Primary Malignant Epithelial Neoplasm of Skull Masquerading as Extra Dural Hematoma: A Little was Dangerous, a Lot was Deadly

A bstract An extra dural hematoma (EDH) is a potentially life-threatening clinical condition that requires immediate surgical evacuation. Delay in treatment may be associated with significant morbidity and mortality. The EDH is most commonly caused by trauma; however, the non-traumatic spontaneous causes of EDH include hematological tumors, metastasis, malignant skull tumors, coagulopathy, infections, and vascular malformations of skull and dura. Here, the authors report a case of a 14-month-old girl who presented with a history of trivial trauma with an alleged history of a fall from bed 20 days back, followed by headache, weakness of the right upper and lower limbs. On examination, her GCS was E4V5M6, irritable with the left lateral rectus palsy and power in the right upper and lower limbs of 4/5, left periorbital edema and raccoon eye. Her non-contrast computed tomography head revealed a large left fronto-parietal biconvex hyperdense lesion (simulating acute EDH) with midline shift. Bone window films revealed erosion of the left fronto-parietal bone. She underwent left parieto-temporal craniotomy and evacuation of hematoma. The bone was eroded with a mottled appearance. There was an epidural hematoma with a firm, spicule-like reddish-brown highly vascular mass that was adherent to the bone. Complete excision of the lesion could not be done due to hemodynamic instability of the patient. A biopsy sample including eroded bone was sent for histopathological examination. Postoperative CT head showed an adequate decompressive craniectomy defect with operative site hematoma. Postoperatively patient deteriorated further and succumbed on postoperative day 4. The histopathology report revealed a malignant epithelial neoplasm.