Pediatric Neurology 51 (2014) 854e855
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
A Christmas Shopping Complication: Traumatic Epidural Hematoma Leading to Cerebral Sinus Thrombosis Katherine E. Delaney BA a, Stephen F. Kralik MD b, Lindsay M. Guzek BS a, Meredith R. Golomb MD, MSc a, * a
Division of Pediatric Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana b Division of Pediatric Neuroradiology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
Patient Description A 3-year-old girl tried to climb out of a shopping cart to explore the Christmas sales. She fell approximately 2.5 feet, hit the back of her head, and began to cry. Overnight, she developed nausea and vomiting and was brought to the emergency department. She was irritable but was moving all extremities, with no headache or focal neurological deficits. Initial computed tomography scan revealed a right posterior fossa
epidural hematoma compressing the right transverse sinus. The sigmoid sinus, which was not compressed by the hematoma, demonstrated the abnormal computed tomography hyperdensity, lack of magnetic resonance imaging enhancement, and loss of signal on magnetic resonance imaging venography consistent with thrombosis (Fig 1). She was treated conservatively. She continued to reveal improvement in her impairments and her examination. Repeat imaging 4 days after admission revealed improvement with partial resolution of the
FIGURE 1. (A) Initial presentation axial noncontrast brain computed tomography demonstrated an acute epidural hemorrhage posterior to the right cerebellar hemisphere (white arrow). There was asymmetric hyperdensity (black arrow) in the location of the right sigmoid sinus suggestive of thrombosis. (B) Initial presentation magnetic resonance imaging (axial T1-weighted postcontrast image) demonstrated an epidural hematoma compressing the right transverse sinus and lack of enhancement of the right sigmoid sinus indicating thrombosis (black arrow). The authors have no conflicts of interest to report. This study did not receive external funding.
* Communications should be addressed to: Dr. Golomb; Division of Pediatric Neurology; Department of Neurology; Riley Hospital for Children at Indiana University Health; 705 Riley Hospital Dr. RI 1340; Indianapolis, IN 46202. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.08.016
K.E. Delaney et al. / Pediatric Neurology 51 (2014) 854e855
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FIGURE 2. (A) Initial presentation magnetic resonance imaging venography (MRV) demonstrated loss of signal in the right sigmoid sinus (white arrow) consistent with complete thrombosis of the sinus. (B) Two-month follow-up MRV image demonstrated complete resolution of sinus thrombosis.
thrombosis and improved blood flow. Follow-up magnetic resonance imaging and magnetic resonance imaging venography at 2 months revealed complete resolution of the thrombus (Fig 2).
Discussion
The mechanism by which closed head trauma causes a cerebral venous thrombosis is sometimes unclear. Proposed mechanisms include injury to endothelial lining, injured emissary veins, and compression of sinuses from intracranial edema.1 However, in this girl, the imaging suggested a probable mechanism. The patient had a posterior fossa hematoma directly compressing the right transverse sinus. That compression obstructed venous flow, which likely led to thrombus formation. Holidays are a festive time, but can present increased opportunities for accidents. This child
presented just before Christmas. Christmas is the holiday with the highest percentage of head injuries compared with injuries to other body parts. Falls occur on stairs, ramps, landings, and floors. Her head injury resulted from hitting her head on the ground in a shopping center. The patient was in the age group (less than 5 years old) most likely to have a Christmas-related injury.2 References 1. Dalgic A, Secer M, Ergungor F, Okay O, Akdag R, Ciliz D. Dural sinus thrombosis following head injury: report of two cases and review of the literature. Turk Neurosurg. 2008;18:70-77. 2. D’Ippolito A, Collins CL, Comstock RD. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2010;125:931-937.
Contents lists available at ScienceDirect
Pediatric Neurology journal homepage: www.elsevier.com/locate/pnu
Visual Diagnosis
A Christmas Shopping Complication: Traumatic Epidural Hematoma Leading to Cerebral Sinus Thrombosis Katherine E. Delaney BA a, Stephen F. Kralik MD b, Lindsay M. Guzek BS a, Meredith R. Golomb MD, MSc a, * a
Division of Pediatric Neurology, Department of Neurology, Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana b Division of Pediatric Neuroradiology, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, Indiana
Patient Description A 3-year-old girl tried to climb out of a shopping cart to explore the Christmas sales. She fell approximately 2.5 feet, hit the back of her head, and began to cry. Overnight, she developed nausea and vomiting and was brought to the emergency department. She was irritable but was moving all extremities, with no headache or focal neurological deficits. Initial computed tomography scan revealed a right posterior fossa
epidural hematoma compressing the right transverse sinus. The sigmoid sinus, which was not compressed by the hematoma, demonstrated the abnormal computed tomography hyperdensity, lack of magnetic resonance imaging enhancement, and loss of signal on magnetic resonance imaging venography consistent with thrombosis (Fig 1). She was treated conservatively. She continued to reveal improvement in her impairments and her examination. Repeat imaging 4 days after admission revealed improvement with partial resolution of the
FIGURE 1. (A) Initial presentation axial noncontrast brain computed tomography demonstrated an acute epidural hemorrhage posterior to the right cerebellar hemisphere (white arrow). There was asymmetric hyperdensity (black arrow) in the location of the right sigmoid sinus suggestive of thrombosis. (B) Initial presentation magnetic resonance imaging (axial T1-weighted postcontrast image) demonstrated an epidural hematoma compressing the right transverse sinus and lack of enhancement of the right sigmoid sinus indicating thrombosis (black arrow). The authors have no conflicts of interest to report. This study did not receive external funding.
* Communications should be addressed to: Dr. Golomb; Division of Pediatric Neurology; Department of Neurology; Riley Hospital for Children at Indiana University Health; 705 Riley Hospital Dr. RI 1340; Indianapolis, IN 46202. E-mail address: [email protected] 0887-8994/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.pediatrneurol.2014.08.016
K.E. Delaney et al. / Pediatric Neurology 51 (2014) 854e855
855
FIGURE 2. (A) Initial presentation magnetic resonance imaging venography (MRV) demonstrated loss of signal in the right sigmoid sinus (white arrow) consistent with complete thrombosis of the sinus. (B) Two-month follow-up MRV image demonstrated complete resolution of sinus thrombosis.
thrombosis and improved blood flow. Follow-up magnetic resonance imaging and magnetic resonance imaging venography at 2 months revealed complete resolution of the thrombus (Fig 2).
Discussion
The mechanism by which closed head trauma causes a cerebral venous thrombosis is sometimes unclear. Proposed mechanisms include injury to endothelial lining, injured emissary veins, and compression of sinuses from intracranial edema.1 However, in this girl, the imaging suggested a probable mechanism. The patient had a posterior fossa hematoma directly compressing the right transverse sinus. That compression obstructed venous flow, which likely led to thrombus formation. Holidays are a festive time, but can present increased opportunities for accidents. This child
presented just before Christmas. Christmas is the holiday with the highest percentage of head injuries compared with injuries to other body parts. Falls occur on stairs, ramps, landings, and floors. Her head injury resulted from hitting her head on the ground in a shopping center. The patient was in the age group (less than 5 years old) most likely to have a Christmas-related injury.2 References 1. Dalgic A, Secer M, Ergungor F, Okay O, Akdag R, Ciliz D. Dural sinus thrombosis following head injury: report of two cases and review of the literature. Turk Neurosurg. 2008;18:70-77. 2. D’Ippolito A, Collins CL, Comstock RD. Epidemiology of pediatric holiday-related injuries presenting to US emergency departments. Pediatrics. 2010;125:931-937.
