Angeles University Foundation

College of Nursing

CASE REPORT:

EPIDURAL HEMATOMA

Submitted to:

Maria Aileen Chanco-Bondoc RN, MN

Submitted by:

Gamboa, Christine G.

BSN IV-9

Group 36

I. INTRODUCTION

Head injuries are caused by a sudden impact or force to the head or inertial

forces within the skull. It is the trauma that leads to the potential injury to the scalp, skull,

or brain in which it can range from a simple bump to the skull to serious brain injury.

Head injuries can cause traumatic brain injury which is an insult to the brain that is

capable of producing intellectual, emotional, social, and vocational changes.

Motor-vehicle accidents are the leading cause of head injuries. Clients admitted

to the emergency department, most are males younger than 30 years and 50% have

evidence of ingestion of alcohol or other substances of abuse. Alcohol slows down the

reflexes and alters cognitive processes and perception. These physiologic changes

increase the chances of being involved in an accident or altercation. A second risk factor

is driving without seatbelts. Peak occurrence is during evenings, nights, and weekends.

Other causes are assaults, falls, and sports related injury.

In the United States, a head injury is experienced approximately every 15

seconds. Head injuries occur in about 7 million Americans every year. Among these

head-injured people, more than 500,000 are hospitalized, 100,000 experience chronic

disability, and about 2000 are left persistent vegetative state (Black, 2008).

Adding to that, Traumatic brain injury is a major cause of death and disability

worldwide, especially in children and young adults. Causes include falls, vehicle

accidents, and violence. Prevention measures include use of technology to protect those

who are in accidents, such as seat belts and sports or motorcycle helmets, as well as

efforts to reduce the number of accidents, such as safety education programs and

enforcement of traffic laws.

Brain trauma can be caused by a direct impact or by acceleration alone. In

addition to the damage caused at the moment of injury, brain trauma causes secondary

injury, a variety of events that take place in the minutes and days following the injury.

These processes, which include alterations in cerebral blood flow and the pressure

within the skull, contribute substantially to the damage from the initial injury.

Traumatic Brain Injury can cause a host of physical, cognitive, social, emotional,

and behavioral effects, and outcome can range from complete recovery to

permanent disability or death.

Epidural hematoma, a type of focal injury caused by traumatic head trauma, also

called as extradural hematoma, which forms between the skull and the dura mater. It

occurs in about 10% of severe head injuries and is usually associated with a skull

fracture. An epidural hematoma occurs from injury to the cerebral blood vessels, most

often the middle meningeal artery. Bleeding is usually continuous, and a large clot forms,

which separates the dura from the skull.

Epidural hematoma (ie, accumulation of blood in the potential space between

dura and bone) may be intracranial or spinal. Intracranial epidural hematoma occurs in

approximately 2% of patients with head injuries and 5-15% of patients with fatal head

injuries. Intracranial epidural hematoma is considered to be the most serious

complication of head injury, requiring immediate diagnosis and surgical intervention.

Intracranial epidural hematoma may be acute (58%), subacute (31%), or chronic (11%).

Spinal epidural hematoma may also be traumatic, though it may occur spontaneously.

In the United States, epidural hematoma complicates 2% of cases of head

trauma (approximately 40,000 cases per year). Spinal epidural hematoma affects 1 per

1,000,000 people annually. Alcohol and other forms of intoxication have been associated

with a higher incidence of epidural hematoma. International frequency is unknown,

though it is likely to parallel the frequency in the United States. Mortality rate associated

with epidural hematoma has been estimated to be 5-50%. No racial predilection has

been reported. Intracranial and spinal epidural hematomas are more frequent in men,

with a male-to-female ratio of 4:1. Intracranial epidural hematoma is rare in individuals

younger than 2 years it is also rare in individuals older than 60 years because the dura is

tightly adherent to the calvaria and Spinal epidural hematoma has a bimodal distribution

with peaks during childhood and during the fifth and sixth decades of life. Increasing age

has been noted as a risk factor for postoperative spinal epidural hematoma.

Manifestations are usually acute in onset because the bleeding is often arterial.

With an epidural hematoma, the following sequence of events may occur: (1) the client is

unconscious immediately after head trauma, (2) the client awakens and is quite lucid, (3)

loss of consciousness occurs and pupil dilation response rapidly deteriorates, with onset

of eye movement paralysis, on the same side as that of the hematoma, (4) the client

lapses into a coma, (5) blood behind the tympanic membrane, (6) periorbital

ecchymoses (bruises around the eyes), and (7) later, a bruise over the mastoid process

or battle’s sign.

Because the underlying brain has usually been minimally injured, prognosis is

excellent if treated aggressively. Outcome from surgical decompression and repair is

related directly to patient's preoperative neurologic condition.

Objectives

Broaden the knowledge about the disease process.

To know the precipitating and predisposing factors that contributed to the

development of the disease.

To know each nursing responsibility that the group of student-nurse

researchers would perform with each abnormality the client may manifest.

To be familiar with the treatment of the disease such as its medications to

be given, laboratory test/s to be performed and the health teachings to be

given to the significant others of the client.

Be able to make three nursing care plan

Completion of case report

Determine the nursing responsibilities (prior, during and after) of all the

medical management given to the patient.

Search the current trends and statistics regarding the disease condition.

Analyze and interpret the different diagnostic and laboratory procedures,

its purpose and its essential relationship to patient’s disease condition.

Current Trends

According to Medscape’s article: Intravascular Temperature Modulation as an

Adjunct to Secondary Brain Injury Prevention in a Patient with an Epidural Hematoma,

Epidural hematoma can result in long-term neurological deficits, prompt surgical

intervention and prevention of secondary brain injury can enable a full recovery.

Maintaining normothermia has been shown to be associated with improved

neurological outcomes (Lasater, 2005). Despite two temperature spikes associated

with coagulase-negative staphylococcus infection and one fever episode

associated with temporary suspension of cooling therapy for a catheter change, a

temperature of 36.5 °C was maintained for 13 days during the acute phase of the

case study patient's hospitalization. Neurological changes such as right-sided

weakness, along with hyperthermia (defined in our institution as a temperature of

>38.5 °C), resolved within several days of thermoregulation. This is an anecdotal

finding with implications for further studies to evaluate the role of

thermoregulation in ameliorating neurological changes in patients with traumatic

brain injuries.

II. ANATOMY AND PHYSIOLOGY

The human cranium and the facial bones are the foundation for the soft tissues of

the face and head. Thus, much of the visible appearance of the human face depends

upon the shapes and qualities of these bones. The cranium is that part of the skull that

holds and protects the brain in a large cavity, called the cranial vault. Eight plate-like

bones form the human cranium by fitting together at joints called sutures. The most

important of these cranial bones for the appearance of the face is the frontal bone,

which underlies the top of the face above the eyeballs. The human skull also includes

14 facial bones that form the lower front of the skull and provide the framework for most

of the face that is important to psychological research. These 22 skull bones form other,

smaller cavities besides the cranial vault, including those for the eyes, the internal ear,

the nose, and the mouth. The important facial bones include the jaw bone or mandible,

the maxilla or upper jaw, the zygomatic or cheek bone, and the nasal bone.

The skull base forms the floor of the cranial cavity and separates the brain from other

facial structures. This anatomic region is complex and poses surgical challenges for

otolaryngologists and neurosurgeons alike. Working knowledge of the normal and

variant anatomy of the skull base is essential for effective surgical treatment of disease

in this area.

The 5 bones that make up the skull base are the ethmoid, sphenoid, occipital, paired

frontal, and paired parietal bones. The skull base can be subdivided into 3 regions: the

anterior, middle, and posterior cranial fossae. (See the image below.) The petro-occipital

fissure subdivides the middle cranial fossa into 1 central component and 2 lateral

components. This article discusses each region, with attention to the surrounding

structures, nerves, vascular supply, and clinically relevant surgical landmarks.

Anterior Skull Base

The anterior limit of the anterior skull base is the posterior wall of the frontal

sinus. The anterior clinoid processes and the planum sphenoidale, which forms the roof

of the sphenoid sinus, mark the posterior limit. The frontal bone forms the lateral

boundaries. The frontal bone houses the supraorbital foramina, which, along with the

frontal sinuses, form 2 important surgical landmarks during approaches involving the

anterior skull base.

