Traumatic epidural hematomas of the posterior cranial fossa

Traumatic epidural hematomas of the posterior cranial fossa

Available online at Surgical Neurology 69 (2008) 247 – 252 Trauma Traumatic epidural hematom...

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Available online at

Surgical Neurology 69 (2008) 247 – 252


Traumatic epidural hematomas of the posterior cranial fossa Aykut Karasu, MD, Pulat Akin Sabanci, MD4, Nail Izgi, MD, Murat Imer, MD, Altay Sencer, MD, Tufan Cansever, MD, Ali Canbolat, MD Department of Neurosurgery, Istanbul Medical Faculty, Istanbul University, Istanbul 34093, Turkey Received 8 February 2007; accepted 8 February 2007


Background: Traumatic EDHs of the posterior cranial fossa are rare and have a higher mortality than supratentorial localizations. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. Active use of cranial CT scanning has taken a major role in the diagnosis, surgical indication, close observation, and strategy planning. As a result, better prognosis is achieved. In this study, we represent our results and experiences in the management of TEHPCF. Methods: Between 1993 and 2006, 65 patients with TEHPCF were treated in Istanbul University Faculty Of Medicine, Neurosurgery and Emergency Surgery Departments. The hospital records of these patients were analyzed retrospectively. Results: Of 65 patients, whose diagnosis and management decisions were determined by cranial CT scans, 53 were treated through surgery and 12 by conservative methods. Of the 53 surgically treated patients, 2 (3%) patients died, and 2 (3%) other patients remained moderately disabled during their discharge. As a result, 61 (94%) of 65 patients had excellent recovery. Conclusion: When compared with the literature, our mortality rate was superior to other previously reported studies. In our opinion, this is a result of extensive use of the cranial CT scan together with aggressive surgery. Patients with occipital trauma should be evaluated using cranial CT scans, and those showing mass effect should be immediately treated surgically. The patients that have no mass effect on CT scans can be closely observed by planned serial control CT scans. D 2008 Elsevier Inc All rights reserved.


Epidural hematoma; Posterior cranial fossa; Computed tomography; Head trauma

1. Introduction Posterior fossa EDH is a rare condition and constitutes 1.2% to 11% of all EDHs [4,5,11,13,17,23-25,31]. Generally, EDHs tend to occur in supratentorial localizations, and the rare occurrence in posterior fossa is associated with high mortality. The most common traumatic lesion of the posterior fossa is EDH [16,24]. Traumatic EDHs of the posterior cranial fossa are generally

Abbreviations: CT, computed tomography; EDH, epidural hematoma; GCS, Glasgow Coma Scale; TEHPCF, traumatic epidural hematoma of the posterior cranial fossa. 4 Corresponding author. Tel.: +90 532 553 26 66, +90 533 439 51 71; fax: +90 212 534 02 52. E-mail address: [email protected] (P.A. Sabanci). 0090-3019/$ – see front matter D 2008 Elsevier Inc All rights reserved. doi:10.1016/j.surneu.2007.02.024

clinically silent, and symptoms are nonspecific and, as such, is difficult to diagnose. Even before clinical findings exist, neuroradiologic findings appear [4,8,18]. Hence, CT scan is of great importance in the diagnosis of TEHPCF [3,8,9,11,18]. Unless adequate management is prompt, clinical deterioration is sudden [4]. Early diagnosis and management are imperative. The technological development in radiological methods in the last few years, including progress in their practicability, feasibility, and speed has facilitated early diagnosis and treatment, allowing better results to be achieved. Improved diagnosis has allowed more patients with TEHPCF that has no mass effect to be treated conservatively and observed closely [14,20,21,29]. The management and risk factors of TEHPCF are different than the EDHs of other localizations.


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2. Clinical material and methods 2.1. Patient population Between January 1993 and August 2006, 65 patients were diagnosed and treated at the Department of Neurosurgery, Istanbul University Istanbul Medical Faculty. The hospital records of these patients were analyzed retrospectively. There were 47 (72%) male and 18 female patients, aged between 3 and 62 years (mean, 16.4 years). The clinical signs and symptoms on admission are summarized in Table 1. 2.2. Evaluation protocol and management All patients were diagnosed via CT among a total number of 663 patients with EDH (9.8% of all EDH cases). Radiography was performed in all cases. The clinical course of traumatic TEHPCF was classified as acute, subacute, and chronic, with the onset of symptoms within the first 24 hours of trauma, from the second to the seventh day after trauma, and later, respectively [12] (Table 3). The GCS was used to assess the level of consciousness in all patients (Table 4) and also to measure clinical status in surviving patients to compare the surgical and the conservative managements. Obliteration of the perimesencephalic cisterns (especially the quadrigeminal cistern), the compression and/or displacement of the fourth ventricle, and the presence of hydrocephalus were carefully recorded to assess the mass effect of the hematoma, and associated traumatic lesions were identified by means of head CT scanning. According to the initial findings, 49 patients underwent surgery, and 16 patients conservative treatment. However, during their clinical observation, 4 of the patients were excluded from the conservative group. Two of these patients had enlargement of EDH in their 24th hour control CT scans. The other 2 clinically deteriorated, and just after their deterioration, the CT scans were performed. Enlargement of the hematoma was determined in the 4th hour CT in 1 patient and in the 11th hour CT in the other. So finally, 53 patients were treated surgically, and 12 patients were treated conservatively. In patients who underwent surgical treatment, there was a mass effect to some degree. Partial to total obliteration of the perimesencephalic cisterns and/or comTable 1 Signs and symptoms

