Acute-on-Chronic Vertex Epidural Hematoma with Diastasis of the Sagittal Suture in an Adult.

BACKGROUND: Vertex epidural hematoma (VEDH) is a rare intracranial mass constituting roughly 2.5% of all epidural hematomas. Bleeding usually derives from the superior sagittal sinus, and presentation is often acute-seldom chronic. Fractures are common, but diastasis of the sagittal suture in adults is unique. We hereby present a case combining these rare features along with diagnostic pitfalls and management.

CASE DESCRIPTION: A 43-year-old male with a history of hitting his head against the roll cage of the racing car 3 weeks before admission presented with unbearable headache of 9 Numeric Rating Scale intensity and decreased muscular strength in the right upper limb down to 4/5 of the Lovett scale. The initial Glasgow Outcome Scale was 4. His axial computed tomography scan mimicked convexity hyperostosis, meningioma, or lymphoma. Coronal reconstruction revealed a 102-mL large biconcave mass of mixed hyperdensity and hypodensity at the vertex. Bone window showed sagittal suture diastasis. Contrast-enhanced magnetic resonance imaging gave evidence of superior sagittal sinus detachment. Parietofrontal craniotomy crossing the midline was performed in order to evacuate the hematoma. On 2-week follow-up his pain decreased, his right arm strength recovered, and he had a Glasgow Outcome Scale score of 5.

CONCLUSIONS: VEDH can present as an intensifying headache even weeks after purported trauma. Axial computed tomography scans can be tricky because of the blind spot. Even large VEDH may be seen only in the very last few axial slices and may mimic other entities. Coronal reconstructions or additional magnetic resonance imaging come in handy. One-piece parietofrontal craniotomy is an option to approach this hematoma.