J Neurosurg 72:660-662, 1990
Clivus epidural hematoma Case report AKIHIRO KUROSU, M.D., KEIICHI AMANO, M.D., OSAMI Kuuo, M.D., HIROSHI HIMURO, M.D., TAKEKI NAGAO, M.D., NAOKI KOBAYASHI, M . D . , YOSHIO KAKINOKI, M.D., AND KOICHI KITAMURA, M.D.
Departments of Neurosurgery and Neuroradiology, Neurological Institute, Tokyo Women "s Medical College, Tokyo, Japan u- A rare case of epidural hematoma of the clivus is reported in an 11-year-old girl involved in a traffic accident which caused a severe hyperextension injury. Only one similar case has been reported in the literature. The mechanism for the formation of the hematoma of this region is discussed. KEY WORDS 9 clivus central cord s y n d r o m e
9 epidural h e m a t o m a
E
PIDURAL hematomas or subarachnoid hemorrhages in the posterior fossa can be diagnosed with the aid of computerized tomography (CT). However, this test can miss epidural hematomas that form on the clivus. This case confirms the diagnosis of an epidural hematoma on the clivus by magnetic resonance (MR) imaging. C a s e Report
This 11-year-old girl was hit by a motorcycle while walking across a street on January 27, 1986. The handlebar struck her lower jaw and she fell to the ground. When the ambulance arrived, she could not respond to verbal orders, her pupils were dilated, and she had very weak respiration. She was placed on an artificial respirator and brought to the emergency room of our hospital 30 minutes after the injury.
Examination. On admission, the patient's Glasgow Coma Scale (GCS) score was 7, the deep-tendon reflexes were hypoactive, and a positive Babinski reflex was present on both sides. A skin laceration and edema were found over the left lower jaw and neck. A subcutaneous hemorrhage over the chest and an open fracture of the left lower leg were present. There was gross blood in the urine. Because of poor spontaneous respiration, she was promptly intubated. No fracture or diastasis of sutures was found in an x-ray study of the head. A C T scan revealed a subarachnoid hemorrhage (Fig. 1), but 660
9 h y p e r e x t e n s i o n injury
9
there were no other abnormalities. In the x-ray study of the neck, the atlanto-odontoid distance was 5 m m and the cervical prevertebral soft-tissue shadow was widened. A chest x-ray revealed a shadow in the left medial lobe of the lung. Fractures of the fight tibia and fibula were also identified. Blood workup was normal except for slight anemia, and the patient was initially managed conservatively.
Course. As her consciousness level gradually improved, tetraparesis (more marked in the upper extremities) began to appear. Repeat CT demonstrated no remarkable intracranial hematomas but did show a questionable high-density area on the clivus. An acute central cord syndrome was suspected. Myelography performed on January 29 suggested the possibility of thin epidural hematoma extending from the lower cervical vertebrae to the upper thoracic vertebrae; however, good passage of the contrast medium was observed and there were no signs of spinal cord compression. Magnetic resonance imaging performed on January 30 revealed two foci of high-intensity areas on the TIweighted image (Fig. 2 left). One high-intensity area was located between the lower cervical vertebrae and the upper thoracic vertebrae and the other lay between the clivus and the nasopharynx. On January 31, a coronal CT scan was obtained which confirmed the presence of h e m a t o m a on the clivus (Fig. 3). A C T scan of the cranial base performed on February 7 revealed a J. Neurosurg. / Volume 72/April 1990
Clivus epidural hematoma
FIG. 1. Computerized tomography scans demonstrating a thin subarachnoid hemorrhage. These scans do not reveal the epidural hematoma over the clivus.
