Epidural hematoma secondary to a ruptured occipital artery.

Background: Most epidural hematomas (EDHs) are caused by middle meningeal artery rupture, though any cranial-facial artery could be involved. Hypertension (HTN) is a major risk factor for intracerebral hemorrhages due to vascular remodeling and dysfunction. Fluid dynamics shows us that blood follows the path of least resistance, which may lead to untypical hemorrhaging patterns. To date, no cases have documented an EDH from an occipital artery bleed. Case Description: A 37-year-old male with an unremarkable medical history except for HTN presented with basal ganglia hemorrhage. Computed tomography (CT) angiography was unremarkable. He underwent decompressive craniectomy. The bone flap was not replaced. At 4-month follow-up, right ventriculomegaly prompted ventriculoperitoneal shunt placement. Within 24 h, clinical deterioration prompted CT, revealing an EDH. Reoperation identified the occipital artery as the bleeding source that caused blood to enter the burr hole. With a small dural opening occupied by the catheter, the blood could not enter the subdural space and accumulated epidurally. Conclusion: Intraoperative injury to the occipital artery would have caused immediate, visible scalp bleeding. Instead, postoperative HTN likely led to arterial rupture. Blood followed the path of least resistance through the burr hole, driven by a pressure gradient from the shunt. This hypertensive episode resulted in an occipital artery epidural hematoma localized at the burr-hole site.