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CASE REPORT
Year : 2021  |  Volume : 18  |  Issue : 2  |  Page : 156-158

Unusual presentation of epidural haematoma with ossified border on computed tomography scan


1 Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna, Nigeria
2 Department of Radiology, College of Medicine, Ahmadu Bello University, Zaria, Nigeria
3 Department of Radiology, College of Medicine, Ahmadu Bello University, Zaria, Nigeria, Nigeria
4 Department of Surgery, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna, Nigeria

Date of Submission04-Jul-2020
Date of Decision17-Aug-2020
Date of Acceptance17-Sep-2020
Date of Web Publication10-Dec-2021

Correspondence Address:
Dr. John Sheyin
Department of Radiology, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_22_20

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  Abstract 


Ossified epidural haematoma is a rare finding in clinical practice. Neuroimaging such as computed tomographic (CT) scan plays an important role in its diagnosis and management. A 58-year-old man came for brain CT on account of 4-month history of epilepsy. He had a history of road traffic accident 4 years ago. A radiologic diagnosis of ossified epidural haematoma was made as the working diagnosis.

Keywords: Computed tomography, epidural haematoma, epilepsy, ossified


How to cite this article:
Sheyin J, Chom N D, Olarinoye Akorede S A, Makama J G. Unusual presentation of epidural haematoma with ossified border on computed tomography scan. Niger J Basic Clin Sci 2021;18:156-8

How to cite this URL:
Sheyin J, Chom N D, Olarinoye Akorede S A, Makama J G. Unusual presentation of epidural haematoma with ossified border on computed tomography scan. Niger J Basic Clin Sci [serial online] 2021 [cited 2022 Jan 17];18:156-8. Available from: https://www.njbcs.net/text.asp?2021/18/2/156/332172




  Introduction Top


Chronic epidural haematoma is a collection of blood in the potential space between the inner table of the skull laterally and the dura mater medially. It is one of the causes of neurosurgical emergency globally. The incidence varies from 1.5% to 4% of all head injuries.[1],[2] It is seen in <1% of all children with cranial trauma and is quite uncommon in infants.[1]. It is more common in younger patients of between 20 and 40 years[1],[3] and usually not related to gender.

Its causes include complications of head trauma or surgical cranial procedures, e.g., craniotomy leading to bleeding from the middle-meningeal artery or one of its branches and more rarely from venous bleeding.

It is seen as a biconvex-shaped hyperdensity immediately subjacent to the vault and frequently located in the frontoparietal regions, but it may also occur in the posterior fossa, which is rare and likely to be missed.[4] Its usual shape is lost after reoccurrence or post-surgery.[4] In about 75%–95% cases, a fracture line in the skull can be demonstrated radiographically.[1],[5]

Ossification of chronic epidural haematoma is rare,[6],[7],[8],[9] since most of it is removed surgically before it occurs.[1],[2] The precise mechanism of an osseous transformation is still not well understood.[3],[10]

The time of presentation is usually in the first few days of occurrence. History of transient loss of consciousness, lucid interval, delayed somnolence, progressive deterioration of consciousness and focal neurologic signs are all symptoms and signs of epidural haematoma.


  Case Report Top


A 58-year-old man who was referred from a government hospital in Kaduna for a brain computed tomography (CT) scan in the Department of Radiology, Ahmadu Bello University Teaching (ABUTH) Zaria, with a history of several episodes of epilepsy of 4 months duration. There was a history of road traffic accident 4 years ago in which there was no loss of consciousness or fracture. He had only bruises on the body, which were treated. He has been well until 4 months ago when he developed generalised tonic-clonic convulsions. The generalised tonic-clonic convulsions were initially twice in a month for 1 month and subsequently, it became weekly. Each convulsion usually lasts for 15 min. There was no associated preceding aura, tongue biting, sphincteric disturbances or paresis. However, there was associated postictal sleep which usually lasts for about 10 min.

On examination, he was well preserved, not dehydrated, not pale and not in obvious respiratory distress. Examination of the central nervous system and other systems were essentially normal. Based on these findings, a diagnosis of epilepsy was suspected. Investigations requested include full blood count and differentials, urea, electrolytes and creatinine (done in state hospital and were essentially normal) and brain CT which was done at ABUTH. The cranial CT shows an extensive non-enhancing biconvex hypodense lesion with calcified border in the left fronto-parieto-occipital area. A radiological diagnosis of a chronic epidural haematoma with ossified border was made [Figure 1] and [Figure 2]. The patient had craniotomy where intraoperatively an extensive haematoma in the epidural space in the left fronto-parieto-occipital region was found and was drained. He was also placed on prophylactic antibiotics. He improved remarkably without seizure recurrence throughout his hospital stay and was discharged home.
Figure 1: Contrast-enhanced axial computed tomography image showing chronic non-enhanced epidural haematoma with a calcified border in the left frontoparietal area with effacement of the ipsilateral lateral ventricle and mild shift of midline to the right