The greater portion of the anterior floor is convex and grooved by the frontal lobe

gyri. This portion of the skull base consists of the orbital portion of the frontal bone. The

ethmoid bone forms the central part of the floor, which is the deepest area of the anterior

cranial fossa. In the center of this region is the cribriform plate, through which the

olfactory tracts pass. The fovea ethmoidalis, or the roof of the ethmoid cavity, continues

laterally from the cribriform plate. The cribriform plate may be more than 1 cm lower than

the roof of the ethmoid cavity (fovea ethmoidalis), and it is made of extremely thin bone

compared with the relatively thick bone of the lateral fovea ethmoidalis. During

transethmoidal approaches to the anterior skull base, this relationship is extremely

important to remember.

The foramen cecum sits between the frontal crest and the prominent crista galli

and is a site of communication between the draining veins of the nasal cavity and the

superior sagittal sinus. The crista galli, which projects up centrally between the cerebral

hemispheres, serves as the site of attachment for the falx cerebri.

The optic chiasm, or chiasmatic sulcus, sits slightly posteriorly in the midline. The

anterior clinoid processes form the posterolateral segment and help form the roof of the

optic canal. In the medial aspect, the lesser wing of the sphenoid forms the anterior

clinoid process, an important landmark for the optic nerve and supracavernous internal

carotid artery (ICA).

Inferior relationships — extracranial aspects

The most important anatomic structures below the anterior cranial fossa are the

orbits and the paranasal sinuses. A thorough description is beyond the scope of this

article, but important anatomy and relationships are discussed.

The bony orbit is often a route for intracranial and extracranial spread of infection

and tumors because of its direct proximity to the anterior fossa. The posterior wall is thin

and adjacent to the superior sagittal sinus and frontal lobe dura. The posterior aspect

includes the optic canal, the superior orbital fissure (SOF), and the inferior orbital fissure

(IOF). The SOF conveys the oculomotor, trochlear, abducens, and ophthalmic nerves

(cranial nerves [CN] III, IV, VI, and V1, respectively), as well as the ophthalmic veins.

The IOF transmits the maxillary nerve (CN V2) and infraorbital vessels, and it

communicates with the infratemporal and pterygomaxillary fossae. The lateral portion of

the IOF is an important surgical landmark for positioning lateral orbital osteotomies

during anterior skull base resections. The optic canal transmits the optic nerve (CN II)

and the ophthalmic artery.

The image below demonstrates the relationship of the openings described

above. The medial wall is closest to the apex and is formed by the orbital process of the

frontal, lacrimal, ethmoid, and sphenoid bones. The medial wall transmits the anterior

and posterior ethmoid arteries through their respective foramina. These foramina help in

identifying the frontoethmoid suture line, which marks the inferior extent of the anterior

cranial fossa. The posterior ethmoid artery foramen is also an important surgical marker

for the location of the optic canal and nerve, which lies about 0.5 cm posterior to it.

The lesser wings of the sphenoid and the frontal process of the maxilla form the

lateral walls. The posteriormost segment of the lateral orbital wall forms the anterior wall

of the middle cranial fossa and is discussed in greater detail in the next section.

The ethmoid sinuses can be found inferior to the anterior cranial fossa and

medial to the orbits. The frontal sinuses arise as evaginations of ethmoid air cells into

the frontal bone and have a thick anterior and thinner posterior wall. The posterior wall is

adjacent to the superior sagittal sinus and the frontal lobe dura. As a result, the frontal

sinus can be used as a route of surgical entry into the anterior cranial fossa. Infectious

processes and tumors can exploit this relationship as well, to gain intracranial access.

Contents

The dura mater attaches anteriorly at the frontal crest and crista galli to form the

falx cerebri, which transmits the superior and inferior sagittal sinuses. The superior

sagittal sinus drains the superior cerebral and frontal diploic veins of Breschet. These

veins form a potential pathway for infection to spread intracranially, causing

complications such as sagittal sinus thrombosis, empyema, and abscess.

The foramen cecum, found anterior to the crista galli, usually ends blindly, though

it may transmit a vein from the nasal mucosa to the superior sagittal sinus. Its patency

may lead to the formation of developmental anomalies, such as nasal dermoid cysts,

nasal gliomas, encephaloceles, and meningoencephaloceles.

The frontal lobes occupy the anterior fossa and sit superior to the orbits and sinonasal

tract. The major structures in this area are the olfactory bulb and tract. The olfactory bulb

lies along the medial edge of the frontal orbital plate and connects with the olfactory

tract, which courses above the cribriform plate and planum sphenoidale.

Middle Skull Base

Boundaries — intracranial aspects

The greater wing of the sphenoid helps form the anterior limit of the middle skull

base. The posterior limit is the clivus, which is formed from the sphenoid and occipital

bones. The greater wing of the sphenoid forms the lateral limit as it extends laterally and

upward from the sphenoid body to meet the squamous portion of the temporal bone and

the anteroinferior portion of the parietal bone. The greater wing of the sphenoid forms

the anterior floor of the fossa. The anterior aspect of the petrous temporal bone forms

the posterior floor of the middle cranial fossa.

The body of the sphenoid makes up the central portion of the middle fossa and

houses the sella turcica. The sella turcica can be found between the anterior and

posterior clinoid processes and is composed of 3 sections. The tuberculum sellae is an

olive-shaped swelling and sits on the anterior slope between the chiasmal sulcus and

the sella turcica. The hypophyseal or pituitary fossa lies immediately posterior to the

tuberculum sellae. The dorsum sellae is the furthest posterior. In this region lies the

sigmoid groove for the ICA as it traverses the petrous apex through the cavernous sinus.

The floor and the lateral walls are grooved for the middle meningeal artery, which

courses anterolaterally from the foramen spinosum and which divides into frontal and

parietal branches. The former ascends across to the pterion, where it courses

posteriorly. The pterion is an H -shaped suture, where the frontal bone, the greater wing

of the sphenoid bone, the squamous temporal bone, and the parietal bone meet. This

suture is approximately 3.5 cm behind the zygomaticofrontal suture and 4 cm above the

zygomatic arch.

The pterion is made up of thin bone and can be easily fractured during trauma. If

fractured, it can result in injury to the anterior branches of the middle meningeal artery,

with eventual formation of an epidural hematoma.

The petrous portion of the temporal bone forms the posteromedial limit of the

middle cranial fossa. The superior petrosal sinus creates a longitudinal groove in the

petrous ridge. The anteromedial petrous tip houses the trigeminal or gasserian ganglion

in a region known as Meckel cave. This area is superior to the point at which the ICA

enters the cavernous sinus just above the foramen lacerum. Along the superomedial

surface of the petrous temporal bone, the roof of the carotid canal is frequently

dehiscent, a feature that makes dural elevation risky.

The arcuate eminence is the superior extent of the superior semicircular canal. It

can be appreciated on the superior aspect of the midpetrous ridge. The eminence is an

important landmark during the middle fossa approach for localization of the internal

auditory canal (IAC). Lateral to the arcuate eminence, the thin tegmen tympani and

tegmen mastoideum cover the middle ear and mastoid, respectively. The tegmen is a

thin plate of bone that separates the dura of the middle lobe from the middle ear and the

mastoid cavity. The bone of the floor of the middle fossa may be dehiscent over the

geniculate ganglion of the facial nerve.

Foramina — intracranial aspects

The SOF, foramen rotundum, foramen ovale, and foramen spinosum lie in an

anteroposterior and mediolateral plane. (See the image below.) Beginning lateral to the

clinoid process anteriorly, the SOF extends inferomedially and toward the orbital apex

and transmits the oculomotor nerve (CN III); the trochlear nerve (CN IV); the lacrimal,

frontal, and nasociliary branches of CN V1; and the abducens nerve (CN VI). It also

transmits the superior ophthalmic vein.

The foramen rotundum lies posteroinferior to the base of the SOF, at the level of

the sella turcica. It transmits the maxillary division (CN V2) of the trigeminal nerve into

the pterygopalatine fossa. The foramen sits near the lateral wall of the sphenoid sinus.