Fig. 1. Cranial CT of a patient with TEHPCF. Perimesencephalic cisterns are totally obliterated.

pression and/or displacement of the fourth ventricle was observed on CT scans (Fig. 1). In all surgical cases, the patient was placed in prone position to prevent the development of air embolism. The standard approach in surgical cases was the wide unilateral or bilateral suboccipital craniectomy. In cases where the hematoma extended to the supratentorial occipital region, occipital craniotomy was also performed when the supratentorial portion of the clot was large. In the 12 patients receiving nonsurgical treatment, the decision to undertake conservative therapy was based on the clinical absence of brainstem compression or posterior fossa hypertension. The perimesencephalic cisterns were fully open, the fourth ventricle was not compressed or displaced, and hydrocephalus was not present. These patients underwent careful observation of neurological status and control CT scanning. 3. Results 3.1. Clinical presentation

Signs and symptoms

No. of signs

Percentage of signs

Occipital swelling Headache Vomiting Transient loss of consciousness Disturbance of consciousness Cerebellar signs and symptoms Anisocoria Otorrhagia Amnesia Epistaxis Loss of consciousness Asymptomatic

62 31 30 27 23 20 5 3 2 2 2 4

95 47 46 41 35 30 7 4 3 3 3 6

In our series, the most important findings were occipital swelling (57 cases), headache (31 cases), and vomiting (30 cases) (Table 1). Table 2 Trauma types Trauma types



Falls from height Traffic accidents (outside) Traffic accidents (inside) Falls from same altitude Bicycle accidents

27 16 10 9 3

42 24 15 14 4

A. Karasu et al. / Surgical Neurology 69 (2008) 247–252 Table 3 Clinical course


Table 5 Additional lesions to TEHPCF

Clinical course

No. of cases


Additional lesions to TEHPCF

No. of cases


Acute Subacute Chronic

59 4 2

90 6 3

Contusion Hydrocephalus Supratentorial EDH Diffuse cerebral edema Traumatic subarachnoidal hemorrhage Subdural hematomas Pneumocephalus

15 5 3 2 1 1 4

23 8 4 3 1 1 6

All hematomas were of traumatic origin. The causes included falls from height (27 cases), traffic accidents outside the vehicle (16 cases), traffic accidents inside the vehicle (10 cases), falls from the same altitude (9 cases), and bicycle accidents (3 cases) (Table 2). A total of 59 patients were considered to have acute TEHPCFs, 4 subacute lesions, and 2 chronic TEHPCFs (Table 3). On admission, a GCS score of 3 to 5 was documented in 2 patients, a score of 6 to 8 in 4, a score of 9 to 12 in 7, and a score of 13 to 15 in 52 patients (Table 4). 3.2. Radiological findings Skull radiographs and CT scans were obtained in all 65 patients, and in 62 (95%) of them, occipital fractures were detected. Diastatic fractures, occipital linear fractures, or both were most commonly encountered. In 4 patients, the TEHPCFs extended into the supratentorial region; in 1 case, the TEHPCF coexisted with a supratentorial subdural hematoma. Unilateral TEHPCFs were present in 58 patients (35 on the left and 23 on the right); bilateral hematomas were present in 7 patients (Table 5). 3.3. Associated lesions Among the lesions in association with TEHPCF, hemorrhagic contusion was encountered in 15 cases, hydrocephalus in 5, pneumocephalus in 4, acute supratentorial EDHs in 3, diffuse cerebral edema in 2, traumatic subarachnoid hemorrhage in 1, and acute subdural hematomas in 1 (Table 5). 3.4. Conservative management In 16 patients with small hematomas without mass effect, conservative treatment was planned. Four patients demonstrated TEHPCFs without any mass effect on the initial CT; however, the hematoma became larger in the first 24 hours, necessitating removal of the clot in these cases (Table 6). Admission GCS score in these 4 patients was 15, and none died. At discharge, the patients were free of deficits, and their GCS scores remained 15. All conservative cases were in

