====== Vertex epidural hematoma ======

{{ ::vertex_epidural_hematoma.jpg?400|}}

[[Vertex]] epidural hematomas occurs in the quadrangular area of the [[skull]], bounded anteriorly by [[bregma]] and [[coronal suture]]s, posteriorly by [[lambda]] and [[lambdoid suture]], laterally by the [[parietal eminence]]. 

====Etiology====
The source of this [[epidural hematoma]] are any of the following: 

(1) A tear in the [[sagittal sinus]], which is the commonest source
((Ramesh VG, Sivakumar S. Extradural hematoma at the vertex: a case report. Surg
Neurol. 1995 Feb;43(2):138-9. PubMed PMID: 7892657.
)).

(2) Bleeding from the [[skull fracture]] line itself
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
)).

(3) Dural stripping from the [[inner table]] of the skull
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
)).

(4) Bleeding from the diseased vascular skull bone, as in [[Paget's disease]]
((Ramesh VG, Sivakumar S. Extradural hematoma at the vertex: a case report. Surg
Neurol. 1995 Feb;43(2):138-9. PubMed PMID: 7892657.
)).

(5) [[Arteriovenous fistula]] of [[meningeal artery]] created by a laceration of dura underlying a linear skull fracture
((Matsumoto K, Akagi K, Abekura M, Tasaki O. Vertex epidural hematoma associated
with traumatic arteriovenous fistula of the middle meningeal artery: a case
report. Surg Neurol. 2001 May;55(5):302-4. PubMed PMID: 11516475.
)).

====Epidemiology====

Wylen and Nanda reported that VEDH account for 1.3-8.2% of all [[traumatic intracranial hematoma]]s
((Wylen EL, Nanda A. Vertex epidural hematoma with coronal suture diastasis
presenting with paraplegia. J Trauma. 1998 Aug;45(2):413-5. PubMed PMID: 9715209.
)).

Vertex [[intracranial epidural hematoma]]s (VEH) account for only 8% of all [[epidural hematoma]]s. However, these traumatic injuries may be underestimated or overlooked altogether when only computed tomography (CT) scans are used for diagnosis. The vertex may be a potential anatomic "blind spot" on this radiological method. In such cases, magnetic resonance (MRI) offers a great diagnostic aid
((Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: imaging
findings and diagnostic pitfalls. Eur J Radiol. 2000 Dec;36(3):150-7. PubMed
PMID: 11091016.
))
((Navarro JN, Alves RV. Vertex epidural hematoma: A rare cause of post-traumatic
headache and a diagnostic challenge. Surg Neurol Int. 2016 May 6;7(Suppl
10):S276-8. doi: 10.4103/2152-7806.181982. eCollection 2016. PubMed PMID:
27213114.
)).

====Clinical features====
The clinical presentation of VEDH is variable. They might present either in the immediate posttraumatic period or later. In the series of Borzone et al., 9 out of 14 patients presented in the acute phase
((Borzone M, Gentile S, Perria C, Rivano C, Rosa M. Vertex epidural hematomas.
Surg Neurol. 1979 Apr;11(4):277-84. PubMed PMID: 441913.
)).

In the series of Ramesh et al., 22 out of 29 patients presented within the first 24 h with severe headache
Headache was the presenting symptom in all the cases. Papilledema was present in five patients and lower limb weakness in five patients. None of the patients had any cranial nerve involvement.
((Ramesh VG, Kodeeswaran M, Deiveegan K, Sundar V, Sriram K. Vertex epidural
hematoma: An analysis of a large series. Asian J Neurosurg. 2017
Apr-Jun;12(2):167-171. doi: 10.4103/1793-5482.145555. PubMed PMID: 28484524;
PubMed Central PMCID: PMC5409360.
)).

Severe headache is considered to be a major symptom of VEDH. This has been emphasized by Columella et al. 
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
))
and by Miller et al.
((Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical
versus conservative management: two case reports and review of the literature.
Neurosurgery. 1999 Sep;45(3):621-4; discussion 624-5. PubMed PMID: 10493382.
)).

The pathogenesis of the headache in these cases could be either due to direct dural irritation around the SSS, which is rich in pain sensitive fibers or raised intracranial pressure (ICP) due to obstruction of SSS. Some patients may present with other features of increased ICP (visual impairment and papilledema)
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
))
((Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical
versus conservative management: two case reports and review of the literature.
Neurosurgery. 1999 Sep;45(3):621-4; discussion 624-5. PubMed PMID: 10493382.
)).