The foramen ovale is posterior and lateral and transmits the mandibular division (CN V3)

of the trigeminal nerve, the accessory meningeal artery, the lesser superficial petrosal

nerve (LSPN), and emissary veins to the pterygoid plexus into the infratemporal fossa.

The foramen spinosum lies further posterolaterally and transmits the middle

meningeal artery, as well as the meningeal branch of the facial nerve (CN VII).

The carotid canal forms where the petrous apex articulates with the sphenoid

and occipital bone. It continues into the foramen lacerum on the undersurface of the

skull base. The jagged foramen lacerum lies posteromedial to the foramen ovale. Two

inconsistent foramina are the innominate foramen, which may be found medial to the

foramen spinosum, and the foramen of Vesalius, found medial to foramen ovale. The

foramen of Vesalius is found in 40% of individuals and transmits an emissary vein from

the cavernous sinus.

Of note, the petro-occipital fissure, a gap between the medial border of the

petrous temporal bone and the lateral border of the clivus, is an important radiographic

and preoperative surgical landmark, because it lies in close proximity to various middle

cranial fossa foramina. It also serves to anatomically divide the middle skull base into a

central compartment and 2 lateral compartments.

Contents

Important structures in the middle fossa include but, are not limited to, the

temporal lobe, the pituitary gland, the trigeminal or gasserian ganglion, the greater

superficial petrosal nerve (GSPN), the intracranial portion of the ICA, and the cavernous

sinus and its contents. In the middle fossa, the dura strongly adheres to the clinoid

processes, the petrous and sphenoid ridges, and the basal foramina. In the midline, it

forms the diaphragma sellae—a circular dural plate—which covers the pituitary gland.

The pituitary stalk or infundibulum and the hypophyseal veins perforate this structure.

The cavernous sinus resides on both sides of the sella turcica and the body of the

sphenoid bone. Details of cavernous sinus anatomy are discussed further in following

sections of this article.

The temporal lobe takes up most of the space of the middle fossa and extends to

the inferior portion of the anterior fossa. The GSPN branches from the geniculate

ganglion and passes through a small hiatus into the middle fossa before coursing

parallel to the petrous ridge of the temporal bone and entering the foramen lacerum. The

GSPN, which is composed of parasympathetic fibers from the facial nerve to the lacrimal

gland, is an important surgical landmark. It is easily identified and can be followed back

medially to the foramen lacerum and the petrous ICA.

The GSPN and rostral LSPN run along the floor beneath the dura and parallel

the anterior edge of the petrous bone into foramen lacerum. Here, the GSPN joins with

the deep petrosal nerve to form the vidian nerve or the nerve of the pterygoid canal. This

area is also a landmark for the ICA, which lies deep and parallel to the temporal bone

and medial to the styloid process.

The facial nerve (CN VII) and vestibulocochlear nerve (CN VIII) originate from the

caudal pons. They course through the subarachnoid space and enter the porus

acusticus and IAC. CN VII continues through the temporal bone, the middle ear, and the

mastoid bone to exit at the stylomastoid foramen and innervate the facial nerve

musculature. The eustachian tube originates at the protympanum and runs

anteromedially and inferiorly. The bone directly medial to the eustachian tube may be

dehiscent, and the ICA may be seen. This feature is clinically relevant during surgical

exploration of the middle fossa, because the eustachian tube must be traversed before

the ICA is reached in this area.

Cavernous sinus

The cavernous sinus is a complex plexus of veins in the dura that can be found

lateral to the sphenoid sinus. It extends from the SOF to the apex of the petrous

temporal bone. The anterior and posterior petroclinoid folds serve as the lateral borders.

Along the lateral wall runs the ICA, which gives off 2-6 caroticocavernous branches that

supply the hypophysis and that join branches from the middle meningeal artery.

Running lateral to the ICA, the abducens nerve (CN VI) enters the dura superior

to the clivus and enters the Dorello canal. Infection of the petrous apex classically

manifests as abducens palsy due to inflammation in the Dorello canal. The petroclinoid

and petrosphenoidal ligaments of Gruber form the roof of the canal; the roof lies in close

proximity to the trigeminal ganglion and within 3 mm of the sphenoid sinus.

Running superoinferiorly in the lateral wall are the oculomotor nerve (CN III), the

trochlear nerve (CN IV), the ophthalmic nerve (CN V1), and the maxillary nerve (CN V2).

The oculomotor nerve divides into superior and inferior divisions at the most anterior

portion of the cavernous sinus. The trochlear nerve enters at the angle between the

anterior and posterior petroclinoid folds and courses the lateral wall.

The 3 divisions of the trigeminal traverse inferior to the tentorium cerebelli into

the Meckel cave, within the subarachnoid space. From here, V1, V2, and V3 pass into

the lateral wall of the cavernous sinus.

The cavernous sinus has complex venous drainage. It connects anteriorly to the

superior ophthalmic vein and the sphenoparietal sinus and drains posteriorly into the

superior and inferior petrosal sinuses en route to the basilar plexus. The superior and

inferior petrosal sinuses emerge from the posterior aspect of the cavernous sinus and

eventually drain into the sigmoid sinus and the internal jugular vein. The superficial,

middle, and inferior cerebral veins drain into the cavernous sinus from above, and the

emissary veins drain into the pterygoid plexus below the sinus. Interruption of the

anastomotic branch of the superficial middle cerebral vein as it connects to the

transverse sinus is likely to cause an infarction.

Knowledge of these complex relationships is necessary for recognizing the

manifestations of carotid-cavernous fistulas, which are reported to occur with basilar

skull fractures. In the case of such fistulas, traumatic tears of the intracavernous carotid

result in high-pressure arterial blood flooding the cavernous sinus. Clinically significant

backflow in the low-pressure superior ophthalmic veins draining into the cavernous sinus

then leads to venous engorgement, proptosis, and chemosis. In severe cases, pulsating

exophthalmos can be observed.

In rare cases, infections may enter the skull base from the facial venous system

and travel retrograde through the valveless ophthalmic veins into the anterior portion of

the cavernous sinus. The result is cavernous sinus thrombosis. Pimples and pustules,

which occur in the medial canthal, nasal, and labial areas (danger zone of the face), may

pass through the valveless angular and facial veins and drain superiorly into the

ophthalmic veins. They may eventually seed the cavernous sinus. Dental infections may

spread into the cavernous sinus by means of the pterygoid plexus.

Internal carotid artery

The course of the ICA is complex, and landmarks must be recognized during

skull base surgery. The course can be divided into 4 parts: cervical, intratemporal,

cavernous, and supracavernous.

The cervical portion passes near the third and fourth cervical vertebrae. At this

point, it is deep to the posterior digastric muscle and styloid process and superior and

posteromedial to the external carotid artery. The cervical ICA can be distinguished from

the external carotid because it has no branches. This feature is clinically important,

because the relationship with the external carotid may be aberrant. The ICA enters the

petrous bone through the carotid foramen and runs cranially into the foramen lacerum.

The intratemporal segment is difficult to mobilize because of an adherent fibrous

ring. This vertical portion ascends 5 mm and turns anteromedially into the horizontal

portion. At this point, it is medial to the eustachian tube and anterolateral and inferior to

the cochlea. At times, the carotid artery can be dehiscent in this area and extend into the

middle ear cleft. In these cases, the artery is at great risk during surgery involving the

middle ear. A dehiscent or aberrant ICA can appear as a pinkish or white-blue mass

filling the inferior portion of the middle ear. A pulsatile tympanic membrane is sometimes

observed.

In the normal case, the temporal carotid artery runs forward along the petrous

bone at a 45° angle to the midsagittal plane, giving off the caroticotympanic and

pterygoid branches. At this point, the artery is superior and lateral to the sphenoid bone

in an area referred to as the carotid siphon. The artery then enters the cavernous sinus

medial to the abducens nerve (CN VI).

On traversing the roof of the cavernous sinus medial to the anterior clinoid

process, the ICA enters the supracavernous portion. The last segment turns backward

under the optic nerve to the anterior perforated substance, where it joins the circle of

Willis through its terminal anterior and middle cerebral arteries.

