Introduction: Vertex epidural hematoma (VEH) comprises 2-8% of all extradural hematomas. It can represent a surgical dilemma regarding when and how to operate, particularly considering the potential implication of the superior sagittal sinus (SSS). Here, we illustrate the surgical technique for VEH as well as review of the existing literature.

Methods: A 60-year-old male sustained a ground level fall resulting in complete diastasis of the sagittal suture with underlying large VEH causing significant mass effect on the SSS and bi-hemispheric convexities. Twenty-four hours later, the patient deteriorated with decreased level of alertness and worsening asymmetric paresis on his lower extremities. He subsequently underwent surgical evacuation of the hematoma, decompression of the SSS, and fracture repair. A modified bicoronal approach, with bilateral parasagittal craniotomies was performed. A central island of bone was left intact in order to spare the diastatic fracture from the craniotomies and ensure a stable anchor-point for tacking-up the underlying displaced dura and SSS, preventing further re-accumulation, extensive bleeding from the diastatic fracture, and eliminating the risk of further tearing a potentially injured sinus during bone flap elevation.

Results: The technique performed, allowed us to completely evacuate the hematoma while preserving the SSS and repairing the sagittal suture to avoid further bleeding. Complete neurologic recovery of the patient occurred after VEH evacuation.

Conclusions: Due to its rare nature, VEH represents a surgical challenge. As neurosurgeons encounter this condition relatively infrequently, literature regarding the medical and surgical management of this entity is warranted.

Patient Care: Vertex epidural hematomas are an uncommon presentation of epidural hematomas. Surgical management still controversial due to its low incidence. Surgeons may have scant exposure during their training. Unifying criteria for surgical management of VEH may decrease complications at the moment of surgery (such as profound SSS bleeding and/or air embolism).

Learning Objectives: -Describe the surgical technique for VEH evacuation. -Describe the management of SSS in the context of a diastatic fracture of the Sagittal suture. -Review and compare the literature available. -Identify those patients who may warrant a surgical intervention over medical treatment.

References: 1. Alexander GL. Extradural Haematoma at the Vertex. J Neurol Neurosurg Psychiatry. 1961;24(4):381-384. 2. Bimpis A, Marcus HJ, Wilson MH. Traumatic bifrontal extradural haematoma resulting from superior sagittal sinus injury: case report. JRSM Open. 2015;6(4):2054270415579137. 3. Borzone M, Gentile S, Perria C, Rivano C, Rosa M. Vertex epidural hematomas. Surg Neurol. 1979;11(4):277-284. 4. Guha A, Perrin RG, Grossman H, Smyth HS. Vertex epidural hematomas. Neurosurgery. 1989;25(5):824-828. 5.Jones TL, Crocker M, Martin AJ. A surgical strategy for vertex epidural haematoma. Acta Neurochir (Wien). 2011;153(9):1819-1820. 6.Osborn AG. Osborn's brain: imaging, pathology, and anatomy. Amirsys Salt Lake City; 2013. 7. Harbury OL, Provenzale JM, Barboriak DP. Vertex epidural hematomas: imaging findings and diagnostic pitfalls. Eur J Radiol. 2000;36(3):150-157. 8. Le TH, Gean AD. Neuroimaging of traumatic brain injury. Mt Sinai J Med. 2009;76(2):145-162. 9. Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical versus conservative management: two case reports and review of the literature. Neurosurgery. 1999;45(3):621-624; discussion 624-625. 10. Navarro JN, Alves RV. Vertex epidural hematoma: A rare cause of post-traumatic headache and a diagnostic challenge. Surg Neurol Int. 2016;7(Suppl 10):S276-278. 11. Kett-White R, Martin JL. Bilateral frontal extradural haematomas caused by rupture of the superior sagittal sinus: case report. Br J Neurosurg. 1999;13(1):77-78. 12. Lapadula G, Caporlingua F, Paolini S, Missori P, Domenicucci M. Epidural hematoma with detachment of the dural sinuses. J Neurosci Rural Pract. 2014;5(2):191-194. 13. Mishra SS, Senapati SB, Deo RC. Traumatic bilateral frontal extradural hematomas with coronal suture diastases. Neurol India. 2011;59(6):940-942. 14. Stevenson GC, Brown HA, Hoyt WF. Chronic Venous Epidural Hematoma at the Vertex. J Neurosurg. 1964;21:887-891.