The Value of Angiography in Diagnosis of Extradural Hematoma of the Anterior Fossa

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1 The Value of Angiography in Diagnosis of Extradural Hematoma of the Anterior Fossa Report of Two Cases IBRAHIM HIGAZI, M.D., AND AHMED EL-BANHAWY, M.D. Department of Neurological Surgery, Ein-Shams University School of Medicine, Cairo, Egypt Ever since it was described in 886 by Jacobson, 9 extradural hematoma has come to be closely associated with the middle cranial fossa. This association has been so repeatedly emphasized over the years that the possible formation of extradural hematoma elsewhere is apt to be overlooked. The incidence of hematomas outside the middle fossa and their contribution to the total high mortality rate of extradural hematoma in general has only been recently recognized. 7,s,'~ 2,4,6,7 Recently ~ cases of extradural hematoma of the anterior fossa came to our notice. Despite the classic clinical picture pointing to the middle cranial fossa, angiography was used as a method of diagnosis. The hematoma was accurately and promptly localized in both cases and treatment successfully carried out. These cases stimulated us to review the literature of anterior fossa extradural hematoma for methods of diagnosis and the result of treatment.,2,6,7,s,~ It became clear to us that the generally accepted method of multiple burr-hole inspection leaves much to be desired, and that more use should be made of angiography in cases of suspected intracranial hematoma. The purpose of this paper is: () to report cases of a rare lesion and to review its literature; (~) to demonstrate the value of angiography in the management of these cases and (3) to describe the angiographic features of an extradural hematoma of the anterior fossa. Case Reports Case. This 4~-year-old man was unconscious for 5 minutes after a car accident. Thereafter his consciousness cleared but in 3 hours he became confused and irritable and began to develop weakness on his left side. On examination 5 hours later, there was left hemiparesis with bilateral extensor plantar responses. The right pupil was dilated and fixed, the left normal. The vital signs were within normal range. Roentgenograms of the skull revealed an extensive linear fracture involving the right temporo-frontal area and extending across the midline to the left frontal region. Right carotid angiography was performed 8 hours after the accident. It revealed a huge subfrontal mass (Figs. and 8). Operation. Right frontal craniotomy was done ~ hours after the accident. A large extradural clot was Received for publication August ~, evacuated. Multiple linear fractures were noted in the right orbital roof but no definite source of bleeding was seen. Postoperative course. Tracheostomy was performed hour postoperatively. Thereafter the patient made an uneventful recovery. A repeat right carotid angiography done on the 6th postoperative day was normal (Fig. ~). The patient was neurologically normal, and was discharged on the same day. Comment. The protracted course of the case is noticeable. Exploration of the middle fossa, abundantly justified by the classic clinical picture, would certainly have missed the hematoma. The linear fracture was not diagnostically helpful. '~ It was extensive and involved both sides. There is little doubt that angiography saved the patient. Case 2. This!t~.-year-old recruit was rendered unconscious immediately following a car accident. When seen 6 hours later he was in deep coma. He seemed to react to painful stimuli less readily on the left side. Abdominal reflexes were bilaterally absent. The Babinski response was extensor on both sides. The right pupil was dilated and reactive, the left normal. The vital signs were little affected. X-rays showed a linear fracture crossing the middle meningeal groove in the right temporal region. Right carotid angiography, done 4 hours after the accident, revealed a right frontolateral mass (Figs. 4A, 5B, and 6 A and D). First Operation. Right frontal craniotomy performed ~0 hours following the accident revealed a large clot on the lateral aspect of the right frontal lobe. It was completely evacuated. No definite source of bleeding was detected. Postoperative Course. The patient made a fairly smooth recovery. It was noted, however, that at times he was confused and drowsy and complained of severe head= aches. The optic discs looked normal. The visual fields could not be determined due to the patient's lack of cooperation. A repeat right carotid angiography was done on the 7th postoperative day. It showed the anterior cerebral artery almost on the midline, with the transverse segment stretched and displaced upward (Fig. 6 B and E). The elevation of the anterior cerebral artery in the anteroposterior view of the angiogram suggested a suprasellar mass. To rule out a normal variant, an air study was done on the following day. The result confirmed the presence of a suprasellar mass. Second Operation. On the 7th postoperative day, the original frontal flap was elevated. Neither in the frontal nor in the suprasellar region was there any evidence of extradural clot. On incising the bulging dura in the prechiasmatic region about ~5 cc. of liquid blood were