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Figure 2: Non-enhanced axial computed tomography showing a chronic epidural haematoma with calcified border in the left parieto-occipital area

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  Discussion Top


Majority of patients with epidural haematoma present within 24 h of head injury and usually show the progressive deterioration of consciousness, a proportion presents much later as seen in this patient. Morbidity and mortality are related to a delay in diagnosis and treatment.[11]

Traumatic intracranial haematoma increases the incidence of epilepsy in both acute and late states[10] as was seen in this case.

Prior to the era of CT, the diagnosis was made by the following investigation which includes:

  1. Exploratory burr or trephine holes[3],[5]
  2. Skull radiography showing shift of calcified pineal gland[3]
  3. Carotid angiography[3],[5]
  4. Ventriculography[3]
  5. Pneumoencephalography[5] and nuclear scanning.[12]


CT has overtaking the above mention investigations, it is reliable in demonstrating intracranial haematomas and other associated intracranial lesions, which are important for prognosis.

  • Magnetic resonance imaging can also be used, but the calcific components may be missed
  • Ultrasound is also used before the closure of the fontanelles in children which was not applicable in this case
  • The main treatment is craniotomy; other mode of treatment is conservative management.[2],[11]


Our index patient was an elderly man, who presented with generalised tonic-clonic seizures, preceding history of head trauma, radioimaging evidence of chronic epidural haematoma with ossified border in the fronto-parieto-occipital areas; he had craniotomy with remarkable improvement.


  Summary Top


A case of an unusual presentation of epidural haematoma has been presented. The clinical features, radiological diagnosis and the review of literature have been discussed.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dong KY, Dong H, Sung MC, Yong J C. Rapidly calcified epidural haematoma in neonate. J Korean Neurosurg Soc 2008;44:98-100.  Back to cited text no. 1
    
2.
Yasar B, Ali KU, Aykan U, Ahmet HK, Adnan D. Iatrogenic chronic calcified/ossified epidural haematoma. J Nerv Syst Surg 2009:2:91-94.  Back to cited text no. 2
    
3.
Erdogan B, Sen O, Bal N, Cekinmez M, Altinors N. Rapidly calcifying and ossifying epidural hematoma. Pediatr Neurosurg 2003;39:208-11.  Back to cited text no. 3
    
4.
Wolfgang D. editor, Radiology Review Manual. 5th ed.London: Lippincott Williams and Wilkins; 2003. p. 280-1.  Back to cited text no. 4
    
5.
Yeo CG, Jeon WY, Kim SH, Kim OL, Kim MS. The effectiveness of subdural drains using urokinase after burr hole evacuation of subacute subdural hematoma in elderly patients: A prelimilary report. Korean J Neurotrauma 2016;12:101-6.  Back to cited text no. 5
    
6.
Sharma R, Verma SK, Sinha S. Chronic extradural hematomas: An illustrative case report and review of literature. Indian J Neurosurg 2016;5:163-171.  Back to cited text no. 6
    
7.
Akhaddar A, Boulahroud O. Ossified chronic epidural hematoma of the posterior fossa. Pan Afr Med J 2015;20:238.  Back to cited text no. 7
    
8.
Bishnoi S, Bishnoi I, Gahlawat N, Saini V. Ipsilateral Two Spontaneous Chronic Calcified Epidural Hematoma. Asian J Neurosurg 2019;14:1048-9.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Pappmikail L, Rato R, Novais G, Bernardo E. Chronic calcified subdural hematoma: Case report and review of literature. Surg Neurol Int 2013;4:21.  Back to cited text no. 9
    
10.
Lee BH, Hwang YJ, Choi CY. Serial CT findings of a rapidly calcified epidural hematoma in a young adult: A case report. J Neuroimaging 2014;24:531-2.  Back to cited text no. 10
    
11.
Huaqiang D, Shuai L, Liang L. A case with a post-operative rapidly calcified subdural hematoma. Br J Neurosurg 2019;33: 1-3. [Doi. 10.1080/02 688697.20019.1689230].  Back to cited text no. 11
    
12.
Boiten J. Epidural haematoma of the posterior fossa: Good results after prompt diagnosis with CT. J Neurol Neurosurg Psychiatry 1989;52:914-5.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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