Epidural Hematomas and Frontal Skull Fractures
Yes, epidural hematomas are associated with frontal skull fractures, and while they are typically arterial in origin, frontal epidural hematomas can arise from multiple arterial sources beyond the classic middle meningeal artery.
Association with Frontal Skull Fractures
Frontal skull fractures carry significant risk for epidural hematoma development, with 8-10% of patients with frontal sinus fractures requiring surgical intervention for subdural or epidural hematoma 1. The ACR Appropriateness Criteria emphasizes that in cases where radiographs failed to detect skull fractures, half of those patients eventually developed an epidural hematoma 2. This underscores the critical importance of CT imaging over plain radiographs, as CT can detect fractures missed on radiography and identify associated intracranial pathology 2.
- Frontal bone fractures are associated with intracranial injuries in 56-87% of cases, making comprehensive evaluation essential 1
- Displaced posterior table fractures often indicate disruption of the underlying dura, creating communication between the frontal sinus and anterior cranial fossa, which can facilitate hematoma formation 1
Arterial Nature of Epidural Hematomas
Epidural hematomas are predominantly arterial in origin, but frontal epidural hematomas present unique challenges due to multiple potential arterial sources:
Classic vs. Frontal Sources
- The middle meningeal artery is the traditional source for most epidural hematomas, but in the frontal region, other arterial sources must be considered 3
- Frontal epidural hematomas can arise from frontal branches of the middle meningeal artery, posterior ethmoidal artery feeders, or other dural arterial vessels 3
- Multiple arterial sources can contribute simultaneously to a single frontal epidural hematoma, requiring thorough intraoperative exploration 3
Critical Clinical Pitfall
A major pitfall is assuming a single arterial source in frontal epidural hematomas. One case report demonstrated that after cauterizing a frontal branch of the middle meningeal artery and evacuating the hematoma, routine follow-up imaging revealed a residual hematoma in a more medial location from posterior ethmoidal artery feeders 3. This necessitated a second operation to achieve definitive control 3.
Venous Considerations
- While less common, venous sources can contribute, particularly in vertex epidural hematomas where arteriovenous fistulas between the middle meningeal artery and venous lakes have been reported 4
- Microvessel injury in the dura can cause epidural hematomas, especially in contrecoup injuries where no obvious fracture or major arterial injury is identified 5
Diagnostic Approach
Multidetector CT without contrast is the gold standard for diagnosing frontal bone fractures and associated epidural hematomas 1:
- 3D reconstructions are critical for surgical planning and characterizing complex fractures 1
- Complementary CT head is essential since the majority of frontal bone fractures have associated intracranial injuries 1
- Consider preoperative angiography when frontal epidural hematomas are identified, particularly to map multiple potential arterial sources 3
- Acute postoperative imaging is mandatory to ensure successful evacuation and identify residual or recurrent hematomas from alternative arterial sources 3
Management Implications
- Surgical exploration via bifrontal craniotomy may be required for combined anterior and posterior table fractures with associated hematomas 1
- Intraoperative vigilance for multiple bleeding sources is essential, with extensive exploration after frontal lobe retraction if initial hemostasis is inadequate 3
- High-energy trauma mechanisms (motor vehicle collisions, falls from height) increase the risk of epidural hematoma formation 6, 7