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Neurology India
Medknow Publications on behalf of the Neurological Society of India
ISSN: 0028-3886 EISSN: 1998-4022
Vol. 52, Num. 4, 2004, pp. 450-452

Neurology India, Vol. 52, No. 4, October-December, 2004, pp. 450-452

Original Article

Double extradural hematoma: An analysis of 46 cases

Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005
Correspondence Address:Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi - 221005,

Code Number: ni04153


AIMS: The authors analyze epidemiology, location, clinical profile and outcome of double extradural hematoma (EDH) or EDH at more than one site.
DESIGN: A retrospective clinical study.
MATERIALS AND METHODS: 46 cases of double EDH were studied. All the cases were evaluated for their mode of injury, clinical presentation, level of sensorium at the time of injury, CT scan finding and outcome after surgery, and were compared with single EDH cases.
RESULTS: Out of 1025 cases 46 cases had 'double' EDH. There was bilateral EDH in 39 cases; multiple EDH in 3 cases and ipsilateral double EDH was present in 4 cases. The most common site was frontal (70%). The majority of the patients (80.3%) were in altered sensorium from the time of injury, similar situation was seen in 52.2% of cases with single EDH. The number of patients having a low GCS score was higher when first examined in the double EDH group and the mortality rate was 34.8% as compared to 9% in the single EDH group.
CONCLUSION: Majority of the double EDH cases presented with a low GCS and there was a relatively quick neurological deterioration in these cases.

Key Words: Double extradural hematoma, head injury, CT scan.


Double acute extradural hematoma (EDH) was rarely detected before the introduction of computed tomography (CT). Roy (1884) reported the first case of bilateral EDH.[1] Only isolated cases were described prior to 1980 and most of these were diagnosed at autopsy.[2],[3] Double EDH may be unilateral or bilateral. The incidence varies from 2 to 25% of all EDHs in different series and its presence at more than two sites is rare.[4] Incidence of double EDH in children is rarer and our literature search revealed reports of five such cases.[4] We retrospectively analyzed our cases with ′double′ acute EDH.


Between 1984 and 2003, 1025 cases with EDH were surgically treated in our neurosurgical department. All the cases were examined clinically and plain computerized tomography scan of the head was performed.


Double EDH was found in 46 patients (4.48%). These cases were in the age group of 2 to 85 years, mean age being 29 years. Five cases were in the age group of 2-12 years. 72% were males and 28% were females.

Vehicular accident was the cause of head injury in 67.4% of cases. In the pediatric age group fall from a height was found in 80% cases. The clinical state at the time of neurological examination is shown in [Table - 1]. The site of hematoma is shown in [Table - 2a, 2b] [Figure - 1], [Figure - 2], [Figure - 3].

The mortality in single EDH patients was 9% while it was 34.8% in patients having double EDH. The mortality was significantly higher in patients who sustained vehicular accident and in those having subdural or intracerebral clots. There was no mortality in patients whose GCS score was between 13-15. In patients with GCS score between 3-8, the mortality was 47.6% in cases with double EDH as compared to 25% in patients with single EDH.

Out of 46 patients with double EDH, 39 patients with bilateral EDH underwent surgical evacuation on both sides. Of these, 13 patients died (33%) and the rest clinically improved. Three patients with multiple EDH underwent evacuation of the clot from more than two sites. One of these patients improved and two patients died. Of the four patients operated for ipsilateral double EDH, three patients recovered and one died.


Among the EDH cases the incidence of bilateral EDH has been reported in various studies ranging from 2-25%[5],[6],[7],[8],[9],[10] while its presence at more than two sites is extremely rare.

It has been suggested that the force of impact to the head could produce bilateral hematomas, which is more predominant in the anteroposterior direction than from the lateral direction.[11] This is probably the reason for a higher frequency of EDH in the frontal region. In our series 70% patients had frontal EDH and 30% patients had bilateral EDH. Patients with double EDH less frequently have a lucid interval, have a lower GCS, lateralization is frequently absent and deteriorate more often than individuals with unilateral hematomas.[11],[12] Similar features were observed in our series.

There were two types of bilateral EDH. In the commoner first type, the bleeding is venous in nature and occurs as a delayed phenomenon, while in the second type the bleeding is arterial in nature.[11],[13],[14],[15]

The overall mortality in this series is 34.8% in the double EDH group as compared to 9% in the single EDH group. Gorgulu reported 15.7% mortality in his study of 19 cases of bilateral EDH when the diagnosis was made within 6 hours in 80% of the cases.[16]


The authors thank Mr. Raghvendra Pandey for assistance in the preparation of the article.

1.Roy GC. Fracture of skull, extensive extravasation of blood on dura mater, producing compression of brain, trephining, partial relief of symptoms, death. Lancet 1884;2:319.  Back to cited text no. 1    
2.Soni SR. Bilateral asymmetrical extradural hematoma. Case report. J Neurosurg 1973;38:647-9.  Back to cited text no. 2  [PUBMED]  
3.Subrahmanian MV, Rajendraprasad GB, Dibbala BR. Bilateral extradural hematomas. Br J Surg 1975;62:397-400.  Back to cited text no. 3    
4.Sharma V, Newton G. Bilateral extradural hematoma. Neurology India 1990;38:455-9.  Back to cited text no. 4    
5.Rivas JJ, Lobatto RD, Sarabia R, Cordobes F, Cabrera A, Gomez P. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988;23:44-51.  Back to cited text no. 5    
6.Krayenbuhi H, Brihaye J, Loew F. Advances and technical standards in Neurosurgery. In: Zander E, Campiche R, editors. Extradural hematoma. Vol. 1, New York: Springer Verlag; 1974. p. 1231-9.  Back to cited text no. 6    
7.Gallagher JP, Browder EJ. Extradural hematoma - experience with 167 patients. J Neurosurg 1968;29:1-12.  Back to cited text no. 7  [PUBMED]  
8.Mckissock W, Taylor JC, Bloom WH. Extradural hematomas - Observations on 125 cases Lancet 1960;2:167-72.  Back to cited text no. 8    
9.McCarty CS, Homing ED, Weaver EN. Bilateral extradural hematoma. J Neurosurg 1948;5:88-90.   Back to cited text no. 9    
10.Dharkar SR, Bhargava N. Bilateral epidural hematoma. Acta Neurochir 1991;110:29-31.  Back to cited text no. 10    
11.Frank E, Berger TS, Tew JM Jr. Bilateral epidural hematomas. Surgical Neurology 1982;17:218- 22.  Back to cited text no. 11    
12.Rasmussen GL, Holme S. Bilateral epidural hematomas. Ugeskr Laeger 1991;154:203-4.  Back to cited text no. 12    
13.Barlow P, Kohli YM. Acute simultaneous bilateral extradural hematoma. Surgical Neurology 1985;23:411-3.  Back to cited text no. 13    
14.Rochat P, Johannesen HH, Poulsgard L, Bogeskov L. Sequentially evolved bilateral epidural haematomas. Clin Neurol Neurosurg 2002;105:39-41.   Back to cited text no. 14  [PUBMED]  
15.Baricolo AP, Pasup LM. Extradural hematoma: Towards zero mortality. Neurosurgery 1984;14:8-12.  Back to cited text no. 15    
16.Gorgulu A, Cobanoglu S, Armagan S, Karabagli H, Tevruz M. Bilateral epidural hematoma. Neurosurg Rev 2000;23:30-3.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]

Copyright 2004 - Neurology India

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