2 766 Ibrahim Higazi and Ahmed E-Banhawy FIG.. Subfrontal extradural hematoma. Right carotid angiogram: preoperative. A. Lateral view. The anterior cerebral artery is displaced upward and backward. The fronto-polar artery is also displaced. Note the absence of vessels in the subfrontal region. B. Anteroposterior view. The anterior cerebral artery is stretched, bowed and markedly displaced toward the left side. FIo. ~. Subfrontal extradural hematoma. Right carotid angiogram: postoperative. The anterior cerebral and fronto-polar arteries have resumed their normal position. The subfrontal area is revaseularized. A. Lateral view. B. Anteroposterior view. released. There was a well-formed though thin, outer membrane. Second Postoperative Course. The patient made an uneventful recovery. Right carotid angiography was repeated on the 0th day following the ~nd operation, and showed the transverse segment of the anterior cerebral artery within normal limits (Fig. 6 C and F). Comment. A g a i n t h e r e was a p r o l o n g e d course. A n g i o g r a p h y was v a l u a b l e in d e m o n s t r a t i n g t h e m u l t i p l e lesions. T h e linear f r a c t u r e in t h e m i d d l e fossa w a s a n u n r e l i a b l e guide t o t h e l o c a t i o n of t h e clot. S u p r a s e l l a r s u b d u r a l h e m a t o m a is rare. D a n d y 4 d e s c r i b e d a n d d e p i c t e d a case, b u t his was a c h r o n i c i s o l a t e d lesion, d i a g n o s e d b y v e n t r i c u l o g r a p h y a y e a r a f t e r t h e accident. T h e s i m u l t a n e ous o c c u r r e n c e of t w o u n u s u a l l y located h e m a t o m a s in t h e s a m e case m u s t be considered rare indeed.

3 Extradural Hematoma of Anterior Fossa 767 FrG. 3. Subfrontal extradural hematoma. Preoperative anteroposterior view. Avascular area extending to opposite side represents the hematoma. Note the absence of vessels at base and irregular margin above and on both sides (arrows). A. Right carotid angiogram. B. Tracing of A to bring out details of the hematoma. FIG. 4. Lateral-frontal extradural hematoma. Right carotid angiogram: lateral view. A. Preoperative. The proximal segment of the Sylvian vessels is displaced downward and backward. The carotid siphon is pushed downward. There is little or no effect on the anterior cerebral artery. B. After first operation. Normal arterial pattern. Discussion I n 945, D a n d y wrote " a n e x t r a d u r a l hemorrhage of dangerous size occurs in only one location, the t e m p o r a l fossa. ''3 Since t h e n numerous cases have been recorded in places o t h e r t h a n the t e m p o r a l fossa, l'2'6-s'l~ I n a series of 34 cases, 0 (~9 per cent) were e x t r a t e m p o r a l. Six were in the anterior fossa. ~2 T h e anterior fossa e x t r a d u r a l h c m a t o m a is our concern in this paper. I n 960, W h i t t a k e r ~7 collected 2 cases from the literature and a d d e d ~ of his own. His Case died following bilateral negative exploration. A u t o p s y r e v e a l e d a h e m a t o m a missed by a few millimeters. His Case ~ was diagnosed by angiography following bilateral n e g a t i v e exploration. H e c o m m e n t e d t h a t a n g i o g r a p h y

