic factors. Conclusion: Our study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.