Late fatal deterioration of supra- and infratentorial acute epidural hematoma in a 13-year-old: case report and literature review

Introduction: Supra- and infratentorial epidural hematomas are rare, representing only 2% of traumatic, cases. They often remain clinically silent or present with nonspecific symptoms but carry a risk of delayed yet rapidly fatal deterioration and life-threatening foramen magnum herniation. Case summary: A previously healthy 13-year-old male presented following sports-related head trauma with a 2-minute loss of consciousness, frontal headaches, and vomiting. Brain computed tomography (CT) revealed a right parieto-occipital supra- and infratentorial epidural hematoma with a volume of 27.6 cm 3 for the supratentorial component and 9.3 cm 3 for the infratentorial component, as well as a minimal 3 mm left-sided midline shift. He remained asymptomatic for 5 days with stable hematoma volume. On day 6, he experienced rapid neurological deterioration; repeat CT showed hematoma expansion. Urgent craniectomy for decompression was performed. Postoperatively, he was transferred, intubated, to the intensive care unit with a Glasgow Coma Scale of 3 T and nonreactive miotic pupils. Within hours, he developed hypotension and died from brain herniation. Clinical discussion: Simultaneous supra- and infratentorial epidural hematoma is an exceptionally rare injury that may remain clinically silent despite the potential for catastrophic delayed deterioration. This case demonstrates that fatal hematoma expansion can occur beyond the typical 24–48-hour window, highlighting the limitations of relying solely on neurological stability and the importance of vigilant radiological surveillance. Conclusion: This case highlights the potential for delayed, rapidly fatal deterioration in supratentorial and infratentorial epidural hematomas. Vigilant monitoring and timely intervention are essential. Because of the rarity and unpredictability of supra- and infratentorial epidural hematoma, further studies are needed to guide optimal management.