close clinical observation, and frequent (6th, 12th, 24th, 48th, 72nd hours after trauma, for the first 3 days) CT scanning was performed. In 12 of these 16 patients, no further increase in the size of the hematoma occurred, and the neurological status remained fully intact throughout, allowing the patients to be discharged approximately on the fourth uneventful day. Of the cases treated conservatively, 7 were in the pediatric and 5 in the adult age group. In this conservatively treated group, 2 patients had chronic hematomas, 4 patients had subacute hematomas, and 6 had acute TEHPCFs. All of the cases in this group were neurologically intact. In the conservatively treated group, CT showed a unilateral and thin hematoma without any mass effect. In the conservatively treated patients, a control CT scan was obtained after initial CT examination without waiting for any clinical deterioration. Two patients from the conservative group were taken to surgery after enlargement was determined on the 24th hour routine control CT scan. A CT was taken immediately after any observed clinical deterioration. In this way, 2 patients whose GCS was 15 during admission and which decreased to 13 were excluded from the conservative group and was operated on. Besides the decrease in the GCS, one of them started vomiting in the 4th hour, the other one had cerebellar signs in the 11th hour of trauma. The hospitalization was continued for at least 4 days until clinical and neuroradiological deterioration had been excluded. The patients were called for both clinical and radiological examination on the 30th day after the discharge. Spontaneous resolution of the hematoma was observed in all cases, and no patients in this group deteriorated. 3.5. Surgical management A total of 53 patients with hematoma causing mass effect were treated surgically even if the lesion was small. Two patients with acute TEHPCF died despite prompt evacuation Table 6 The patients with planned conservative treatment, with their hematomas becoming larger and requiring operative intervention

Table 4 Glasgow Coma Scale scores GCS Scores

No. of cases


3-5 6-8 9-12 13-15

1 4 7 53

2 6 10 81


Admission GCS

GCS after clinical deterioration

Time that enlargement of EDH is determined on CT

1 2 3 4

15 15 15 15

13 (vomiting) 13 (cerebellar signs) 15 15

4th hour 11th hour 24th hour (routine control) 24th hour (routine control)


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Table 7 Mortality chart Mortality



Additional characteristics Tranverse sinus rupture + supratentorial extension Diffuse cerebral edema + multitrauma + cardiorespiratory instability

Mort 1



Mort 2



of the clot and supportive intensive care treatment. The mortality rate was 3.8%. One of them had GCS 4, and the other one had GCS 7. Two of the patients who had GCS score 6 to 8 on admission were moderately disabled at their discharge from hospital. The other 8 patients in whom the GCS score was less than 13 on admission improved after surgery, making an excellent recovery without neurological deficit. Forty-one patients in whom the GCS score was 13 to 15 on admission and with large hematomas exerting mass effect underwent surgery, and their level of consciousness remained unchanged, without neurological deficit at discharge. Two patients with acute TEHPCF remained disabled after surgery. In both of these patients, we determined multiple intracranial contusions in their cranial CTs. 3.6. Mortality and morbidity A total of 53 patients were operated on for TEHPCF; 2 patients were lost as a result. The surgical mortality in our series was 3% (overall mortality). There was no mortality and morbidity in the conservatively treated patients. In the surgically treated group, 2 patients died (surgical mortality 3.8%), whereas 2 patients with a GCS score of 6 to 8 on admission improved after surgery but remained moderately disabled. These 2 patients had additional intracranial pathologies. One of them had diffuse cerebral edema, and the other had multiple intracranial contusions. The other 49 TEHPCF operated patients had excellent recovery without any neurological deficit. Two patients died in the series despite prompt surgical evacuation and supportive treatment (Table 7).

4. Discussion In the present series, as expected in groups with a lesion caused by trauma, our population was primarily composed of young male individuals, and the most common findings were occipital swelling, headache, vomiting, transient loss of consciousness, disturbance of consciousness, and cerebellar signs and symptoms. In the present series, we did not encounter any specific type of injury for TEHPCF, but occipital trauma and occipital bone fracture were almost always present. We observed occipital fracture in 62 of our cases, and this was an alerting sign for TEHPCF, which has also been mentioned in the literature. A high percentage of occipital trauma and fracture in patients with TEHPCF has been reported and considered as the most reliable indicator for the location of the hematoma [5,6,29]. Fisher et al [10]

