Delayed Bilateral, Post-Traumatic Extra-Subdural Hematomas in a Patient with Meningioma

Abstract

Concomitant acute epidural hematoma (EDH) and subdural hematoma (SDH) is a rare finding, and its bilateral onset has not yet been reported in literature. We present the first report of a patient affected by post-traumatic concomitant EDH and SDH, with the contralateral, delayed onset of another, associated with meningioma previously treated with gamma knife. A 60-year-old female patient with a history of simple focal seizures with motor symptoms and well-controlled by drugs since childhood, arterial hypertension, and incidental diagnosis of multiple meningiomas was referred to our department after falling down the stairs. Initially, the patient was prescribed gamma knife treatment of the right frontal convexity meningioma. The patient was admitted to our emergency department with Glasgow Coma Scale (GCS) score of 7/15 and isochoric, myotic pupils. An immediate head CT scan revealed a small acute SDH in the right hemisphere and an acute blood collection in the left hemisphere, which exerted mass effect; furthermore, we discovered complex skull fractures across the superior sagittal sinus, and dislocated bone fragments. A left decompressive craniectomy was performed, and intraoperatively we observed a concomitant EDH/SDH. Due to the patient's anisocoria, an urgent postoperative CT scan was performed, revealing a massive blood collection in the right hemisphere, which was discovered to be another concomitant EDH/SDH, during right trauma flap. Through this approach, we also removed the right frontal convexity meningioma. After 5 days in the intensive care unit (ICU), the patient died because she presented an acute heart failure. The development of a contralateral, delayed EDH/SDH must be considered in severe traumatic patients, especially if associated fractures across major dural sinuses are present. Intraoperative CT scan, if available, or immediate postoperative CT scan, is mandatory for adequate management of complex neurotrauma cases.