Lateral relationships — extracranial aspects

As previously discussed, the petro-occipital fissure divides the middle cranial

fossae into central and lateral components.

Boundaries — extracranial aspects

The anterior boundary of the middle cranial fossa is the posterolateral wall of the

maxillary sinuses; the petro-occipital sutures form its posterior boundary. The lateral

margin consists of primarily the squamous and petrous portions of the temporal bone.

Many surgical approaches in the lateral skull base involve the infratemporal

fossa. Working knowledge of this area is imperative for the surgeon. The anterior

boundary of the infratemporal fossa is the posterior wall of the maxillary sinus. The

posteroinferior boundary is the parapharyngeal space. The lateral pterygoid plate forms

the medial boundary, whereas the mandibular ramus and condyle create the lateral

boundary. Finally, the greater wing of the sphenoid bone forms the superior border of the

infratemporal fossa.

Contents — extracranial aspects

When viewed from the extracranial lateral aspect, the infratemporal fossa lies below the

temporal bone, inferomedial to the zygomatic arch, and posterior to the maxilla.

Structures first identified in the infratemporal fossa include the muscles of mastication,

namely, the temporalis, masseter, and medial and lateral pterygoid muscles. The

internal maxillary artery, one of the terminal branches of the external carotid artery,

provides blood to these muscles and should be preserved in case a temporalis flap is

necessary to reconstruct skull base defects.

The medial and lateral pterygoid muscles take up most of the space of the infratemporal

fossa. Dissecting further in a medial direction reveals the cartilaginous eustachian tube

and the tensor and levator veli palatini muscles.

Moving anteriorly past the pterygoid process, one finds the pterygomaxillary fissure,

which transmits the maxillary artery to the pterygomaxillary fossa. (See the image

below.) The greater petrosal nerve joins the deep petrosal nerve to form the vidian

nerve, which enters the fossa through the vidian or pterygoid canal en route to the

pterygopalatine ganglion. The maxillary nerve enters through the foramen rotundum and

branches thereafter to supply sensory information from regions of the face. Both nerves

send branches to the parasympathetic sphenopalatine ganglion. The IOF is at the most

anterior limit of the pterygomaxillary fossa and is continuous with the infratemporal

fossa.

Two important bony surgical landmarks may be identified in the infratemporal

fossa. The first is the root of the lateral pterygoid plate. This plate serves as a marker for

the foramen rotundum, which lies immediately anterior to it, as well as for the foramen

ovale, which lies immediately posterior. Once the foramen ovale is identified, the

foramen spinosum is easily identifiable immediately posterior to the foramen. The

second landmark is the sphenoid spine, which helps in identifying the highest portion of

the cervical ICA and the carotid canal. The sphenoid spine is just medial to the condylar

or glenoid fossa and posterolateral to the foramen spinosum.

Drainage of the external lateral skull base involves the internal and external

jugular venous system and the retromandibular vein. The mastoid and occipital emissary

veins can link the intracranial dural sinus system with the external circulation, namely,

with branches of the occipital, postauricular, or retrofacial veins. The pterygoid venous

system can be highly variable in this region.

The facial, superficial temporal, and occipital and postauricular branches of the

external carotid artery provide arterial supply to the lateral skull base. The internal

maxillary artery, with its deep temporal and middle meningeal branches, can be

identified in the infratemporal fossa as well. The cervical portion of the ICA ascends

vertically to enter the middle fossa medial to the sphenoid spine.

The deep lobe of the parotid gland and the accompanying facial nerve (CN VII)

and its branches may be encountered in the lateral aspect of the extracranial skull base.

The facial nerve exits the mastoid through the stylomastoid foramen and enters

the substance of the parotid gland. Before exiting, the postauricular branch of the facial

nerve branches off and gives rise to the occipital, auricular, digastric, and stylohyoid

branches, as well as to a communicating branch that joins the glossopharyngeal nerve.

The chorda tympani nerve arises from the temporal segment of the facial nerve and

eventually joins the lingual nerve to supply taste to the anterior two thirds of the tongue.

The jugular foramen, which transports CNs IX, X, and XI, is a large, bony gap

between the jugular process of the occipital bone and the jugular process of the petrous

bone. In the extracranial aspect, its anterior border is the carotid canal, its lateral border

is the styloid process sheath, and its medial borders are the hypoglossal foramen and

canal. It lies posterolaterally in the lateral skull base and anteromedially to the mastoid

tip. The jugular foramen can be divided into the pars nervosa anteriorly and the pars

venosa posteriorly. Intracranial details of the jugular foramen are discussed in the

Posterior Skull Base section.

Medial relationships

The sphenoid sinus can serve as an access route to the pituitary and the clivus.

Sellar pneumatization of the sinus facilitates entry during transsphenoidal approaches. It

is important to avoid disrupting the lateral wall during instrumentation, because the ICA

and optic nerve are just lateral to a thin margin of bone. Dehiscence may be present in

the lateral wall of the sphenoid, resulting in exposure of the carotid artery, optic nerve, or

vidian nerve.

The nasopharynx lies posterior and inferior to the sphenoid sinus along the

midline. Mucosa covers the medial surface of the medial pterygoid plate. Along with the

investing pharyngobasilar fascia and the superior pharyngeal constrictor muscle, it helps

to form the lateral portion of the choana and part of the lateral portion of the

nasopharynx.

The sinus of Morgagni is a weak point in the superolateral nasopharyngeal wall.

It is created by the passage of the levator veli palatini and the cartilaginous eustachian

tube through the superior constrictor muscle. This is a region for infections or tumor to

potentially invade the skull base. Directly superior to the nasopharynx is the foramen

lacerum and the ICA, just before its entry point into the cavernous sinus.

The investing fascia of the nasopharynx, also known as the pharyngobasilar fascia, is

suspended from the skull base and clivus, located superiorly. The vertebrobasilar artery

and the brainstem lie posterior to the clivus.

Posterior Skull Base

Boundaries

The posterior skull base consists of primarily the occipital bone, with

contributions from the sphenoid and temporal bones. The basal portion of the occipital

bone (the basiocciput) and the basisphenoid form the anterior portion of the posterior

skull base. These 2 regions combine to form the midline clivus.

The posterior surface of the petrous temporal bone and the lateral aspect of the

occipital bone form the lateral wall. The occipital bone also fuses with the mastoid

portion of the temporal bone to form the occipitomastoid suture. The petrous portion of

the temporal bone and the greater wings of the sphenoid bone are particularly important

for identifying structures. The overlying tentorium cerebelli separates the cerebellum

from the cerebral hemispheres above, whereas the occipital bone forms the lateral walls

and floor.

The floor is grooved for the cerebellar hemispheres, and the midline internal

occipital crest runs from the foramen magnum to the internal occipital protuberance. The

crest serves as an attachment for the falx cerebelli, which contains the occipital sinus.

Grooves for the superior sagittal sinus are superior to the internal occipital protuberance.

The horizontal grooves for the paired transverse sinuses can be found lateral to the

internal occipital protuberance. They descend to the mastoid angle of the parietal bone

to become continuous with the sigmoid sulcus.

The sigmoid sulcus can be found in the lateral aspect of the posterior cranial

fossa in the mastoid portion of the temporal bone. It ends at the jugular foramen. The

sulcus for the inferior petrosal sinus sits posterior to the clivus and anterior to the petrous

apex.

Foramina

The porus acusticus is the opening of the IAC. Found on the posterior surface of

the petrous bone, it transmits the CNs VII and VIII, the nervus intermedius, and the

labyrinthine vessels (branches of the anterior inferior cerebellar artery en route to the

inner ear). The vestibular aqueduct is posteroinferior to the IAC. It transmits the

endolymphatic duct.

The jugular foramen extends laterally from the posterior aspect of the occipital

condyle. It is formed by the anterior processus jugularis of the petrous bone and the

occipital bone in its posterior aspect, and it lies at the posterior end of the petro-occipital

fissure. The sigmoid sinus and the jugular bulb enter the foramen at its smooth posterior

end (pars venosa). CNs IX, X, and XI enter its rough anterior end (pars nervosa). The

inferior petrosal sinus usually enters this portion of the jugular foramen between CNs IX

and X, but its path is highly variable. It may even enter the internal jugular vein below the

skull base.