reported that an occipital fracture in case of occipital trauma was an ominous sign and found 14 cases of posterior fossa hematomas in a group of 98 patients with occipital fracture. Early detection of the lesion is critical. In most acute TEHPCF cases, the signs and symptoms were mild and nonspecific. According to our series, CT scanning should be conducted immediately in cases of head injury, especially if there is occipital trauma or occipital fracture, because in most patients with TEHPCF, the GCS score was 15, and they were asymptomatic. An early diagnosis is mandatory for good recovery. We and some other authors have suggested that urgent CT scanning be conducted in all patients with fracture of underlying occipital bone with or without occipital soft tissue ecchymotic swelling [10,16]. A high level of clinical suspicion, a prolonged period of clinical and radiological observation, and application of the broadest criteria for indication of head CT scanning are the key points in managing this situation [2]. Deciding between conservative or surgical management is controversial [1,4,14,20,22,26]. Clear criteria for surgery are mandatory. We know that radiological findings always occur earlier than clinical changes, and they should be monitored to predict the clinical progression [2,4]. Computed tomography has aided prompt recognition and localization of TEHPCFs, the mass effect of hematoma, and associated intracranial lesions. We think that obliteration of perimesencephalic cisterns and compression of the fourth ventricle should be regarded as evidence of brainstem compression. Computed tomography findings have to be taken into consideration primarily in decision making. This could be a simple and effective way to evaluate mass effect and to determine the need for surgical evacuation. In our series, we did not observe mass effect in 12 patients; thus, surgical intervention was not required. Our protocol involves serial control CT scanning within the first 72 hours (6th, 12th, 24th, 48th, and 72nd hours of trauma). It plays a central role in this observation period because a slower course of the TEHPCF or a delayed hematoma may be possible [4,14,22,29]. After detecting the enlargement of the hematoma in 4 patients on control CT scans, operations were performed. Neurologically intact patients with a posterior fossa lesion and no CT evidence for mass effect (compression of cisterns, distortion of fourth ventricle, hydrocephalus) have been successfully managed nonoperatively with close observation and serial imaging [4,5,7,19,27,29]. It is important to define mortality and morbidity risk factors in patients with TEHPCF. In the previous studies, the risk factors were mentioned as pediatric age group, supratentorial extension of the hematoma, major sinus tear, cardiorespiratory instability, low admission coma score, and additional intracranial pathologies [5]. In our series, 2 patients died, and 2 patients were moderately disabled. The patients who died had cardiorespiratory instability and major sinus tear, and one was in the pediatric age group. The disabled patients had low admission GCS and

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additional intracranial pathologies. Our findings were consistent with the literature with the exception of the pediatric age group. In our series, the overall mortality rate is 3%. The mortality rate in the surgical group was 3.8%. This could be considered as a good result when compared with the other series in the literature [3-6,10,15,28-30]. The reported surgical mortality rate was 5% in the series of Bor-sengShu [2] and 6.7% in the series of Bozbuga [4]. We believe these discrepancies can be explained by 2 factors; first, our active CT scan usage protocol and consequent early diagnosis, the other factor being rapid surgical management after the detection of the mass effect on CT. In early diagnosis, early CT scanning is very important and should never be delayed. Control CT scanning is also critical for evaluating whether the hematoma is getting larger or not, especially within the first 24 hours. In our experience, we first open one burr hole in the occipital region, immediately evacuate the hematoma from this burr hole, then perform craniectomy. Bilateral or unilateral suboccipital craniectomy was the standard approach in the surgical group. All patients in the subacute or chronic groups experienced an excellent outcome compared with the poorer prognosis (higher morbidity and mortality rates) found in the acute group; this is comparable with reports in the literature [4]. 5. Conclusion Patients with occipital trauma should be evaluated immediately using cranial CT scans, and those having mass effect should be immediately treated surgically. Early diagnosis of TEHPCF and prompt surgical evacuation provide excellent recovery. On the other hand, patients with no mass effect on CT scans can be closely observed by consecutive control CT scans. New multicenter cooperative studies are required for defining clear surgical criteria and the risk factors of TEHPCF. References [1] Ammirati M, Tomita T. Posterior fossa epidural hematoma during childhood. Neurosurgery 1984;14(5):541 - 4. [2] Bor-Seng-Shu E, Aguiar PH, de Almeida R, Leme J. Epidural hematomas of the posterior cranial fossa. Neurosurg Focus 2004;15(2):16. [3] Bricolo AP, Pasut LM. Extradural hematoma: toward zero mortality. A prospective study. Neurosurgery 1984;14(1):8 - 12. [4] Bozbuga M, Izgi N, Polat G. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev 1999;22:34 - 40. [5] Bullock MR, Chesnut R, Ghajar J. Surgical Management of Traumatic Brain Injury Author Group: surgical management of posterior fossa mass lesions. Neurosurgery 2006;58(3 Suppl):47 - 55. [6] Ciurea AV, Nuteanu L, Simionescu N. Posterior fossa extradural hematomas in children: report of nine cases. Childs Nerv Syst 1993;9:224 - 8. [7] d’Avella D, Servadei F, Scerrati M. Traumatic intracerebellar hemorrhages: a clinico radiological analysis of 81 cases. Neurosurgery 2002;50:16 - 25.


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Commentary This article reports a large series of posterior fossa epidural hematomas. There is no randomized study in the literature. The experience of these authors is reasonable, and