Single piece craniotomy in the management of a patient with large vertex epidural haematoma and deteriorating brain function in a limited resources community. Case report from Southwestern Uganda

TL;DR

A patient with a large vertex epidural hematoma in rural Uganda was successfully treated with a single craniotomy by non-specialist doctors, highlighting the feasibility of emergency care in resource-limited settings.

Contribution

Demonstrates the successful use of single-piece craniotomy for vertex epidural hematoma in low-resource settings without neurosurgeons.

Findings

Single-piece craniotomy can be safely performed by non-neurosurgical specialists in rural areas.

Emergency surgical evacuation improves brain function in patients with large vertex epidural hematomas.

Preoperative planning is critical to reduce complications in the absence of neurosurgical resources.

Abstract

Vertex epidural haematoma is a rare form of epidural haemorrhage and a complication of head trauma that is both a diagnostic and therapeutic challenge for the trauma surgeon. It's usually as result of laceration in the superior sagittal sinus. Whereas most patients with small vertex epidural hematomas improve with conservative treatment, large or rapidly expanding lesions are fatal and require emergency craniotomy.

Ours was a 28-year-old male patient who arrived at our emergency department in rural Southwestern Uganda with Glasgow coma scale of 12/15 following a head on collision of two Boda Boda motorcycles. CT scan imaging revealed a large acute Vertex Epidural haematoma and a linear skull fracture of the parietal bones crossing the midline. The haematoma was evacuated through a single piece craniotomy and hemostasia achieved by surgicel. Patient was transfused with two units of whole blood. Patients Glasgow coma scale improved to 15/15 after 24 h postoperatively.

Vertex epidural hematomas are both diagnostic and therapeutic challenges. Small haematomas do not require surgical intervention. Large and expanding haematomas are fatal and require urgent surgical evacuation by neurosurgeons. In rural centres in lower- and middle-income countries like our own, surgery is often more challenging. This is mainly due to nonavailability of neurosurgeons and lack of medical supplies. With careful planning, available midlevel medical doctors can safely evacuate a large vertex epidural hematoma through a single piece craniotomy.

When performed timely, emergency surgical decompression results into rapid improvement of brain function in patients with large vertex epidural hematoma and deteriorating brain function as observed in our patient. Massive haemorrhage from superior sagittal sinus and air embolism are important intraoperative complications that should be kept in mind. Careful pre operative planning is of paramount importance especially in centres without neurosurgeons and essential neurosurgery supplies.

•Vertex epidural hematoma is rare and is often missed during clinical assessment of trauma patients•Large and rapidly expanding vertex epidural haematoma are fatal and require emergency surgical evacuation.•In rural communities in southwestern Uganda with limited access to surgical care and no neurosurgeons, vertex epidural hematomas are treated by non specialist medical practitioners•Single piece craniotomy is simple and quick to perform using basic neurosurgical equipment by a non-neurosurgical specialist.•Massive haemorrhage from superior sagittal sinus and air embolism are important intraoperative complications that should be kept in mind.•Careful preoperative preparation reduces morbidity and Mortality from intraoperative complications.

Vertex epidural hematoma is rare and is often missed during clinical assessment of trauma patients

Large and rapidly expanding vertex epidural haematoma are fatal and require emergency surgical evacuation.

In rural communities in southwestern Uganda with limited access to surgical care and no neurosurgeons, vertex epidural hematomas are treated by non specialist medical practitioners

Single piece craniotomy is simple and quick to perform using basic neurosurgical equipment by a non-neurosurgical specialist.

Massive haemorrhage from superior sagittal sinus and air embolism are important intraoperative complications that should be kept in mind.

Careful preoperative preparation reduces morbidity and Mortality from intraoperative complications.

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