4 768 Ibrahim Higazi and Ahmed E-Banhawy "localized a mass lesion conclusively and a hopeless situation was converted to a total recovery. ''7 He concluded "in the future, carotid angiography in the clinically suspicious case will make the diagnosis. ''7 On reviewing the literature we found 9 more cases. The 2 cases reported by Connolly 2 and cited in Whittaker's paper 7 are discounted. Including our ~ patients, there were ~3 cases suitable for analysis (Table ). Of the e3 cases, 0 survived, a mortality rate of 57 per cent. This high figure taken at face value gives an unwarranted lethal character to anterior fossa hematomas. In fact it is a benign lesion. There were ~ cases in which the localization was correct. Ten of these recovered, making a mortality rate of 7 per cent (Table ). This observation suggests that the overall mortality rate is due mainly to inaccurate diagnosis. Other observations on the anterior fossa extradural hematoma support the concept of a favorable progress. The anterior fossa contains no vessels approaching in size the middle meningeal artery in the temporal fossa. The source of bleeding is, consequently, small and the course of development of the hematoma comparatively slow. la Whittaker's Case died 6 hours after the accident and Case e was operated upon 4~ hours following the injury. 7 In our Cases and 2, the operation was performed ~0 and ~ hours respectively after the accident. A review by McLaurin and Ford la of their cases of all types of extradural hematoma shows the importance of the time interval between the injury and the operation. The mortality rate of patients who had to be operated upon within the first 6 hours was 60 per cent. In those operated upon after ~4 hours, it was 7 per cent. The slow development of a hematoma of the anterior fossa allows time for consideration of angiography as a practical method of diagnosis. Precise localization by angiography will in turn lead to much better treatment. The work of McLaurin and Ford, both clinlcap 3 and experimental, 5 clearly demonstrates that an extradural hematoma of the anterior fossa is less dangerous than that of the middle fossa. It gives rise to tentorial herniation only late in its course of development. 5 The benign nature of the extradural hematoma of the anterior fossa is too often offset by difficulty of diagnosis. The burr-hole method is particularly unrewarding: the subfrontal clot is completely out of reach; the lateral frontal clot is very seldom disclosed. This is often missed by a few millimeters. ~ Not only is this method inadequate but it is often time-consuming. In a recent text book of surgery no less than 6 burr-holes are JacobsonS Jefferson lo Briesen x TABLE Extradural hematoma of the m~terior fossa Author Gross & Savitsky 7 Rowbotham '5 Gordy 6 Lewin 2 [rsigler s Whittaker ~7 MeLaurin & Ford~3 tiigazi & EI-Banhawy Total Year 886 9~ ~ 94~ Cases Recorded No Cases Discovered at Operation Recovered No. Recovered s recommended, in each of which the extradural, subdural and intracerebral spaces are to be explored. The value of angiography in precise diagnosis and the confidence derived from knowing exactly what to expect cannot be overestimated. This is demonstrated quite clearly by our ~2 cases and by Whittaker's Case ~. That angiography can detect multiple lesions is demonstrated in Case ~. To save time, a factor always of vital importance in extradural hematoma, angiography should be used as soon as the hematoma is suspected. This was done in our ~ cases. We are convinced that, except in emergency, the burr-hole method of exploration has outlived its usefulness. The whole situation is summed up admirably in Lewin's words: "these frontal cases illustrate how easily even a large clot may be missed although the exploratory burr-hole may lie less than cm. from the edge of the clot. In these circumstances the brain is so tight that adequate exploration within the vicinity of the burr-hole may prove impossible. '''2 He described ~ of his cases as illustration. Angiography We have described extradural hematomas of the anterior fossa in ~ locations: () the subfrontal and (~) the lateral frontal. These are illustrated by our Cases and ~ respectively. Angiography is eminently successful in displaying masses in both regions. TM The angiographic signs are indicated in Table 2, but some points need emphasis.. In the lateral view the normal variability in the curve of the anterior cerebral artery may lead to an erroneous diagnosis of a subfrontal mass. TM

5 FIG. 5. Lateral-frontal extradural hematoma. Hematoma is represented by avascular area in the frontal region. Note its crenated margin (arrows). A. Right carotid angiogram, early venous stage. B. Tracing of A to bring out details. FIG. 6. Lateral-frontal extradural hematoma. Right carotid angiograms: anteroposterior views. A and D. Preoperative: The anterior cerebral artery is markedly displaced to the left side. Its transverse segment is stretched and pushed upward by suprasellar subdural hematoma. B and E. After first operation: The anterior cerebral artery is almost in the midline. The transverse segment is still pushed upward by unevacuated subdural hematoma. C and F. After second operation: The anterior cerebral artery is in the midline. The transverse segment is normal in calibre and position.

