I N individuals who have sustained antenor polar brain injury, the differentiation

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1 VOL. 122, No. 3 FRONTAL EPIDURAL HEMATOMA* THE ANGIOGRAPHIC DIAGNOSIS WITH A NEW FINDING By DAVID DEE, JR., M.D.,f MERLIN E. WOESNER, M.D., and ISAAC SANDERS, M.D. LOS ANGELES, CALIFORNIA I N individuals who have sustained antenor polar brain injury, the differentiation of brain contusion or pulping, subdural hematoma, and epidural hematoma can be difficult clinically and angiographi- It is the purpose of this presentation to report 2 instances of frontal head trauma in which an angiographic observation by one of us (D.D.) led to the correct preoperative diagnosis of frontal epidural hematoma. From our review of the literature, this angiographic finding has not previously been recorded. In both patients a posterior displacement of a meningeal branch of one of the ethmoidal arteries of the ophthalmic artery system was observed. Definitive angiographic diagnosis led to prompt surgical exploration and evacuation of an epidural hematoma in both cases. The absence of displacement of this artery in a third patient with otherwise similar clinical presentation and angiographic findings contributed to a diagnosis of frontal lobe contusion, a conservative approach in clinical management, and complete recovery without craniotomy. REPORTS OF CASES CASE I. A i year old Mexican-American male was admitted to the White Memorial Medical Center following head trauma. At the time of admission he was lethargic, showed a short attention span, but did respond to commands. The right pupil was larger than the left and bilateral Babinski reflexes were elicited. Skull roentgenograms disclosed no fracture. An echoencephalogram (A-mode) showed a 2 mm. L FIG. I. Case i. The pericallosal arteries are shifted 4 mm. to the left. shift of the mid-line structures to the left. On the third hospital day he began to show some signs of circumorbital hematoma but the neurologic findings remained unchanged. Because of neurologic stability and the initial clinical impression that the patient had sustained cerebral contusion and concussion, no surgical intervention was instituted at that time. On the fifth hospital day a cerebral angiography was performed with imaging in the anteropostenor, lateral and oblique projections. The cerebral angiogram revealed a mm. shift of the pericallosal arteries to the left (Fig. I), a stretching of the frontopolar branches of the right anterior cerebral artery on lateral projection (Fig. 2), and associated posterior displacement of the sylvian triangle and pencallosal artery. In addition a posterior displacement of a meningeal branch of the right ophthalmic artery system was noted (Fig. 3). The demonstration of this displaced vessel was significantly improved on a magnified subtraction view (Fig. ). The right posterior oblique projection also disclosed an avascular extra-axial space at the anterior pole of the right frontal lobe. The avascular extra-axial mantle was interpreted to be an epidural hematoma rather than a subdural hematoma because of the associated displacement of the meningeal * From the Department of Radiology, White Memorial Medical center, Los Angeles, california. t Director, Section of Angiography. Chief of Diagnostic Radiology; Associate Clinical Professor of Radiology, Loma Linda University School of Medicine. Director of Training, Radiological Sciences; Associate Professor of Radiology, Loma Linda University School of Medicine. 525

2 526 David Dee, Jr., Merlin E. Woesner and Isaac Sanders NOVEMBER, 1974 FIG. 2. Case I. There is stretching of the frontopolar branches of the right anterior cerebral artery with associated posterior displacement of the pericallosal artery and sylvian triangle vessels consistent with an anterior polar mass effect.posteriordisplacement of a meningeal branch of the right ophthalmic artery system is observed (open arrowheads). Iki LI t FiG. 3. Case I. A subtraction angiogram in the right posterior oblique projection reveals an avascular extra-axial space at the anterior pole of the right frontal lobe. The open arrowhead identifies the same meningeal branch observed in Figure 2. - FIG. 4. Case I. Magnified subtraction view better demonstrates the posteriorly displaced meningeal branch of the ophthalmic artery system (closed arrowheads). The vessel can be traced back to the ophthalmic artery and is probably a branch of the posterior ethmoidal artery. branch of the ophthalmic artery system. At surgery, a large epidural hematoma of approximately 175 cc. was evacuated from the anterior fossa. A fracture line (not visible on the roentgenograms) across the distribution of a small meningeal artery involving only the internal table of the skull was observed. This was believed to be the source of the epidural bleeding. The postoperative course was uneventful and the patient recovered without neurologic deficit. CASE II. A 13 year old Caucasian female was brought to the White Memorial Medical Center Emergency Room following an automobile accident. She was stuporous and agitated and exhibited bilateral Babinski reflexes, but was able to move all extremities. She also had multiple lacerations and abrasions about the head. She was admitted to the hospital for observation and on the second day demonstrated signs of decerebration on the left side with a partial third cranial nerve palsy. Bilateral carotid arteniography was performed with imaging in the anteroposterior, lateral, and left posterior oblique projections. A 1.2 cm. round shift of the anterior cerebral and penicallosal arteries from left to right (Fig. #{231}) was observed in the anteropostenior view. The lateral projection (Ii ig. 6) revealed posterior displacement of the pericallosal artery and frontopolar branches of the anterior cerebral artery as well as similar displacement of

