Here is a treatment summary of Depressed Midline Skull Fracture with EDH treated in Indore by Dr Sandeep Moolchandani (Brain and Spine Surgeon). Compound Midline depressed fractures are rare. They are seen in patients with high velocity injury like road traffic accidents. Depressed fracture over venous sinuses requires special handling. Surgical elevation involves a risk of massive blood loss due to Superior Sagittal Sinus Bleed. Performing the procedure with the team on the night of Diwali. Patient made through with limited blood loss.
22y/M with H/O High speed RTA due to skidding of bike with H/o LOC(+), VOMITING(+) , CONVULSION(+) /ENT BLEED(-)
Preoperative Condition
GC- POOR
AFEB
P-90/MIN
BP-110/72mmHg
Chest BL AE+
PA- Soft
E1VtM3
PUPIL- Rt NRTL 3.5mm
Lt. RTL 3.0mm
LE-
L/W on high parietal region 6x2cm bone deep
Postoperative Condition
GC- Improved
E1VtM5
PUPIL- Rt SR 3.0 mm
Lt. RTL 3.0mm
Pre vs Postoperative CT
Depressed skull fractures occur when part of the skull bone is pushed inward towards the brain. In cases of midline depressed fractures, the bone is displaced along the midline of the skull, a region that houses the superior sagittal sinus (SSS)—a major venous structure responsible for draining blood from the brain. Compound midline depressed fractures are particularly rare and are most commonly observed in patients who suffer from high-velocity injuries, such as road traffic accidents or severe falls.
The involvement of the SSS presents a critical challenge: surgical intervention in this region carries a high risk of bleeding due to the proximity to the brain’s central venous system. An injury or tear to the SSS during surgery can lead to significant blood loss, making it one of the more complex types of skull fractures to address.
In addition to the depressed skull fracture, this patient had developed an epidural hematoma (EDH)—a collection of blood between the skull and the dura mater (the brain’s outer membrane). EDH often requires urgent surgical intervention, as the accumulated blood can exert pressure on the brain, potentially causing brain damage or even death if not promptly treated. The presence of EDH in combination with a midline skull fracture further compounded the complexity of the case, demanding a delicate and expertly handled surgical approach.
The task of elevating a midline depressed skull fracture is inherently risky due to the need for precise manipulation near the SSS. The SSS bleed risk adds an extra layer of difficulty for surgeons: not only must they avoid disrupting this essential blood drainage channel, but they also must remain prepared for any signs of unexpected bleeding. Hemorrhage from the SSS can lead to massive blood loss, which in emergency cases can escalate into a life-threatening situation within seconds.
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