Delayed onset of traumatic extradural hematoma

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✓ During a 4½-year period, seven patients with delayed onset of an extradural hematoma were seen among 80 consecutively treated cases of extradural hematoma for a frequency of 8.75%. The hematomas were insignificant or not present on initial computerized tomography (CT) scanning. Repeat CT scans within 24 hours of admission showed sizeable hemorrhages. Six hematomas were evacuated, and one was reabsorbed spontaneously. In only one patient did neurological deterioration herald the onset of the extradural hematoma, four patients remained unchanged, and two improved before diagnosis. Intracranial pressure (ICP) was monitored in five patients, four of whom showed intermittent rise in pressure despite preventive treatment. Intracranial hypotension and rapid recovery from peripheral vascular collapse seemed to be contributory factors in the delayed onset of an extradural hematoma. Awareness of this entity, a high degree of vigilance, ICP monitoring, and repeat CT scanning within 24 hours of injury are strongly recommended in these cases, especially after decompression by either surgical or medical means, recovery from shock, or whenever there is evidence of even minimal bleeding under a skull fracture on the initial CT scan.

Article Information

Address reprint requests to: Bernardo Borovich, M.D., Department of Neurosurgery, Rambam Medical Center, Technion School of Medicine, Haifa, Israel.

© AANS, except where prohibited by US copyright law.

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    Case 1. Initial computerized tomography scans showing a left acute subdural hematoma with ventricular compression and midline shift to the right.

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    Case 1. Repeat computerized tomography scans 24 hours postinjury and 18 hours after left parietal craniectomy. A contralateral delayed traumatic extradural hematoma is revealed with slight ventricular compression and midline shift to the left.

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    Case 4. Initial computerized tomography scans showing a right parietal extradural hematoma. A left parietal brain contusion and a thin subdural hematoma are also visible.

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    Case 4. Repeat computerized tomography scans 8 hours postinjury and 3 hours after right parietal craniotomy with cerebral contusion underneath. A left contralateral delayed traumatic extradural hematoma and hemorrhagic contusion of the brain can be seen, with ventricular compression and midline shift to the right.

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