Background and Importance: Epidural hematoma (EDH) is a rare complication of cranioencephalic trauma. It accounts for 1 to 4% [1,2]. Supra- and infra-tentorial EDH is unusual and accounts for 2-10% of all acute EDH. It is a rare pathology and very few articles have been published on the subject [3]. Infra-tentorial EDH has a natural course of rapid deterioration and sudden death. We report our experience of the management of a supra- and infra-tentorial epidural hematoma, this case will be presented with a review of the literature.

Case Presentation: The patient was admitted to the neurosurgical emergency room for a rapidly progressive alteration of consciousness after a fall. The physical examination revealed a Glasgow score of 8/15, the pupils were of intermediate size and reactive, and the cerebral computed tomography revealed an extradural hematoma above and below the tentorial. The patient benefited from an evacuation of the hematoma and the postoperative course was simple.

Conclusion: Supra- and infra-tentorial epidural hematoma is an emergency in neurosurgery. This location is rare and has no specific clinical signs. Treatment consists of emergency evacuation of the haematoma

Keywords: Epidural Hematoma; Supra and Extra Tentorial; Cranioencephalic Trauma

Epidural hematoma is a serious complication of cranioencephalic trauma accounting for 1 to 4% [1,2]. The associated supra- and infra- tentorial location is unusual as it accounts for only 2-10% of all acute EDH [3]. Very few articles have been published on the subject. The circumstances of onset are essentially traumas, notably by public road accident or by fall. The clinical signs make it possible to identify the site of the hematoma, essentially at the supra tentorial level. There are no specific signs of EDH of the posterior cerebral fossa, the patient may be asymptomatic in the acute phase. However, signs of spinal cord compression may appear but are late for effective treatment [4]. An occipital fracture is associated in 84% of HEDs and of these 39% have parenchymal lesions [4]. Cerebral CT has made the diagnosis easy, emergency surgical management and improved the prognosis of these patients [5,6]. In this article, we report a rare case of an extradural supra and infra tentorial epidural hematoma, managed at the Fann University Hospital in Dakar followed by a review of the literature.

This is a 23 year old male patient admitted to the neurosurgical emergency room for rapidly progressive altered consciousness following a fall that occurred 48 hours earlier, the circumstances and mechanism of which are not clear. He was found on the ground. The physical examination revealed a hemodynamically and respiratorily stable patient, the Glasgow score was 8/15 (E2 V1 M5), the pupils were of intermediate size, symmetrical and photoreactive, and the reflexes were normal. The rest of the examination was unremarkable. The brain CT scan showed a 22 mm thick subacute left parieto-occipital epidural hematoma with an 8 mm subfalcoral involvement associated with an epidural hematoma of the right posterior cerebral fossa. There was a fracture of the right parietal bone and the greater wing of the sphenoid (Figure 1). The biological work- up showed a hyperleukocytosis of 13.10³/mm³, a slightly increased reactive protein chain of 11 mg/l. The ionogram and renal function were normal. An indication for evacuation of the hematoma was taken urgently.

Figure 1: CT scan in sagittal reconstruction showing a supra and infra-tentorial epidural hematoma.

The    patient under    general anaesthesia and orotracheal intubation was placed in the prone position with the head fixed on a Mayfield headrest. A left parieto-occipital lower hinge incision was made. We made a left parieto-occipital flap without going too far down, which allowed us to visualize the epidural hematoma. We proceeded to evacuate it by aspiration by reclining the supratentorial and subtentorial elements with a malleable blade (Figure 2). A dural suspension was performed and then a closure after repositioning the flap. The patient was immediately transferred to the intensive care unit. The postoperative course was normal with a return of consciousness (GCS: 15). The evolution was favourable and the patient was discharged after 20 days. Postoperative follow-up revealed no particularities. He was seen again in consultation 4 months later. The neurological examination was unremarkable. The follow-up CT scan showed a disappearance of the hematoma and the craniotomy area (Figure 3).

Figure 2: Intraoperative iconography showing the epidural hematoma on the left; on the right we can see reclining of the dura mater to access the infra-tentorial hematoma.

Figure 3: A control CT scan showing on the left the pariéto-occipital craniotomy zone and on the right we can see that all the hematoma has been evacuated.

Supra- and infra-tentorial epidural hematoma is a rare entity that occurs in front of and behind the lateral sinus. It is usually associated with a lesion of the lateral sinus [7,8]. EDH of the posterior cerebral fossa is mostly found in young subjects, Jang et al, reported a frequency of 55% [8]. This could be explained by the rich vascularity of the dura mater and diploea. In addition, craniocerebral trauma is common in the occipital region in children. A fracture of the occipital bone is usually associated [1,4]. Supra- and infra-tentorial epidural hematoma has no characteristic clinical signs. In the supra-tentorial region, these include headache, nausea, vomiting, and loss of memory, hemiparesis and consciousness disorders. At the infra tentoria level, the symptoms are cervical pain, cranial nerve paralysis and cerebellar disorders. The absence of signs does not exclude the diagnosis [1]. The natural course is towards rapid deterioration with sudden death due to involvement of the cerebellar amygdala [3]. Our patient presented with altered consciousness with a Glasgow score of 8. The diagnosis must be made urgently by performing a cerebral CT scan. Some authors suggest that a cerebral CT scan should be performed in all patients with occipital soft tissue lesions even in the absence of any symptoms [3,9]. Surgery remains the gold standard for the treatment of EDH. It should be performed as an emergency as in our case. Several authors recommend a supra and infra tentoria craniotomy leaving bone opposite the transverse sinus for dural suspension [1,8,10]. In our patient, we performed a left parietal-occipital craniotomy without too much downward overhang with evacuation of the supra tentorial epidural hematoma. The hematoma had caused a dural detachment. This allowed us to easily slide a malleable blade downwards. Access to the infratentorial EDH was achieved by reclining the dura mater revealing blood clots in the posterior cerebral fossa evacuated by aspiration. We then suspended the dura mater, repositioned the flap with fixation and closed it. The origin of the bleeding was venous by parietal-occipital fracture. Nasi et al reported that the source of bleeding in supra and infra tentorial epidural hematoma was venous by fracture with bleeding from the diploea (50%), sigmoid sinus (22%), meningeal venules (8%), detachment of the transverse sinus without lesion (6%), the rest the cause is not found [10]. Some authors suggest a conservative approach but with strict clinical and radiological monitoring [8]. The prognosis is good if the diagnosis is made early and the treatment done urgently. The poor prognostic factors are initial or secondary disturbances of consciousness associated with parenchymal lesions. Adji et al report a 17% mortality rate for HED, a 14% operative mortality rate and a 6% morbidity rate [1]. Nasi et al, found a mortality of 4%, 92% of favorable evolution after surgery and 8% of unfavorable evolution [10]. Our patient recovered completely in terms of consciousness after the surgery and the postoperative follow-up was without particularity.

Supra and infra-tentoria epidural hematoma is an emergency in neurosurgery. This location is rare and has no specific clinical signs. Diagnosis must be made early; cerebral CT is the examination of choice. Treatment consists of emergency evacuation of the hematoma. The prognosis in this case is good.

Declaration of Competing Interest
The authors declare no funding of interest related to this work.

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No funding was obtained for this study.

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All the authors

Declaration of Competing Interest
The authors declare no funding of interest related to this work.

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Consent was obtained for experimentation with human subjects

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Written informed consent was obtained from the patient for publication of this case report and accompanying images.

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Corresponding Author: Dr. Yakhya Cisse, Neurosurgery Department, Fann University Hospital Center, Senegal.

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