3 VOL. 122, No. 3 Frontal Epidural Hematoma 527 FIG.. Case u. There is a round shift of the anterior cerebral and penicallosal arteries from left to right. the sylvian triangle vessels. An avascular space was observed to be an extra-axial mantle on the left posterior oblique projection (Fig. 7). Again (as in Case i) the depression, posterior displacement and arching of a meningeal branch of the ophthalmic artery system, observed best in lateral projection, resulted in a definitive angiographic diagnosis of acute epidural hematoma. Trephines were placed in the frontal bone and a relatively large volume of epidural blood was evacuated. Although the patient experienced a stormy postoperative course and later spent some time in the rehabilitation unit, she exhibited yin- 1L1. FIG. 6. Case II. Posterior displacement of the pencallosal artery and frontopolar branches of the anterior cerebral artery indicates the presence of an anterior polar mass lesion. Closed arrowheads outline the course of a posteriorly displaced meningeal branch of the ophthalmic artery system. This vessel is traced back to the ophthalmic artery (open arrowhead). 31 FIG. 7. Case II. An avascular extra-axial mantle in the left posterior oblique projection suggests either a subdural or epidural hematoma. Because of the displaced meningeal branch of the ophthalmic artery system (Fig. 6), a definitive angiographic diagnosis of epidural hematoma was made. tually no demonstrable neurologic deficits I year following surgery. DISCUSSION The angiographic findings in frontal epidural hematoma mimic those observed in intracerebral hemorrhage or pulping as described by Davis and Coxe.2 It is of interest to note that the anteroposterior and lateral illustrations of our Case E are almost identical to many of the illustrations presented by those 2 authors. Others have stressed that additional information is provided by oblique projections. The demonstration of an avascular extra-axial mantle provides evidence of a subdural or epidural

4 528 David Dee, Jr., Merlin E. Woesner and Isaac Sanders NOVEMBER, 1974 FIG. 8. Displacement of the penicallosal arteries from right to left was observed in a patient with cerebral edema in the right anterior polar aspect of the brain following concussion. hematoma, but does not differentiate well between these 2 diagnoses in the frontal area. We believe that the displacement of the meningeal branches of the anterior or posterior ethmoidal arteries of the ophthalmic artery system, such as occurred in the 2 cases presented here, may be an important clue favoring the diagnosis of epidural hematoma. Although we have not been afforded the opportunity as yet of testing this hypothesis with the absence of the finding in a suitable case of frontal subdural hematoma, we have noted the absence of such displacement in a patient with clinical and angiographic findings of cerebral edema in the anterior polar aspect of the brain following concussion (Fig. 8; and 9). In this instance the absence of the sign supported the clinical decision for a conservative approach to management of the patient. Craniotomy was not performed and the patient has returned to the pretrauma neurologic state with a i year follow-up. Epidural hematoma has its difficult and treacherous facets clinically as well. It may occur following a trivial blow or a minor fall, resulting in a tearing away of the dura from the internal table of the skull.5 In the early course, the patient may seem to be recovering from a concussion and then quite suddenly exhibit signs of deepening cerebral depression leading to death if not treated. The mortality rate of extradural hematoma has been reported from 27 to 50 per cent in most series and as high as 86 per cent in one series.6 In about one-third of the cases of extradural hematoma, the pathology is not in the middle fossa, but in atypical locations including the anterior polar areas.5 McKissock et al.,6 in reporting on 126 cases of epidural hematomas, found 9 in the frontal area. Two of the deaths in this series were in patients with frontal epidural hematoma, who had multiple bilateral exploratory trephines in the parietal and temporal regions without discovery and evacuation of the blood which was in the anterior fossa. Also noteworthy is the fact that the majority of their patients were young, over one-half being under the age of ic years. It can be postulated that one primary reason for the high mortality associated with extradural hematoma is that it is not infrequently missed when occurring in one of the atypical sites. Fracture may involve the internal table of the 4: -. 4k ilih..! FIG.. The subtraction angiogram of the same patient as in Figure 8 reveals posterior displacement of the penicallosal, frontopolar, and sylvian triangle vessels. However, a meningeal branch of the ophthalmic artery system (closed arrowheads) is not displaced posteriorly. This is probably a branch of the anterior ethmoidal artery and can be traced back to the ophthalmic artery (open arrowhead). The patient survived without craniotomy with a clinical and angiographic diagnosis of concussion and cerebral edema.