Finally, the ascending pharyngeal artery may send a posterior meningeal branch

through the jugular foramen. The jugular tubercle may be medial to the lower aspect of

the jugular foramen, and it serves as a landmark for the hypoglossal foramen.

The hypoglossal foramen is inferomedial to the jugular foramen and near the

jugular tubercle. It transmits the hypoglossal nerve (CN XII), a meningeal branch of the

ascending pharyngeal artery, and the hypoglossal venous plexus. Emissary veins in

connection with the sigmoid sinus may leave the posterior fossa through mastoid

foramina.

The brainstem communicates with the vertebral canal through the foramen

magnum. The structures that pass through are the medulla oblongata, the spinal

accessory nerve, the vertebral and posterior spinal arteries, and the apical ligament of

the dens and membrane tectoria.

Contents

The midbrain, the pons, the medulla, and the cerebral and cerebellar

hemispheres lie in the posterior fossa. Dura and the tentorium cerebelli enclose the

various aforementioned venous sinuses. CNs VII-XII exit through the posterior fossa.

CNs VII and VIII and the nervus intermedius exit through the porus acusticus, and

nerves IX, X, and XI traverse the jugular foramen. CN XII exits through the hypoglossal

canal.[8]

On entering the posterior fossa through the foramen magnum, the vertebral

arteries ascend ventral to the roots of CNs IX, X, and XI. The posterior inferior cerebellar

arteries usually branch off from the vertebral arteries before forming the midline basilar

artery at the base of the pons. The basilar artery then branches into the anterior inferior

cerebellar arteries, which travel to the cerebellopontine angle in close relationship to

CNs VII and VIII. The basilar artery then branches into the labyrinthine artery, numerous

long and short pontine arteries, and, finally, the superior cerebellar arteries, which make

up the posterior portion of the circle of Willis. (See the image below.)

Inferior relationships — extracranial aspects

A surgeon must have knowledge of the outer regions of the skull base, because

these regions often serve as access points during surgery.

Suboccipital region

The mastoid tip serves as the origin for the sternocleidomastoid, while the

posterior digastric muscle originates deep to this area. In the posterior aspect, the

trapezius muscle is most superficial. Immediately deep lies the splenius capitis and

cervicis muscles and the semispinalis capitis muscle. On reflection of these muscles

from the superior nuchal line, the suboccipital triangle is exposed. (See the image

below.)

The suboccipital triangle is superficial to the ligaments connecting the atlas to the

axis and contains the occipital artery, the vertebral artery, a complex of veins, the

greater occipital nerve, and the C1 nerve. The occipital artery courses posteriorly deep

to the mastoid tip. Surgical approaches in this area allow mobilization of the vertebral

artery and access to the foramen magnum.

Vertebral artery

The vertebral artery originates from the subclavian artery and has 4 parts:

cervical, foraminal, atlantic, and subarachnoid. The atlantic portion is encountered in the

suboccipital triangle of the nuchal region and is covered by the semispinalis capitis

muscle.

The atlantic portion exits the atlas at the transverse foramen medial to the lateral

rectus capitis muscle and curves posteriorly behind the lateral mass of the atlas. It then

passes medially along the groove on the posterior arch of the atlas and pierces the

atlantooccipital membrane to enter the vertebral canal and subarachnoid space. The

subarachnoid portion of the artery is considered to lie in the posterior cranial fossa

proper.

III. PATHOPHYSIOLOGY

Schematic Diagram

MODIFIABLE FACTORS:

Alcohol Drinking

Substance Abuse

Motor-Vehicular

Accident

Assaults

Falls

Sport-related injuries

NON-MODIFIABLE FACTORS:

AGE

GENDER

Brief contact force

Severe head injuries or skull fracture

Injury to the cerebral blood vessels (Middle Meningeal Artery)

Rapid continuous bleeding

Rupture of the outer surface of the dura mater and the skul

Synthesis of the disease

Definition of the disease

Epidural hematoma is a mass of blood in the space between the inner

table of the skull and the dura mater (the leathery outer covering of the brain). Typically

caused by traumatic brain injury, the bleeding into the epidural space can cause

pressure on the brain which can lead to neurological symptoms including coma and

death if severe enough.

Leaking of blood between dura mater and the skull

Collection of blood

Mass or Clot Formation

Pressure on the brain

Rapid increase of the pressure inside the head (Increase Intracranial pressure)

Additional brain injury

Coma Confusion Drowsiness or Altered level of awareness

Enlarged Pupil in one eye

Severe headache

DeathPermanent brain damage

This can occur with more severe head injury, they can also occur with

relatively mild injuries, particularly if they are in the temporal area and cause a fracture of

the bone of the skull. The fracture can tear blood vessels in this area, leading to the

hematoma.

Modifiable/Non-Modifiable Factors

Modifiable factors

Alcohol Drinking – Alcohol slows the reflexes and alters

cognitive processes and perception that could lead potential

accident due to decrease alertness.

Substance Abuse – contributes to injuries among adolescents

and young adults because it has negative effects on perception,

judgment, and reaction time

Motor-Vehicular Accident – leading cause of death from injury

and sometimes associated with alcohol drinking causes slight to

severe physical injuries.

Assaults – physical assaults that are caused by an object that

causes a strong impact on a certain body part that could lead to

minor or to even severe injury.

Falls – most common cause of non-fatal injuries sometimes

associated with alcohol drinking.

Sport-related injuries – injuries that happen accidentally that is

acquired during falling, slipping, etc.

Non-Modifiable factors

Age – any age group is affected and can have the potential of

acquiring injuries. In children, due to increase activity could

engage in dangerous activities such as climbing, which can cause

injury if they accidentally fall. In older persons, due to the increase

age, there could be degeneration of certain abilities, problems in

vision and ambulation is sometimes the cause of injuries to the

elderly.

Sign and symptoms with rationale

The clinical manifestations of an epidural hematoma are increase ICP,

permanent brain damage, coma, confusion, enlarged pupil in one eye,

drowsiness or altered level of consciousness and even death. Not all of these

clinical manifestations are present in every epidural hematoma. The diagnosis of

an epidural hematoma is based on the patient symptoms, the physical signs and

the CT scan and MRI findings.

Increase ICP – increase in ICP is brought about the accumulation

of blood that causes compression, thus causing an increase

pressure on the brain.

Permanent brain damage – due to the increase pressure in the

brain, this causes additional damage on the brain and permanent

brain damage could occur if it is not immediately manage.

Coma, Confusion, and Drowsiness or altered level of

consciousness – due to the pressure caused in the brain, this

causes depressed level of consciousness, leading to confusion

and even coma.

Enlarged pupil in one eye - pressure on one side of the brain,

causing shift of the brain from one side to the other, can often

cause changes in the pupils of the eyes

Death – due to the permanent brain damaged caused by the

increased pressure, this can sometimes lead to irreversible brain

damage that in long run could cause dysfunction of the brain

leading to death.

IV. CLINICAL INTERVENTION AND MANAGEMENT

Diagnostic Procedures

CT scan

Plain radiography of the head (skull radiography) may reveal skull

fractures, though CT scanning has largely replaced the use of skull

radiography because the diagnostic information is so much greater with CT.

Cervical spine radiographs with anteroposterior, lateral, and odontoid views

are useful to identify associated traumatic fractures. Plain radiographs of the

vertebral column may identify a cavernous angioma.

Myelography outlines the epidural space and may illustrate a space-

occupying mass. CT myelography may be used when MRI is unavailable or if

the patient cannot tolerate MRI.

Noncontrast CT scanning of the head not only visualizes skull fractures

but also directly images an epidural hematoma.

o Acute epidural hematoma may appear as a hyperdense

lenticular-shaped mass situated between the brain and the

skull, though regions of hypodensity may be seen with serum

or fresh blood. On rare occasion, an acute epidural may

appear completely isointense with respect to brain.

