Spontaneously occurring epidural haematomas (SEDH) are an uncommon entity. The possible causes are neoplastic 
lesions, craniofacial infections, bleeding disorders, 
uraemia, sinus thrombosis, heart surgery, arterio-
venous malformation and intra-diploic epidermoid 
cysts. The case reported by Ahmad et al. is the 
only case of spontaneous posterior fossa epidural 
haematoma which occurred in a child with a 
cardiopulmonary bypass.1 We report the first case 
of spontaneous posterior fossa epidural haematoma 
in a patient of sigmoid sinus thrombosis secondary 
to mastoiditis.

Case Report 
A 40 year-old man was referred to the outpatients 
department of C.S.M. Medical University Hospital, 
India, with complaints of mild headache and 
incoordination. He had a 10-year history of 
recurrent right ear discharge which had been treated 
by oral antibiotics, but had no ear discharge at the 
time of presentation. He had no history of bleeding 
diathesis or trauma and was not a known case of any 
medical ailment. On examination, he was conscious, 
oriented and higher mental functions were normal. 
All his cranial nerves were intact with no signs of 
meningitis. He had an impaired tandem gait with 
no positive cerebellar signs. His haematological 
parameters, including renal function test, liver 

SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 108-111, Epub. 12th Feb 11
Submitted 13th May 10
Revision ReQ. 23rd Jun 10, Revision recd. 11th Aug 10
Accepted 24th Aug 10

Department of Neurosurgery, C.S.M. (Chattrapati Sahuji Maharaja, previously King George’s) Medical University, Lucknow, Uttar 
Pradesh, India - 226003.
Email: dr_kaifmohd@yahoo.co.in

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
:مفتاح الكلمات

aBStract: Spontaneously occurring epidural haematomas are an uncommon entity. A spontaneous post fossa 
epidural haematoma due to sigmoid sinus thrombosis secondary to mastoiditis has not been reported in English 
medical literature. We report a 40 year-old man who presented to us with headache and incoordination. A magnetic 
resonance imaging (MRI) confirmed epidural sub-acute bleeding in the right side of posterior fossa with mastoiditis 
and right sigmoid sinus thrombosis. A right suboccipital craniotomy and evacuation of the haematoma was done 
and the patient was relieved of his complains.

Keywords: Haematoma, epidural; Cranial fossa posterior; Sinus thrombosis; Mastoiditis; Case report; India 

Mastoiditis causing Sinus Thrombosis and 
Posterior Fossa Epidural Haematoma

Case report
Mohamed Kaif

CASE REPORT



Mohamed Kaif

Case Report | 109

function test and coagulation profile, were normal. 

The magnetic resonance imaging (MRI) scan 
of his brain with a venogram was already available  
and showed a well defined extra axial lesion on 
right side of the posterior cranial fossa postero-
medially to the right mastoid with hypointense 
signal on T1W, T2W and GRE images [Figure 1]  
and peripherally hyperintense on T1W and T2W 
image suggestive of early subacute epidural bleeding. 
The right mastoid showed T1 hypointense and T2 
hyperintense lesion suggestive of mastoiditis. A 
magnetic resonance (MR) venogram imaging scan 
demonstrated a right sigmoid sinus thrombosis 
[Figure 2]. As both the MRI and the venogram 
demonstrated a haematoma with thrombosed right 
sigmoid sinus, no other investigation was done and 
surgery was planned.

A retromastoid suboccipital craniotomy was 
done and an epidural organised clot of 30 ml 
volume evacuated. A craniotomy was preferred 
over craniectomy as peroperatively no evidence of 
infection was found and the craniotomy prevents 
a bone defect. The free bone flap was washed with 
chloramphenicol saline and kept in chloramphenicol 

saline during the surgery. 
Mild oozing was noted from the transverse 

sinus region which was managed by packing 
with absorbable haemostat (Surgicel®, Ethicon, 
Inc., Summerville, NJ, USA). The patient was 
complaint free in the postoperative period and 
was subsequently transferred to the Ear Nose 
and Throat Department for the management 
of right mastoiditis and then modified radical 
mastoidectomy after 4 weeks. The haematoma  
was confirmed on histopathology and the culture 
was found to be sterile. 