5 VOL. 122, No. 3 Frontal Epidural Hematoma 529 skull, as in I ofour cases, and not be visualized on skull roentgenograms. Such fractures not uncommonly occur in association with epidural hematoma. The anatomy of the meningeal branches of the ophthalmic artery system has been described in some detail by Kuru.4 The anterior meningeal and the anterior falcial arteries are quite commonly described vessels.7 The vessels that are demonstrated and exemplified by our cases are apparently meningeal branches of the ophthalmic artery complex and probably actually branches of one of the ethmoidal arteries. In our cases they have been traced back on magnification subtraction angiograms to an ophthalmic artery origin. For that reason we refer to them as meningeal branches of the ophthalmic artery system. They apparently arise from either or both the anterior and posterior ethmoidal arteries which arise from the ophthalmic artery. #{176}They supply the dura mater in the anterior polar area. Angiographic demonstration of the meningeal branches of the ophthalmic artery system in the anterior fossa is not always possible. Meticulous technique enhanced by magnification subtraction efforts are helpful. The examples presented in this article were in patients in their second decade of life. Attempts at demonstrating these vessels in elderly patients have been less satisfactory. However, they are quite consistently recognized in elderly patients with occlusive disease of the internal carotid artery proximal to the origin of the ophthalmic artery. This is presumably due to the development of a rich collateral circulation. Similarly, they have been reported as prominent in patients with subfrontal meningioma, falx meningioma, frontopolar arteriovenous malformation, epidural lymphoma, Paget s disease of the frontal bone, and metastatic tumor invasion of the frontal dura.7 In conclusion, we recommend that when selective carotid angiographies are performed on patients who have sustained frontal head injury, imaging be carried out in the anteroposterior, lateral and ppropriate oblique projections. The study should include subtraction roentgenograms, particularly in the lateral projection, on which a search for displacement of the meningeal branches of the ophthalmic artery system may be made. Ifsuch displacement is documented, a diagnosis of epidural hematoma is favored and immediate surgical intervention may be life saving. The visualization of the meningeal branches of the ophthalmic artery is more likely in young patients. SUMMARY The angiographic recognition of displacement of the meningeal branch of the anterior or posterior ethmoidal artery of the ophthalmic artery system-a sign not previously reported in the literature-led to the correct preoperative diagnosis of frontal epidural hematoma in 2 patients with frontal head injury. Furthermore, the validity of the sign is strengthened by its absence in a third patient, who also sustained anterior polar brain trauma, otherwise demonstrated classical angiographic manifestations of post-traumatic frontopolar cerebral edema, and recovered without craniotomy. The differential diagnosis of anterior polar space occupying lesions of traumatic origin is reviewed. Merlin E. Woesner, M.D. White Memorial Medical Center 1720 Brooklyn Avenue Los Angeles, California REFERENCES I. CRONQvIST, S., and KOHLER, R. Angiography in epidural haematomas. Acta radiol. (Diag.), 1961, I, DAVIS, D. 0., and COXE, W. S. Angiographic evaluation of anterior polar brain injury. Radiology, 1969, 93, HIGAZI, I.,and EL-BANHAwY, A. Value of angiography in diagnosis of extradural hematoma of anterior fossa. 7. Neurosurg., 1966, 24, KURU, Y. Meningeal branches of ophthalmic artery. Acta radiol. (Diag.), 1967, 6, LEWIN, W. The Management of Head Injuries.

6 530 David Dee, Jr., Merlin E. Woesner and Isaac Sanders NOVEMBER, 1974 Baillire, Tindall & Cassell, London, 1966, p McKI550CK, W., TAYLOR, J. C., BLOOM, W. H., and TILL, K. Extradural haematoma: observations on 125 cases. Lancet, 1960, 2, POLLOCK, J. A., and NEWTON, T. H. Anterior falx artery: normal and pathologic anatomy. Radiology, 1968, 91, SCHECHTER, M. M., and ZINGES5ER, L. H. Special procedures in management of traumatic lesions of head and neck. Radiol. C/in. North America, 1966, 4, STATTIN, S. Meningeal vessels of internal carotid artery and their angiographic significance. Actaradiol., 1961,55, WARWICK, R., and WILLIAMS, P. L. Gray s Anatomy. Thirty-fifth edition. W. B. Saunders Company, Philadelphia, 1973, pp ; 986. ii. WHEELER, E. C., and BAKER, H. L., JR. Ophthalmic arterial complex in angiographic diagnosis. Radiology, , WORTZMAN, G. Roentgenologic aspects of extradural hematoma. AM. J. ROENTOENOL., RAD. THERAPY & NUCLEAR MED., 1963, 90,

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