Lower limb weakness, either unilateral or bilateral, is also a presenting feature of VEDH. This is because of the direct pressure of VEDH on the motor cortex representing the leg area. Paraparesis may mislead the attending physician into suspecting a spinal cord injury
((Alexander GL. EXTRADURAL HAEMATOMA AT THE VERTEX. J Neurol Neurosurg
Psychiatry. 1961 Nov;24(4):381-4. PubMed PMID: 21610904; PubMed Central PMCID:
PMC495403.
))
((Wylen EL, Nanda A. Vertex epidural hematoma with coronal suture diastasis
presenting with paraplegia. J Trauma. 1998 Aug;45(2):413-5. PubMed PMID: 9715209.
))
((Messori A, Pauri F, Rychlicki F, Veronesi V, Salvolini U. Acute posttraumatic 
paraplegia caused by epidural hematoma at the vertex. AJNR Am J Neuroradiol. 2001
Oct;22(9):1748-9. PubMed PMID: 11673172.)).

Some patients also have upper-limb weakness or hemiparesis
((Alexander GL. EXTRADURAL HAEMATOMA AT THE VERTEX. J Neurol Neurosurg
Psychiatry. 1961 Nov;24(4):381-4. PubMed PMID: 21610904; PubMed Central PMCID:
PMC495403.
))
((Da Pian R, Benati A, Bricolo A, Tomasi A, Perbellini D, Dalle Ore G. Traumatic extradural hematoma of the middle third of the superior sagittal sinus (Italian) Osp Ital Chir. 1963;8:667–76.))

Cranial nerve involvement is unusual in VEDH. Alexander has reported a case of VEDH presenting with unilateral third-nerve palsy
((Alexander GL. EXTRADURAL HAEMATOMA AT THE VERTEX. J Neurol Neurosurg
Psychiatry. 1961 Nov;24(4):381-4. PubMed PMID: 21610904; PubMed Central PMCID:
PMC495403.
)).
====Diagnosis====
Demonstration of VEDH in the pre-CT era had been by venous phase of angiography, which showed an avascular area separating SSS from the inner table of the skull and narrowing of the SSS
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
))
((Alexander GL. EXTRADURAL HAEMATOMA AT THE VERTEX. J Neurol Neurosurg
Psychiatry. 1961 Nov;24(4):381-4. PubMed PMID: 21610904; PubMed Central PMCID:
PMC495403.
)).

With the advent of multi-planar imaging modalities like CT and MRI, the diagnosis of VEDH has become much easier. In routine axial CT scan, done in cases of head trauma, VEDH is missed many of a time. In the axial CT scan, VEDH may be seen as: 

(1) Vague hyper-dense lesion in highest slices, which might be dismissed as an artifact
((Messori A, Pauri F, Rychlicki F, Veronesi V, Salvolini U. Acute posttraumatic 
paraplegia caused by epidural hematoma at the vertex. AJNR Am J Neuroradiol. 2001
Oct;22(9):1748-9. PubMed PMID: 11673172.
))
((Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: imaging
findings and diagnostic pitfalls. Eur J Radiol. 2000 Dec;36(3):150-7. PubMed
PMID: 11091016.
)).

(2) Fracture line is running across the vault of the skull on either side. 

(3) Diastasis of coronal or sagittal suture. In these cases, the diagnosis can be confirmed with direct coronal CT.

Ramesh and Sivakumar reported the first case of VEDH diagnosed with MRI
((Ramesh VG, Sivakumar S. Extradural hematoma at the vertex: a case report. Surg
Neurol. 1995 Feb;43(2):138-9. PubMed PMID: 7892657.
)).

MRI scans are very useful in diagnosing VEDH, due to multi-planar capability and lack of bone artifacts
((Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical
versus conservative management: two case reports and review of the literature.
Neurosurgery. 1999 Sep;45(3):621-4; discussion 624-5. PubMed PMID: 10493382.
)) 
((Messori A, Pauri F, Rychlicki F, Veronesi V, Salvolini U. Acute posttraumatic 
paraplegia caused by epidural hematoma at the vertex. AJNR Am J Neuroradiol. 2001
Oct;22(9):1748-9. PubMed PMID: 11673172.
))
((Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: imaging
findings and diagnostic pitfalls. Eur J Radiol. 2000 Dec;36(3):150-7. PubMed
PMID: 11091016.
)).
However, the MRI is not used routinely because of the longer time taken and higher cost. Direct coronal CT is the preferred radiological investigation in suspected cases of VEDH.