Discussion
Spontaneously occurring cranial epidural 
haematomas have been reported in the literature 
worldwide. Liedbeck et al. in 1848 reported the 
first case of SEDH in a patient with haemophilia.2 

Schnieder et al., in 1951, were the first to report a 
case of SEDH in a case of craniofacial infection in 
autopsy of two patients.3 To date there have been 55 
reported cases of SEDH [Table 1].

There are seven possible causes for SEDHs 
mentioned in the world literature. The commonest 
possible cause for spontaneous epidural 
haematoma reported in the international literature 
is neoplastic condition.4-11 The most common type 
of SEDH is hepatocellular carcinoma reported 
in seven cases. The other neoplastic conditions  
mentioned are eosinophilic granuloma,5 Langerhans’ 
cell histiocytosis,6 lung carcinoma,7 ovarian 
carcinoma,8 malignant fibrous histiocytoma,9 and 
Ewing's sarcoma.10

The second commonest possible cause for 

Figure 1: A: Axial T1-weighted magnetic resonance 
image showing hypointense signal with peripheral 
hyperintensity and right mastoid showing hypointense 
signal; B: Axial T2-weighted image showing 
hypointense signal with peripheral hyperintensity and 
right mastoid showing hyperintense signal; C: Gradient-
echo sequence showing hypointense signal.

Figure 2: Magnetic resonance venography 
demonstrating thrombosis in the right sigmoid sinus.



Mastoiditis causing Sinus Thrombosis and Posterior Fossa Epidural Haematoma 
Case report

110 | SQU Medical Journal, February 2011, Volume 11, Issue 1

SEDH reported is associated craniofacial infection 
which was present in 17 of the 55 reported cases.12-19  

Two mechanisms have been proposed for such 
bleeding. The first is arteritis, which results in 
weakening of the meningeal vessel wall and causes 
subsequent bleeding. The second mechanism 
proposed is progressive detachment of the dura 
mater from the inner table of the skull by the 
accumulation of exudates, pus, or air. 

The next most common cause reported is 
bleeding disorders. There are 11 case reports 
of bleeding disorders causing SEDH. The 
possible causes mentioned are haemophilia,20 

thrombocytopenia, hypofibrinogenaemia21 and 
vitamin K deficiency. Epidural haematomas  
(EDH) are reported to be caused by chronic 
renal disease and uraemia.22 The coagulation 
abnormalities associated with uraemia or heparin 
use during haemodialysis may be the factors 
responsible for the EDH in such patients. Platelet 
dysfunction, as has been reported in uraemia, may 
further explain EDH formation in these patients.

There are two case reports of SEDH in 
patients of cardiopulmonary bypass.1,23 Ahmad 
et al. reported a case of spontaneous posterior 

fossa epidural haematoma in a child who had  
undergone a cardiopulmonary bypass. This was the 
first reported case of spontaneous posterior fossa 
extradural hematoma.1 Other causes of spontaneous 
extradural haematoma reported are dural vascular 
anomalies and intradiploic epidermoid cysts.11

Knopman et al. reported a case of SEDH 
secondary to venous sinus thrombosis.24 The 
mechanism for the development of the haematoma 
is that the venous haemodynamic pressure increases 
secondary to poor outflow, causing tension on the 
proximal venous system. This tension causes blood 
to dissect between leaflets of the proximal sinus and 
into the epidural space. 

Mastoiditis is known to cause sigmoid sinus 
thrombosis.25 Our patient developed spontaneous 
posterior fossa epidural haematoma secondary 
to sigmoid sinus thrombosis which was due to 
mastoiditis. This is the first reported case of SEDH 
of the posterior fossa in sigmoid sinus thrombosis 
due to mastoiditis. 

Conclusion
Spontaneously occurring EDH is an uncommon 
entity. Certain conditions have been reported 
to be associated with SEDH such as craniofacial 
infections, hepatocellular carcinoma and bleeding 
disorders. Craniofacial infections are the most 
commonly associated condition. This is the first 
case report of sigmoid sinus thrombosis secondary 
to mastoiditis thus causing EDH of the posterior 
cranial fossa.