Planoconvex or crescent-shaped epidural hematoma must be

differentiated from subdural hemorrhage. Subdural

hematomas may rarely appear convex and mimic epidural

hematomas. Subacute lesions are homogenously hyperdense.

o Chronic epidural hematoma may have a heterogeneous

appearance due to neovascularization and granulation, with

peripheral enhancement on contrast administration.

o CT scanning may also depict air collections and displacement

of brain parenchyma.

o Clinical deterioration should prompt repeat imaging with CT

scanning.

MRI

Demonstrates the evolution of an epidural hematoma, though this imaging modality may not be appropriate for patients in unstable

condition. Spinal MRI may delineate the location of an epidural hematoma

and identify an associated vascular malformation. Spinal cord enhancement may be apparent and should be

distinguished from inflammation or neoplasia. Diffusion-weighted imaging with the use of periodically rotated

overlapping parallel lines with enhanced reconstruction (PROPELLER) MRI may be used for improved detection of acute spinal epidural hematoma.

Gadolinium-enhanced magnetic resonance arteriography (MRA) may further define the extent of an arteriovenous malformation.

Surgical Procedure

Although several recent reports have described successful conservative

management of epidural hematoma, surgical evacuation constitutes definitive treatment

of this condition. Craniotomy or laminectomy is followed by evacuation of the hematoma,

coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the

bone and, occasionally, epidural drains are employed for as long as 24 hours.

Minimally invasive surgical procedures, including the use of burr holes and negative

pressure drainage, may be used in selected cases.

Craniotomy

Craniotomy is the surgical removal of a section of bone (bone flap) from the skull

for the purpose of operating on the underlying tissues, usually the brain. The bone flap is

replaced at the end of the procedure. If the bone flap is not replaced, the procedure is

called a craniectomy. A craniotomy is used for many different procedures within the

head, for trauma, tumor, infection, aneurysm, etc.

Procedure

The craniotomy is labeled by which part of the skull is opened. A frontal

craniotomy indicates the opening is in the frontal bone while a parietal

craniotomy involves opening the parietal bone. If part of two adjacent bones is

opened, then both bones are mentioned, for example, fronto-temporal

craniotomy (Figure 10) 

1. In the temporal areas, which are covered by muscle, the neurosurgeon

may carry out a craniectomy in which the bone is not replaced 

2. Surgery on the back part of the brain beneath the tentorium is usually

carried out by removal of the lower part of the occipital bone. This is

called a suboccipital craniectomy. The craniectomy may be in the midline

or to one side or the other. When the bone removal is more to the side and

just behind the mastoid bone it may be called a retromastoid craniectomy.

Occasionally an abnormality is situated in the low brainstem or cerebellum

and may extend to the upper spinal cord. In these instances a cervical

laminectomy may also accompany the suboccipital craniectomy

Outline of

a fronto-

temporal

craniotom

y. The

small

circles

indicate

bur holes.

Outline of

a midline

suboccipit

al

craniecto

my. Note

the bur

holes that

are used

The

darker

blue area

indicates

where

bone is

removed

and not

replaced.

The dark

blue line

indicates

where the

bone is

cut. The

light blue

area is

replaced

after the

surgery.

to start

the bone

removal.

The blue

area

indicates

the bone

removed.

The incision in the scalp is designed to expose the skull over the lesion to be

removed 

Removal of the bone flap is done in the following manner: 

1. A series of small holes (bur holes) are made in the skull. The holes are

positioned around the periphery of the proposed bone flap. Making the

holes may be accomplished in one of three ways at the discretion of the

surgeon 

The oldest method, which is still used by many surgeons, involves

a set of three drill bits and a hand drill. The first bit has a point and

is used to just penetrate the bone. The second and third bits,

which have more of a curvature, widen the hole without cutting the

underlying dura, which lines the inner surface of the skull 

Another method is by using a special air powered drill. The drill bit

is made so that as soon as the center of the drill bit penetrates the

bone, the drill stops 

The last method uses an air driven burr to gradually remove bone

until the dura is seen. This method allows the smallest holes, and

the holes can also be tailored in shape.

2. The skull is cut between each two adjacent burr holes in a progressive

manner until the bone flap is separated from the surrounding skull. This is

accomplished in one of two ways

The oldest method involves the passage of a thin metal strip (saw

guide) between two adjacent holes. The strip is placed between

the skull and the dura. A small hook on saw guide allows a wire

saw (Gigli saw) to be drawn under the skull in the same path as

the guide. The saw driven by hand then cuts the bone from inside

out

The air driven craniotome has for the most part replaced the

manual method. The craniotome resembles an air drill with a

protective footplate. Cuts are then made with the craniotome from

hole to hole until the bone flap is free

Photograph

of an air drill

making a bur

Wire Gigli

saw for

hole. cutting bone.

Operative

photograph

showing the

Gigli saw

being used.

Air

craniotome

being used

in surgery.

3. After the bone flap is removed, the underlying dura is cut to expose the

lesion. The dura is then cut within the margins of the skull opening. If the

lesion is a meningioma that is attached to the dura, the dura is cut around

the tumor leaving a margin of normal dura. When there is a loss of dura,

various substitutes can be used such as bovine pericardium (covering of

the heart), banked human dura, Gortex plastic or an absorbable collagen

matrix 

4. What occurs next depends on the specific lesion that is found. When the

surgery is for a malignant brain tumor, the surgeon may wish to line the

cavity left by removal of the tumor with an absorbable wafer impregnated

with an anticancer drug. This has been shown to extend life by two to four

months.

The

cut

bone

is

elev

ated.

MRI

obtain

ed

after

partial

remo

val of

a

malig

nant

brain

tumor

(gliobl

astom

a

multif

orme)

in

which

the

tumor

was

treate

d with

absor

bable

wafer

s

(arro

ws)

impre

gnate

d with

an

antica

ncer

drug.

Court

esy

A.

Sloan

, M.D.

5. Following removal of the lesion, all bleeding is secured, the dura is

sutured closed and the bone flap restored to the skull with wire sutures or

titanium miniplates and screws. Burr holes in cosmetically exposed areas

are covered with small titanium plates. If the bone cannot be replaced

(infected or invaded by tumor) a prosthesis can be used. These are

usually made of titanium mesh or plastic. The scalp is then sutured closed

Titanium

mesh

cranioplast

y used for

replaceme

nt of an

infected

bone flap.

There are several instruments that have improved the ease and accuracy of a

craniotomy:

1. Operating Microscope. The human hand can make very small and

accurate movements as long as the eye can see it. The magnification

provided by the operating microscope has added another dimension to

operating. The magnification varies between 4 and 16x. This allows

magnification of small brain structures particularly the blood vessels and

nerves at the base of the brain. The microscope has markedly improved

the surgery of aneurysms of the brain arteries and tumors at the brain

base 

2. Ultrasonic Aspirator. The ultrasonic aspirator is used to remove tumors

from the brain with a minimum of brain movement. The small tip of the

instrument vibrates back and forth at thousands of times per second, thus

liquefying the tumor tissue and allowing it to be easily sucked away with a

minimum of injury to the surrounding brain 

3. Intraoperative Doppler Ultrasound. The intraoperative ultrasound is used

for localizing a lesion below the surface of the brain. It is similar to the

ultrasound used by an obstetrician to image a fetus in the womb. Sound

waves are sent out from the instrument (transducer) that strike the target

lesion and bounce back to the recording portion of the transducer. A

picture is thus produced which can guide the surgeon to the lesion 

4. Stereotaxic Image Guided Craniotomy in the last few years, a significant

improvement in brain surgery is made possible by the marriage of modern

imaging studies (CT and MRI) and computer graphics. This frameless

stereotaxic (three dimensional) image guided surgery is a major advance

in the removal of lesions inside the skull, particularly small lesions and

lesions beneath the surface of the brain. It has only slightly affected large

lesions, diffuse brain lesions and surgery for ruptured cerebral aneurysm 

Prior to surgery, small markers (feducials) that show up on CT or

in the MRI are applied to the head of the patient. The patient is

then placed in the CT or MRI unit and a series of images are

obtained. The electronic data that are the source of the images

are transferred to a computer in the operating room. This

computer reconstructs the CT or MRI images and produces a

three dimensional picture of the head containing the lesion as well

as a reconstruction of the head and lesion in three planes 

After the patient is anesthetized, the head is pinned in a head

holder to rigidly hold it in place. The feducials are registered on

the CT or MRI are matched to the corresponding feducials on the

patient's head. The latter is accomplished with a pointer containing

an array of light emitting diodes. A receiver positioned near the

operating table registers the position of the diodes and thus the

position of the head feducials. This information is transferred

directly to the computer. The pointer or any other instrument

containing the diode array can then be used to direct the surgeon

to the lesion with no more than a 1-2 mm. error 

Using this technique, the surgical trauma to the brain is reduced

and the size of the craniotomy is minimized. This is translated into

a faster and better recovery with discharge from hospital frequently

occurring in 24 hours

a. MRI

of

left

fron

tal

met

ast

atic

brai

n

tum

or

(arr

ow)

.