====Treatment====
The management of VEDH is better considered on a case to case basis
((Columella F, Gaist G, Piazza G, Caraffa T. Extradural haematoma at the vertex.
J Neurol Neurosurg Psychiatry. 1968 Aug;31(4):315-20. PubMed PMID: 5684390;
PubMed Central PMCID: PMC496367.
))
((Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical
versus conservative management: two case reports and review of the literature.
Neurosurgery. 1999 Sep;45(3):621-4; discussion 624-5. PubMed PMID: 10493382.))
====Case series====
The majority of the cases reported so far have been either isolated case reports or small series. Columella et al. reported the first series in an Italian language journal
((COLUMELLA F, DELZANNO GB, NICOLA GC. [Rare form of epidural hematoma: epidural
hematoma at the vertex]. Sist Nerv. 1959 Mar-Apr;11(2):104-18. Italian. PubMed
PMID: 13668671.
)).

Alexander reported the first major series in English language literature
((Alexander GL. EXTRADURAL HAEMATOMA AT THE VERTEX. J Neurol Neurosurg
Psychiatry. 1961 Nov;24(4):381-4. PubMed PMID: 21610904; PubMed Central PMCID:
PMC495403.
)).

===2017===
Twenty nine cases of VEDH encountered over a period of 17 years have been analyzed, including 26 males and 3 females. Majority were due to road accidents. Headache, papilledema and lower limb weakness have been the major presenting features in these cases. The diagnosis was by direct coronal computerized tomography (CT) scan in most of them. Majority were managed conservatively with observation and serial imaging. Four patients who had large VEDH with altered sensorium were managed surgically. The source of bleeding was mainly from superior sagittal sinus.

VEDH has to be suspected when a patient presents with impact over the vertex and features of raised intracranial pressure. Direct coronal CT or magnetic resonance imaging is useful in the diagnosis. Surgery is required when the patient develops progressive deterioration in sensorium and/or with the hematoma volume more than 30 ml. The present series of 29 cases is the largest reported so far
((Ramesh VG, Kodeeswaran M, Deiveegan K, Sundar V, Sriram K. Vertex epidural
hematoma: An analysis of a large series. Asian J Neurosurg. 2017
Apr-Jun;12(2):167-171. doi: 10.4103/1793-5482.145555. PubMed PMID: 28484524;
PubMed Central PMCID: PMC5409360.
)).

===2000===
The neuroradiologic studies of four patients (CT in four, MR imaging and MR venography in one) were evaluated for EDH shape, size and appearance.

EDHs were biconvex in three patients and crescentic in one patient. CT appearances included a collection that was hyperdense (two patients), generally isodense with a few regions of hyperdensity (one patient) and mixed hyperdense and hypodense (one patient). MR imaging findings in one patient consisted of hyperintense signal on T1-weighted images and hypointense signal on T2-weighted images. Inferior displacement of the superior sagittal sinus was seen in two patients. Diagnosis of a small vertex EDH was difficult on routine axial CT in one patient, but apparent on MR imaging and MR venography.

Small vertex EDHs can be difficult to diagnose on routine CT. MR imaging or thin section CT should be performed to exclude the diagnosis in patients with trauma to the skull vertex
((Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: imaging
findings and diagnostic pitfalls. Eur J Radiol. 2000 Dec;36(3):150-7. PubMed
PMID: 11091016.
)).


====Case reports====
===2017===
A 60-year-old man sustained a ground-level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bihemispheric convexities. Twenty-four hours later, the patient deteriorated, with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies, was performed. A central island of bone was left intact to spare the diastatic fracture from the craniotomies. This was done to ensure a stable anchor point for tacking-up the underlying displaced dura and SSS. The central bone prevents extensive bleeding from the diastatic fracture and eliminates the risk of further blood reaccumulation and tearing of a possible injured sinus during bone flap elevation.

The technique performed allowed to evacuate completely the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation.
Because of its rare nature, VEH represents a surgical challenge. Because neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted
((Fernandes-Cabral DT, Kooshkabadi A, Panesar SS, Celtikci E, Borghei-Razavi H, 
Celtikci P, Fernandez-Miranda JC. Surgical Management of Vertex Epidural
Hematoma: Technical Case Report and Literature Review. World Neurosurg. 2017
Jul;103:475-483. doi: 10.1016/j.wneu.2017.04.040. Epub 2017 Apr 17. PubMed PMID: 
28427975.
)).
===2016===
Navarro et al. reports a head trauma who developed progressive and intractable headache. MRI made the diagnosis of progressive VEH and highlighted the detachment of the [[superior sagittal sinus]] by the hematoma. Surgical treatment, because of the refractory clinical findings, was performed with good postoperative recovery.

Multiple trauma patients with progressive and refractory headache should have their head CT thoroughly reviewed and, if necessary, be investigated with MRI
((Navarro JN, Alves RV. Vertex epidural hematoma: A rare cause of post-traumatic
headache and a diagnostic challenge. Surg Neurol Int. 2016 May 6;7(Suppl
10):S276-8. doi: 10.4103/2152-7806.181982. eCollection 2016. PubMed PMID:
27213114.
)).

===== References =====