Pediatric acute epidural hematoma caused by contrecoup injury: illustrative case

Abstract

BACKGROUND Acute epidural hematomas (AEDHs) are formed by injury of the middle meningeal artery or venous sinus with a linear fracture just above these blood vessels. The incidence of AEDH without fracture is low, and the formation of an acute epidural hematoma due to contrecoup injury is even rarer. Here, the authors report a case of pediatric AEDH due to contrecoup injury. OBSERVATIONS A 6-year-old boy was injured in a traffic accident and was ejected from of the car. At admission, he was clearly conscious without obvious neurological deficits. Computed tomography (CT) revealed a small fracture in the right occipital lobe and a thin epidural hematoma in the contralateral left frontal lobe. A CT scan 3 hours later showed an expanded AEDH. Furthermore, the patient presented with progressive disturbance of consciousness. An emergency craniotomy was performed, but no obvious bleeding point or fracture was observed. LESSONS The source of bleeding in AEDH due to contrecoup injury in the frontal region is thought to be due to microvessel injury in the dura. Anatomical fragility and the amount of energy transferred causing the injury are associated with the AEDH formation due to contrecoup injury; thus, strict management in high-energy trauma is required.

Middle Meningeal Arterial Embolization Combined With Drilling in the Treatment of Acute Epidural Hematoma

“…However, drilling and drainage may not be recommended for treating AEDH caused by active bleeding from the middle meningeal arterial (MMA) due to the significant amount of bleeding involved and a high risk of rebleeding as well as poor stability, and drilling drainage cannot effectively stop bleeding. 10 Unfortunately, it has been established that 85% of AEDHs are caused by meningeal arterial hemorrhage, highlighting this approach's limited value in clinical practice. 10 In recent years, with the development of digital subtraction angiography, endovascular interventional therapy has been widely used in craniofacial diseases.…”

“…10 Unfortunately, it has been established that 85% of AEDHs are caused by meningeal arterial hemorrhage, highlighting this approach's limited value in clinical practice. 10 In recent years, with the development of digital subtraction angiography, endovascular interventional therapy has been widely used in craniofacial diseases. [11][12][13][14] An increasing body of evidence suggests that angiography and embolization can aid in identifying the source of bleeding in AEDH and taking appropriate measures to address it, which compensates for the lack of drilling and drainage.…”

“…There is an increasing consensus that drilling and drainage is an effective method for AEDH emergency treatment. However, drilling and drainage may not be recommended for treating AEDH caused by active bleeding from the middle meningeal arterial (MMA) due to the significant amount of bleeding involved and a high risk of rebleeding as well as poor stability, and drilling drainage cannot effectively stop bleeding 10 . Unfortunately, it has been established that 85% of AEDHs are caused by meningeal arterial hemorrhage, highlighting this approach’s limited value in clinical practice 10 …”