FIG. 2. Midsagittal Tl-weighted magnetic resonance (MR) images of the craniovertebral junction. Left: An MR image performed 3 days after trauma revealing high-intensity areas (HIA's) over the clivus (plain arrow) and nasopharynx (arrowhead), and between the lower cervical vertebrae and the upper thoracic vertebrae (crossed arrow). Center: An MR image obtained 17 days after trauma revealing that HIA's in the same area had become smaller. Right: No HIA's were demonstrated in the same areas when MR imaging was repeated 50 days after trauma.
slight widening of the spheno-occipital synchondrosis. An M R image obtained on February 13 showed that the hematomas in the same areas had become smaller, No hematomas were demonstrated in the same areas when MR imaging was repeated on March 22 (Fig. 2 center and right). Neurological symptoms began to improve during this period and only a slight monoparesis of the right upper extremity remained when the patient was transferred to the orthopedic ward for treatment of fractures o f the left tibia and fibula.
J. Neurosurg. / Volume 72/April 1990
Discussion Epidural hematomas in the posterior fossa are formed most often from bleeding of the transverse sinus or the torcula Herophili. 2,4,5,7 Although contrecoup injury rarely causes an epidural hematoma, this possible mechanism m a y result in a sinus injury due to traumatic detachment o f the dura mater from the occipital bone when the injury transiently deforms the occipital bone. L8,9 Epidural hematomas described in the litera-
661
A. Kurosu, et al. the injured dura mater due to fracture of the clivus or the skull base surrounding the clivus. One should not forget the possibility that head and neck injuries can cause epidural hematomas over the clivus, and careful observation is necessary. Lesions in the posterior fossa, including the clivus, cannot always be diagnosed easily on CT scans because of artifacts caused by the cranial bones. With M R imaging, the diagnosis has become much easier because it is not affected by bones. Although a CT scan may fail to make the diagnosis of an epidural h e m a t o m a of the clivus, M R imaging may be confirmatory. References
FlG. 3. Coronal computerized tomography scan demonstrating a thin epidural hematoma over the clivus (arrowheads).
ture are almost always located between the occipital bone and the corresponding dura mater. There is only one case, reported by Orrison, et al., 6 of an epidural hematoma of the clivus. In our case, the patient had a diastasis of the spheno-occipital synchondrosis, wider than usual for her age. 3 The possible cause of an epidural hematoma on the clivus includes bleeding from
662
1. Abe S, Furukawa K, Endo S, et al: [Acute epidural hematoma of the posterior fossa caused by forehead impact.] Neurol Surg 16:321-325, 1988 (Jpn) 2. Coleman CC, Thompson JL: Extradural hemorrhage hematomas. Surgery 10:985-990, 1941 3. Irwin GL: Roentgen determination of the time of closure of the spheno-occipital synchondrosis. Radiology 75: 450-453, 1960 4. Mathis JM, Sowers J J, Zelenik ME: Pathognomonic CT findings of posterior fossa epidural hematomas. Comput Radiol 8:395-401, 1984 5. McKenzie KG: Extradural hemorrhage. Br J Surg 26: 346-365, 1938 6. Orrison WW, Rogde S, Kinard RE, et al: Clivus epidural hematoma: a case report. Neurosurgery 18:194-196, 1986 7. Roda JM, Gimrnez D, Prrez-Higueras A, et al: Posterior fossa epidural hematomas: a review and synthesis. Surg Neurol 19:419-424, 1983 8. Shigemori M, Moriyama T, Eguchi G, et al: [Acute epidural hematoma of the posterior fossa caused by frontotemporal impact. Case report.] Neurol Med Chit 25: 489-492, 1985 (Jpn) 9. Wright RL: Traumatic hematomas of the posterior cranial fossa. 3 Nenrosurg 25:402-409, 1966 Manuscript received June 13, 1989. Accepted in final form September 29, 1989. Address reprint requests to: Akihiro Kurosu, M.D., Departments of Neurosurgery and Neuroradiology, Neurological Institute, Tokyo Women's Medical College, 8-1 Kawata-cho, Shinjuku-ku, Tokyo, Japan.
