Unusual, Acute, and Delayed Traumatic Torcular Herophili Epidural Hematoma Causing Malignant Encephalocele During Surgery: A Case Report

Patient: Male, 40 Final Diagnosis: Traumatic torcular herophili unusual acute and delayed epidural hematoma Symptoms: Coma Medication: — Clinical Procedure: Craniotomy Specialty: Neurosurgery OBJECTIVE: Unusual setting of medical care BACKGROUND: Traumatic torcular herophili epidural hematoma is a rare and specific type of traumatic brain injury that is technically difficult to treat and, more critically, can lead to malignant encephalocele during the operation. CASE REPORT: A 40-year-old man presented to our hospital 2 h after a motor vehicle crash. Emergency cranial CT showed a frontotemporal subdural hematoma; 3 h after the patient was admitted, the GCS score decreased to 8 and cranial CT re-examination showed that the frontotemporal subdural hematoma was significantly larger than before. We surgically evacuated the hematoma and the patient experienced acute encephalocele 1 h later. An intra-operative cranial CT re-examination showed a large epidural torcular herophili hematoma. Then, via a posterior fossa craniotomy at the torcular herophili, the source of the hemorrhage was identified as the torcular herophili and diploic veins. We used Gelfoam for compression to establish hemostasis and the occipital fascia to repair the broken dura of the torcular herophili and maintain appropriate tension. One month after the injury, CT scans showed absorption of the brain contusion and intracerebral hematoma and reduced cerebral edema, and the patient showed complete resolution of the injury, without neurological dysfunction. CONCLUSIONS: If the first CT scan shows no hematoma in the brain, it can be easy to ignore this complication during the operation. Attention should be paid to confirming a diagnosis as quickly as possible to improve the prognosis of patients with traumatic brain injuries.