References  
1. Ahmad FU, Pandey P, Mahapatra AK. Spontaneous 

posterior fossa extradural hematoma - a rare 
complication following cardiac surgery. Pediatr 
Neurosurg 2005; 4:49–51.

2. Liedbeck PJ. Hygiea 10:363, 1848 (cited in Reference 
58).

3. Schneider RC, Hegarty WM. Extradural hemorrhage 
as a complication of otological and rhinological 
infections. Ann Otol Rhinol Laryngol 1951; 60:197–
206.

4. Endo M, Hamano M, Watanabe K, Wakai S. 
Combined chronic subdural and acute epidural 
hematoma secondary to metastatic hepatocellular 
cancer: case report. No Shinkei Geka 1999; 27:331–
4.

Table 1: Reported cases of spontaneous epidural 
haematomas with aetiology

Aetiology Example

Neoplastic condition Hepatocelluar carcinoma4

Eosinophilic granuloma5

Langerhan's cell histiocytosis6

Lung carcinoma7

Ovarian carcinoma8

Malignant fibrous 
histiocytoma9

Ewing's sarcoma10

Intradiploic epidermoid11

Craniofacial infection Fontal sinusitis12

Middle ear suppuration13

Orbital cellulites14

Pansinusitis15

Maxillary sinusitis16

Cleft palate with frontal 
sinusitis17 
Sphenoiditis18

Nasal polyps19

Coagulation abnormality Haemophila20

Hypofibrinogenemia21

Uraemia22

Heart surgery Open heart surgery23

Cardiopulmonary bypass 
surgery1



Mohamed Kaif

Case Report | 111

5. Cho DY, Liau WR, Chiang IP. Eosinophilic granuloma 
with acute epidural hematoma: a case report. Pediatr 
Neurosurg 2001; 35:266–9.

6. Chen HC, Shen WC, Chou DY, Chiang IP. 
Langerhans cell histiocytosis of the skull complicated 
with an epidural hematoma. AJNR Am J Neuroradiol 
2002; 23:493–5.

7. Hassan MF, Dhamija B, Palmer JD, Hilton D, Adams 
W. Spontaneous cranial extradural hematoma: case 
report and review of literature. Neuropathol 2009; 
29:480–4.

8. Anegawa S, Hirohata S, Tokutomi T, Kuramoto S. 
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9. Leung G, Yip P, Fan YW. Spontaneous epidural 
haematoma associated with radiation-induced 
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1999; 44:404–6.

10. Aslam E, Imran M, Faridi NM. Bilateral parietal 
extradural metastatic Ewing’s sarcoma simulating 
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11. Wani AA, Ramzan AU, Kirmani AR, Bhatt AR, 
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report. J Neurosurg 2008; 62:E971.

12. Kelly DL Jr, Smith JM. Epidural hematoma secondary 
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13. Clein LJ. Extradural haematoma associated with 
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102:1183–4.

14. Schneider RC, Tytus JS. Extradural hemorrhage: 
factors responsible for the high mortality rate. Ann 
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15. Ataya NL. Extradural haematoma secondary to 
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16. Rajput AJ, Rozdilsky B. Extradural hematoma 
following frontal sinusitis: Report of a case and 
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94:83–6.

17. Griffiths SJ, Jatavallabhula NS, Mitchell RD. 
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19. Marks SM, Shaw MD. Spontaneous intracranial 
extradural hematoma. J Neurosurg 1982; 57:708–9.

20. Cooper NA, Lynch M.: Delayed haemorrhagic 
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Br Med J 1979; 1:164–5.

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22. Shahlaie K, Fox A, Butani L, Boggan JE. Spontaneous 
epidural hemorrhage in chronic renal failure: A case 
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72.

23. Hoffman HJ, Mustard WT. Spontaneous intracranial 
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surgery. Can J Surg 1973; 16:130–1

24. Knopman J, Tsiouris AJ, Souweidane MM. J 
Neurosurg Pediatr 2008; 2:416–19.

25. Zheng FX, Chao Y. Spontaneous intracranial 
extradural hematoma: case report and literature 
review. Neurol India 2009; 57:324–6.