J. Neurosurg. / Volume 7 2 / A p r i l 1990
Clivus epidural hematoma Case report AKIHIRO KUROSU, M.D., KEIICHI AMANO, M.D., OSAMI Kuuo, M.D., HIROSHI HIMURO, M.D., TAKEKI NAGAO, M.D., NAOKI KOBAYASHI, M . D . , YOSHIO KAKINOKI, M.D., AND KOICHI KITAMURA, M.D.
Departments of Neurosurgery and Neuroradiology, Neurological Institute, Tokyo Women "s Medical College, Tokyo, Japan u- A rare case of epidural hematoma of the clivus is reported in an 11-year-old girl involved in a traffic accident which caused a severe hyperextension injury. Only one similar case has been reported in the literature. The mechanism for the formation of the hematoma of this region is discussed. KEY WORDS 9 clivus central cord s y n d r o m e
9 epidural h e m a t o m a
E
PIDURAL hematomas or subarachnoid hemorrhages in the posterior fossa can be diagnosed with the aid of computerized tomography (CT). However, this test can miss epidural hematomas that form on the clivus. This case confirms the diagnosis of an epidural hematoma on the clivus by magnetic resonance (MR) imaging. C a s e Report
This 11-year-old girl was hit by a motorcycle while walking across a street on January 27, 1986. The handlebar struck her lower jaw and she fell to the ground. When the ambulance arrived, she could not respond to verbal orders, her pupils were dilated, and she had very weak respiration. She was placed on an artificial respirator and brought to the emergency room of our hospital 30 minutes after the injury.
Examination. On admission, the patient's Glasgow Coma Scale (GCS) score was 7, the deep-tendon reflexes were hypoactive, and a positive Babinski reflex was present on both sides. A skin laceration and edema were found over the left lower jaw and neck. A subcutaneous hemorrhage over the chest and an open fracture of the left lower leg were present. There was gross blood in the urine. Because of poor spontaneous respiration, she was promptly intubated. No fracture or diastasis of sutures was found in an x-ray study of the head. A C T scan revealed a subarachnoid hemorrhage (Fig. 1), but 660
9 h y p e r e x t e n s i o n injury
9
there were no other abnormalities. In the x-ray study of the neck, the atlanto-odontoid distance was 5 m m and the cervical prevertebral soft-tissue shadow was widened. A chest x-ray revealed a shadow in the left medial lobe of the lung. Fractures of the fight tibia and fibula were also identified. Blood workup was normal except for slight anemia, and the patient was initially managed conservatively.
Course. As her consciousness level gradually improved, tetraparesis (more marked in the upper extremities) began to appear. Repeat CT demonstrated no remarkable intracranial hematomas but did show a questionable high-density area on the clivus. An acute central cord syndrome was suspected. Myelography performed on January 29 suggested the possibility of thin epidural hematoma extending from the lower cervical vertebrae to the upper thoracic vertebrae; however, good passage of the contrast medium was observed and there were no signs of spinal cord compression. Magnetic resonance imaging performed on January 30 revealed two foci of high-intensity areas on the TIweighted image (Fig. 2 left). One high-intensity area was located between the lower cervical vertebrae and the upper thoracic vertebrae and the other lay between the clivus and the nasopharynx. On January 31, a coronal CT scan was obtained which confirmed the presence of h e m a t o m a on the clivus (Fig. 3). A C T scan of the cranial base performed on February 7 revealed a J. Neurosurg. / Volume 72/April 1990
Clivus epidural hematoma
FIG. 1. Computerized tomography scans demonstrating a thin subarachnoid hemorrhage. These scans do not reveal the epidural hematoma over the clivus.