6 770 Ibrahim Higazi and Ahmed E-Banhawy Anteroposterior View TABLE Angiographic signs of extradural hematoma of the anterior fossa SUBFRONTAL HEMATOMA. Pronounced displacement of the anterior cerebral artery to the opposite side in a shape characteristic of direct pressure effect (Fig. B). 2. Avascular area in the early venous phase with characteristic crenated margin and absence of vessels next to inner table of the skull (Fig. 3). Lateral View. The anterior cerebral artery is displaced upward and backward with accentuation of its anterior curve (Fig. A). ~. The fronto-polar artery is displaced in the same manner as its parent trunk (Fig. A). 3. NIost of the cerebral vessels are compressed in an anteroposterior direction, consequently they become undulated (concertina effect) (Fig. A). 4. The upper segment of the carotid siphon is pushed downward and backward (Fig. A). 5. The Sylvian vessels are, as a whole, displaced downward and backward, maintaining their diagonal course (Fig. A). 6. The ophthalmic artery is stretched and displaced downward (Fig. A). Anteroposterior View LATERAL FRONTAL HEMATOMA. The anterior cerebral artery is displaced to the opposite side. The transverse segment of the anterior cerebral is stretched and elevated by a suprasellar subdural hematoma (Fig. 6 A and D). ~. The middle cerebral artery is stretched and displaced downward. The distance between the anterior and middle cerebral arteries is increased (Fig. 6 A and D). Lateral View. The proximal segment of the Sylvian vessels is pushed downward and backward leaving the distal segment unaffected. This results in a curving downward of the affected segment, indicative of direct pressure (Fig. 4A). ~. The upper segment of the carotid siphon is pushed downward (Fig. 4A). 3. Avaseular area in the venous phase with characteristic erenated margin and absence of vessels next to inner table of skull (Fig. 5). Participation of the fronto-polar artery in the displacement (Fig. A) and shift of the anterior cerebral artery in the frontal view will dispel any doubt. ~. The distinguishing feature of an extradural hematoma is its avascularity. When head injury is the obvious cause, this sign is pathognomonic. The avaseular area has ~ definite though subtle features. (a) Absence of vessels between it and the inner table of the skull, a point of distinction from intracerebral hematoma which is usually surrounded on all sides by vessels (Figs. 3 and 5). (b) The hematoma margin is crenated due to the uneven detachment of the dura by the hemorrhage. This serves to distinguish it from the membrane of a subdm'al hematoma with its smooth biconcave margin. This avascular area is best seen in the early venous phase. It may appear either in the frontal view (our Case ) or in the lateral view (Case ~). A rapid seriograph is essential. Summary. We have reported ~ cases of extradural hematoma of the anterior fossa, and have analyzed the previously described ~ cases with respect to prognosis and methods of diagnosis. ~. Extradural hematoma of the anterior fossa is essentially a benign lesion. The present high mortality rate is due mainly to inaccurate diagnoses. 8. Angiography should be the first method used in the diagnosis of suspected intracranial hematoma. Burr-hole exploration should be used only if it is felt that angiography is unsafe. Our ~ cases serve to illustrate this principle. 4. We have diseussed the interpretation of angiography of the anterior fossa hematoma. References. BRIESEN, H.V. A head injury survey. Surg. Gynec. Obstet., 940, 7:638-64~. ~. CONNOLLY, C. Intracranial haematoma concealed

7 Extradural Hematoma of Anterior Fossa 77 by leakage of cerebrospinal fluid. Brit. reed. J., 956, 2: DANDY, W.E. Surgery of the brain. Hagerstown, Md.: Prior Co., 945, 67 pp. (see p. ~57) 4. DANDY, W. n. Selected Writings of Walter E. Dandy. C. E. Troland, and F. J. Otenasek, eds. Springfield, Ill.: Charles C Thomas, 957, vii, 789 pp. (see p. 59 and Fig., p. 599) 5. FORD, L. E., and McLAuRIN, R.L. Mechanisms of extradural hematomas. J. Neurosurg., 968, 20: GORDY, P.D. Extradural hemorrhage of the anterior and posterior fossa. J. Neurosurg., 948, 6:~94- ~ GRoss, S. W., and SAVITSKY, N. Extradural hemorrhage in the anterior cranial fossa. Ann. Surg., 94~, 6:8~-8~ IRSIGLER, F. J. Recent experiences with extradural haemorrhage. S. Afr. reed. J., 958, 32: JACOHSON, W. H.A. On middle meningeal haemorrhage. Guy's Hosp. Rep., 886, 43: JEFFERSON, G. Bilateral rigidity in middle meningeal haemorrhage. Brit. reed. J., 9~, 2: LESLIE, O. Basic surgery. London: Lewis, 958, 359 pp. (see p. 64) ~. LEWIN, W. Acute subdural and extradural haematoma in closed head injuries. Ann. Roy. Coll. Surgeons England, 949, 5:~40-~ ]VIcLAvR[N, R. L., and FORD, L. E. Extradural hematoma. Statistical survey of forty-seven cases. J. Neurosurg~, 964, 2: REtort, E. E., and O'CONNELL, T.Z. Extradural hematoma of the posterior fossa with concomitant supratentorial subdural hematoma. J. Neurosurg., 96~, 9: ROWBOTHAM, G. F. Acute injuries of the head. Their diagnosis, treatment, complications, and sequels. Edinburgh: E. & S. Livingstone, Ltd., 949, 3rd ed., xx, 480 pp. 6. STEVENSON, G. C., BROWN, H. A., and HOYT, W. F. Chronic venous epidural hematoma at the vertex. J. Neurosurg., 964, 2: WHITTAKER, K. Extradural hematoma of the anterior fossa. J. Neurosurg., 960, 7:089-09~. 8. WICKBOM, I. Angiography of the carotid artery Acta radiol. Stoekh., 948, Suppl. 72, 90 pp