Not

e:

MRI

ima

ges

sho

w

the

left

side

to

the

vie

wer'

s

righ

t

b. Co

mp

uter

scr

een

as

see

n

by

the

neu

ros

urg

eon

duri

ng

ima

ge

gui

ded

sur

ger

y.

Not

e

the

ima

ges

hav

e

bee

n

flipp

ed

fro

m

side

to

side

so

that

the

sur

geo

n

has

a

left

side

d

ima

ge

to

his

own

left

side

.

The

arro

ws

poi

nt

to a

yell

ow

line

that

repr

ese

nts

the

dire

ctio

n of

'att

ack'

cho

sen

by

the

sur

geo

n.

The

red

'cro

ss

hair

s' is

the

posi

tion

of

the

inst

rum

ent

bei

ng

use

d

by

the

sur

geo

n.

The

righ

t

low

er

ima

ge

sho

ws

the

skin

surf

ace

of

the

pati

ent

with

mul

tiple

don

ut

sha

ped

fed

ucia

ls

on

the

surf

ace

.

The

red

ast

eris

k

lies

on

the

tum

or

ima

ged

in

blu

e

c. Pos

t-

ope

rati

ve

MRI

sho

win

g

co

mpl

ete

rem

oval

of

the

tum

or

Complications

Complications following craniotomy are primarily related to involvement of the brain and

its coverings. Some of the complications are: 

Complications of anesthesia (see Anesthesia)

Infection

Hemorrhage and/or post-operative hematoma

Leak of cerebrospinal fluid

Brain swelling

Raised intracranial pressure (pressure inside the head)

Paralysis

Hydrocephalus (see Shunt for Hydrocephalus)

Loss of sensation

Loss of vision

Loss of speech

Memory loss

Recovery

Following surgery the patient is usually admitted to the intensive care unit

Level of consciousness is carefully observed for any change

Blood pressure is carefully monitored along with the pulse. A catheter inserted in

an artery may be used to continuously monitor the blood pressure

Intracranial pressure may be monitored through a small catheter placed within

the head and connected to a pressure gauge

Blood may be drawn to determine to determine the level of red blood cells, and to

determine the concentration of sodium and potassium

In some cases, a tube may be left in the windpipe to control respiration.

Antibiotics are usually given to prevent infection

Medication is frequently given to suppress the possibility of seizures

If there are no serious problems, the patient may be discharged the following

day, however, hospitalization may be considerably longer depending on the

lesion and the difficulty of the procedure

If there are problems such as weakness, loss of speech, hospitalization may be

delayed 

Transfer to a rehabilitation unit may be necessary

Further care 

The patient returns to the surgeon's office 7-10 days following discharge. At this

time sutures or staples may have to be removed. Continued care depends on the

lesion. Prolonged follow up is usually required for infection and tumor

Infections. A craniotomy for an infection is usually for a brain abscess. Frequently

the patient must be kept on specific antibiotics for the infectious agent causing

the abscess. On occasion antibiotics may be necessary for several months.

Brain tumors. The after care for a brain tumor differs depending on whether it is

benign or malignant

1. Patient with benign tumors usually have to be followed for several years

to be sure there is no recurrence. If there is recurrence, the alternatives

are usually repeat surgery or radiation therapy

2. Malignant tumors of the brain usually have a gloomy outlook. Additional

therapies include

Radiation therapy is usually given following removal of both

metastatic tumors and tumors that originate in the brain such as a

glioblastoma multiforme. Survival following surgery doubles if

radiation therapy is given 

Chemotherapy has been used for glioblastoma but often helps

only slightly and frequently has unwanted side-effects

Immunotherapy involves stimulating the patient's own immune

system to fight the tumor. The patient's tumor (glioblastoma

multiforme) taken at the time of surgery is used to make a vaccine

(like the polio vaccine). The vaccine is given to the patient, which

stimulates blood cells to create lymphocytes that will find and

attack the tumor. Early trials have shown that immunotherapy

improves survival in some patients with minimal side-effects

Novel therapeutic approaches

o Endovascular embolization to minimize bleeding during the acute stage

o Thrombolytic evacuation using closed suction drain

Medication Regimen

Osmotic diuretics, such as mannitol or hypertonic saline, may be used to

diminish intracranial pressure. As hyperthermia may exacerbate neurological injury,

acetaminophen may be given to reduce fevers. Anticonvulsants are used routinely to

avoid seizures that may be induced by cortical damage. Patients with spinal epidural

hematoma may require high-dose methylprednisolone when spinal cord compression is

involved. Immobilized patients may require heparin for prevention of venous thrombosis,

whereas vitamin K and protamine may be administered to restore normal coagulation

parameters. Antacids are used to prevent gastric ulcers associated with traumatic brain

injury and spinal cord damage.

Nursing Management

Obtaining an accurate history, especially the mechanism of injury and clinical

course since that time

Close monitoring of the neurological status, observing for signs of increased

intracranial pressure

Physical examination against a baseline neurological assessment

Elevation of the head of the bed 300 to reduce the intracranial pressure

Administration of diuretics such as mannitol, mild analgesics or codeine to control

pain, and steroids such as dexamethasone according to physician’s prescriptions. In

some cases, the nurse may also need to provide seizure precautions, including the

administration of prophylactic anticonvulsants

Monitor LOC using the Glasgow scale or some other objective scale. 

Assess motor responses bilaterally, check for positive Babinski 

Assess for decreased sensory response bilaterally but with special emphases on

the side opposite the injury. 

Monitor pupillary dilation and response to light. Note precisely the size of the

pupils in mm. Notify the physician immediately if dilation of pupils occurs. 

Monitor vital signs. Notify physician if any deviation from parameters. 

Provide nursing measures related to respiratory care. That would include

suctioning, doing blood gases, monitoring ventilator settings, providing O2 therapy. 

Maintain fluid restriction. These patients need to be kept a little dry to help control

ICP. 

Position the patient to maintain venous outflow from the brain. Elevate the HOB

to 30 degrees (except for a dural tear). Do not put a pillow under the head as it may

flex the head forward and could impede venous outflow. Turn by logrolling every 1 -

2 hours. 

Administer prescribed medications. (will be discussed later) 

Control noise and stimulation from the environment. It is very important to

separate stimuli such as turning, bathing, suctioning, injection, dressing changes,

and changing the bed. Allow a rest period between each activity as

the continued stimuli will cause the ICP to rise. 

Maintain a desired temperature range either with the use of antipyretics or a

hypothermia blanket. If the patient has a hypothalamic injury, the fever will not

respond to antipyretics so a hypothermia blanket will be necessary. 

Provide nursing care to prevent complications such as damage to the eyes, skin,

or oral mucous membranes. 

Provide emotional support to the family. Allow them to spend as much time as

possible with the patient. Involve them in the care of the patient if they wish to

participate. Always encourage them to talk to and touch the patient. Answer

questions for them when possible or refer them to the MD

ICP monitoring device-Monitor ICP via the Epidural catheter if present. EC is a

transducer that is placed between the skull and the dura, leaving the 

dura intact. A similar device is the subdural catheter - a transducer that is placed

under the dura mater.