FIG. 2. Midsagittal Tl-weighted magnetic resonance (MR) images of the craniovertebral junction. Left: An MR image performed 3 days after trauma revealing high-intensity areas (HIA's) over the clivus (plain arrow) and nasopharynx (arrowhead), and between the lower cervical vertebrae and the upper thoracic vertebrae (crossed arrow). Center: An MR image obtained 17 days after trauma revealing that HIA's in the same area had become smaller. Right: No HIA's were demonstrated in the same areas when MR imaging was repeated 50 days after trauma.
slight widening of the spheno-occipital synchondrosis. An M R image obtained on February 13 showed that the hematomas in the same areas had become smaller, No hematomas were demonstrated in the same areas when MR imaging was repeated on March 22 (Fig. 2 center and right). Neurological symptoms began to improve during this period and only a slight monoparesis of the right upper extremity remained when the patient was transferred to the orthopedic ward for treatment of fractures o f the left tibia and fibula.
J. Neurosurg. / Volume 72/April 1990
Discussion Epidural hematomas in the posterior fossa are formed most often from bleeding of the transverse sinus or the torcula Herophili. 2,4,5,7 Although contrecoup injury rarely causes an epidural hematoma, this possible mechanism m a y result in a sinus injury due to traumatic detachment o f the dura mater from the occipital bone when the injury transiently deforms the occipital bone. L8,9 Epidural hematomas described in the litera-
661
A. Kurosu, et al. the injured dura mater due to fracture of the clivus or the skull base surrounding the clivus. One should not forget the possibility that head and neck injuries can cause epidural hematomas over the clivus, and careful observation is necessary. Lesions in the posterior fossa, including the clivus, cannot always be diagnosed easily on CT scans because of artifacts caused by the cranial bones. With M R imaging, the diagnosis has become much easier because it is not affected by bones. Although a CT scan may fail to make the diagnosis of an epidural h e m a t o m a of the clivus, M R imaging may be confirmatory. References
FlG. 3. Coronal computerized tomography scan demonstrating a thin epidural hematoma over the clivus (arrowheads).
ture are almost always located between the occipital bone and the corresponding dura mater. There is only one case, reported by Orrison, et al., 6 of an epidural hematoma of the clivus. In our case, the patient had a diastasis of the spheno-occipital synchondrosis, wider than usual for her age. 3 The possible cause of an epidural hematoma on the clivus includes bleeding from
662
1. Abe S, Furukawa K, Endo S, et al: [Acute epidural hematoma of the posterior fossa caused by forehead impact.] Neurol Surg 16:321-325, 1988 (Jpn) 2. Coleman CC, Thompson JL: Extradural hemorrhage hematomas. Surgery 10:985-990, 1941 3. Irwin GL: Roentgen determination of the time of closure of the spheno-occipital synchondrosis. Radiology 75: 450-453, 1960 4. Mathis JM, Sowers J J, Zelenik ME: Pathognomonic CT findings of posterior fossa epidural hematomas. Comput Radiol 8:395-401, 1984 5. McKenzie KG: Extradural hemorrhage. Br J Surg 26: 346-365, 1938 6. Orrison WW, Rogde S, Kinard RE, et al: Clivus epidural hematoma: a case report. Neurosurgery 18:194-196, 1986 7. Roda JM, Gimrnez D, Prrez-Higueras A, et al: Posterior fossa epidural hematomas: a review and synthesis. Surg Neurol 19:419-424, 1983 8. Shigemori M, Moriyama T, Eguchi G, et al: [Acute epidural hematoma of the posterior fossa caused by frontotemporal impact. Case report.] Neurol Med Chit 25: 489-492, 1985 (Jpn) 9. Wright RL: Traumatic hematomas of the posterior cranial fossa. 3 Nenrosurg 25:402-409, 1966 Manuscript received June 13, 1989. Accepted in final form September 29, 1989. Address reprint requests to: Akihiro Kurosu, M.D., Departments of Neurosurgery and Neuroradiology, Neurological Institute, Tokyo Women's Medical College, 8-1 Kawata-cho, Shinjuku-ku, Tokyo, Japan.
J. Neurosurg. / Volume 7 2 / A p r i l 1990