V. NURSING CARE PLAN

Impaired Skin Integrity

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S > ø

O > The patient

manifests:

-immobility

-destruction in

skin integrity

-redness on the

area

-trauma

-pain

-surgical

incision/wound

>The patient

may manifest:

-edema

Impaired skin

integrity related

to surgery

AEB

destruction of

skin layers and

surface and

invasion of

body structures

20 open

reduction

internal

fixation.

The procedure is

invasive in nature

since it will require

an incision and the

use of mechanical

implants. There is

destruction on the

skin layers of the

affected part.

Short term:

After 2 days of

NI, the patient

will achieve

timely wound

healing.

Long term:

After 7 days of

NI, the patient

will exhibit

improved skin

lesions or

wounds.

>Inspect skin every

shift, describe and

document skin

condition, and report

changes.

>Assist with general

hygiene and comfort

measures.

>Maintain proper

environmental

conditions.

>Use a foam

> To provide

evidence of

the

effectiveness

of the skin

care regimen.

>To promote

comfort and

sense of well-

being.

>To promote

patient’s

sense of well-

being.

Short term:

After 2 days

of NI, the

patient shall

have

achieved

timely wound

healing.

Long term:

After 7 days

of NI, the

patient shall

have

exhibited

-swelling

-itching

mattress, bed cradle,

or other devices.

>Warn against

tampering with the

wound or dressings.

>Position patient for

comfort and minimal

pressure on bony

prominences and

change his position

at least every 2

hours.

>Instruct family

members in a skin

care regimen.

>Perform prescribed

treatment regimen

for the skin condition

involved; monitor

>To minimize

skin

breakdown.

>To reduce

potential for

infection.

>To reduce

pressure,

promote

circulation and

minimize skin

breakdown.

>To

encourage

compliance.

>To maintain

improved skin

lesions or

wounds.

progress.

>Administer pain

medication and

monitor its

effectiveness.

or modify

current

therapy.

>To relieve the

patient of pain.

Risk for Infection

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S> ø

O>The patient

manifests:

-presence of

surgical

incision/wound

>The patient

may manifest:

The pt. may

manifest:

-hyperthermia

-chills

-diaphoresis

-increase WBC

-pain and

swelling on the

surgical site

-alteration in

VS

Risk for

infection

related to

tissue

destruction

20 to open

reduction

internal

fixation.

The surgical wound

is at risk for

infection since

there is destruction

in the first line of

defense of the body

which is the skin.

This entitles

different pathogenic

organisms to

invade the surgical

wound. If it is not

properly taken

cared of like proper

cleaning and

changing of

dressings, there

can be growth and

spread of infectious

microorganisms

and so an infection

Short term:

After 2 days of

NI, the patient

will identify

interventions to

prevent/reduce

risk of infection.

Long term:

After 5 days of

NI, the patient

will manifest

absence of

infection.

>Observe for

localized signs of

infection at

sutures or surgical

incision wound.

>Note signs and

symptoms of

sepsis; fever,

chills, diaphoresis.

>Change

surgical/wound

dressings, as

indicated, using

proper technique for

changing/disposing

of contaminated

>To check for

any

signs of

infection.

>To check for

the presence of

infection and

give

necessary

interventions.

>To facilitate

wound healing

and prevent

infection by

minimizing

growth

and spread of

Short term:

After 2 days of

NI, the patient

shall have

identified

interventions to

prevent/reduce

risk of infection.

Long term:

After 5 days of

NI, the patient

shall have

manifested

absence of

infection.

-seizures will arise. materials.

>Teach family how to

clean incision

site daily and

remind them to

change dressings

as needed.

>Note and report

laboratory values.

>Administer/monitor

medication regimen

and note patient’s

response.

microorganisms.

> To educate the

family about the

right procedure

to clean and

change

dressings.

>To provide a

global view of

the patient’s

immune function

and nutritional

status.

>To determine

effectiveness of

therapy.

Risk for Disuse Syndrome

ASSESSMENT NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVES NURSING

INTERVENTIONS

RATIONALE EXPECTED

OUTCOME

S > ø

O > The patient

manifests:

-coma

-prolonged

inactivity or

immobility

-pain

-changes in

integumentary

and

musculoskeletal

status

-presence of

surgical wound

>The patient

may manifest:

Risk for disuse

syndrome

related

immobilization

due to being

comatose

secondary to

epidural

hematoma

After the surgery,

immobilization of

the affected part is

prescribed for a

few days.

Prolonged

immobilization

may lead to

muscle atrophy,

impeded blood

circulation and

ineffective tissue

perfusion which

arises to the

occurrence of

disuse syndrome.

Short term:

After 3 days of

NI, the patient

will demonstrate

a decrease in

significant

changes in

cardiovascular

status,

respiratory

status, GI

status,

nutritional status

and

genitourinary

status

AEB decrease

fatigability,

> Avoid positions

that put prolonged

pressure on body

parts and

compress blood

vessels.

>Inspect skin

every shift and

protect areas

subject to irritation.

> Monitor

temperature, blood

pressure, pulse

and respirations at

least every 4

hours.

> To enhance

circulation and

help prevent

tissue or skin

breakdown.

>To prevent or

mitigate skin

breakdown.

> To assess

for indications

of infection or

other

complications.

Short term:

After 3 days of

NI, the patient

shall have

demonstrated a

decrease in

significant

changes in

cardiovascular

status,

respiratory

status, GI

status,

nutritional status

and

genitourinary

status

AEB decrease

-changes in

cardiovascular

status,

respiratory

status, GI status,

nutritional status

and

genitourinary

status

ability to move

about and

decrease risk

for muscle

atrophy.

Long term:

After 5 days of

NI, the patient

will maintain

muscle strength

and tone and

joint ROM.

>Perform passive

ROM exercises at

least once per

shift.

>Provide or help

with daily hygiene;

keep skin dry and

lubricated.

>To prevent

joint

contractures,

muscle

atrophy, and

other

complications

of prolonged

inactivity.

> To prevent

cracking and

possible

infection.

fatigability,

ability to move

about and

decrease risk for

muscle atrophy.

Long term:

After 5 days of

NI, the patient

shall have

maintained

muscle strength

and tone and

joint ROM.

VI. CONCLUSION

An Epidural hematoma is a mass of blood in the space between the inner table of

the skull and the dura mater (the leathery outer covering of the brain). Typically caused

by traumatic brain injury, the bleeding into the epidural space can cause pressure on the

brain which can lead to neurological symptoms including coma and death if severe

enough. This can occur with more severe head injury, they can also occur with relatively

mild injuries, particularly if they are in the temporal area and cause a fracture of the bone

of the skull. The fracture can tear blood vessels in this area, leading to the hematoma.

The surgical management most widely used is craniotomy which is indicated to evacuate

the hematoma, prevent and manage coagulation of bleeding sites, and inspection of the

dura. In this case report, the main focus is to broaden the knowledge about epidural

hematoma, its manifestations, risk factors and causes, possible diagnostic procedures or

test, surgical management, and nursing management. Also, the nurse must be aware of

her responsibilities to provide quality care to the patient. She must provide her health

teachings like the proper management of the surgical wound, the benefits of the surgery

and the complications that may occur. The nurse must provide adequate knowledge to

the patient and also to the SO to rule out anxiety and misconceptions. And, the nurse

must help the patient to achieve timely wound healing and to increase the level of

wellness and prevent the occurrence of complications.

VII. BIBLIOGRAPHY

Modern Medical Guide, Revised Edition, 2002

Medical Surgical Nursing, Eight Edition, 2009

http://www.blogtopsites.com/outpost/51b3b6303a2d9b8b95c8ddae04460e4a

http://hematomatreatment.com/nursing-care-of-subdural-and-epidural-hematomas/

http://emedicine.medscape.com/article/824029-followup

http://www.nursing-lectures.com/2011/02/head-trauma-and-nursing-intervention.html

http://health.nytimes.com/health/guides/disease/extradural-hemorrhage/overview.html

http://www.yoursurgery.com/ProcedureDetails.cfm?Proc=19scape.com/viewarticle/

580271_5

http://hematomatreatment.com/nursing-care-of-subdural-and-epidural-hematomas/

http://emedicine.medscape.com/article/882627-overview#a1

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002385/

http://en.wikipedia.org/wiki/Epidural_hematoma