43
Traumatic posterior fossa extradural hematomas Rioano, C; M. Borzone. M. A ltomon te, T. Capuzzo Neurosu rgica l Clinie ofthe Univers ity ofGenova
Clinical Findi ngs Sum mary This series of 17 cc nsec utive patien ts wh o under-
Tra umatische Extrad urale Hä matome der Fossa cra nii pos terior 17 Fälle operierter Epidura lhä matome der hintere n Schädelgrube. trauma tischen Urs pru ngs , werden beschri eben . Die klinischen und neuror ad iologische n Befund e we rden dargelegt und diskuti er t. Die Bedeu tun g der Computertomographie für die genaue DiagnosesteIlung und dadurch bedin gte Senkung der Morbidität s- (13 % ) und Mort alitätsrate (12 %) wird durch die Autoren hervorgeh oben. Key-Word s Computed tomogra phie scanning - Extradura l hem atom a - Head injury- Posterior cra nial fossa Spac e-occupying lesion
we nt s urge ry in the Neuros ur gica l Clinie oft he Unive rs ity of Gcn oa from 1972 to 1986 because of'tra umatic PFEDII, eonsist of 11 male s and 6 femal es . ag e ran ging from 10 to 58 (mea n: 28 yea rs}. Nine patie nts we re less than twen ty years old. Thc others werc three in the third decade , one in the flfth deca de and four in the sixt h
(Table 1). In eac h patie nt , c1 inical a nd/ or ra diologica l evid encc ofa blow in the occipital regio n was prcsc nt. At physical exam ina tion altered conscious ness. localizing neu rological signs , intracrani al hypert cnsion and meni ngea l irr ita tion were found . These findings we rc ra ndo mly joi ned in all thc patlen ts (F a ble 1). At the time ofs urge ry six patients wer e alert. while thc level of conscious ness of the renrainder was ass essed aeeord ing to Fish gold -Mathis 0 9591 eoma scale as follows : I degre e eoma (7 eases l. II degree coma (3 cases). III degr ee coma (1 ca sel.
Neuroradiological Findi ngs All pati ent s had a plain skull Xvray. A fra ctu re in the occip ital regte n \vas found in 13 cases (8 1 %1. Hight verte bral a ngiography was perfo r med as the onlv neuro radio logica l pr ocedur e in two pa tie nts before CT sca n beca me ava ilable. With this procedure it ls poss ible to show a PPEDH in for m of a retrocerebella r avascula r area with a fotwa rd and down,va rd dis placcrncn t of arteries an d possible detach men t of vcn ous sinuses aw ay from calva rium. Cont ra st medium ext ravasation from men ingeal vessels. as reported by other authors (14. 22J. was never observed. CT sca n alone wa s performed in 13 pat ients. while in two cases both CT scan and verte bra l a ngiograp hy we ro ca rried out. Pre-operative CT scan was repeated two and thr ee times res pectively in two cases
Extrad ural hematomas (EIlHs) are the probab ly most common tr aumati c space-occupying lesions in th e posterior fossa, According to literatu re dat a (2.7 .2 5. 27) the incid en ce of th e Posteri or Fossa Extradural Hematoma (PFEDH) rang es from 1.2 % to 12 .9% of all extra dura l hematomas. PFEDHs and associated suprate ntorial lesions have been mor e easily identified since the introduction of th e CT scan. 17 consec utive cases of PFEDH and their clinical picture and tr eatment are discussed.
Neurochlrurgta 35 ( 992) 43-4 7 © Georg Th ieme Verlag Stuugart New York
Fig. 1 Gase 2: Right vertebral angiogra phy pertormec through brachial artery (venousphase, lateral view): avascufarareawithtorward displacement ofthe venous structures.
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17 cas es of operat ed Posterior Fossa Epidural Hem atomas (PFEDH) of tra umatic origin are reporte d. C1inical an d neuro radiological findings are pr esent ed and discussed . Authors emphasize the imp ortan ee of' C'I sean in determi nin g a more pr ecise diagnosis and the related imp rovement in the morhid ity (13 %) and mo rt ality (12 %) rates.
Rivano. C, M. Borzone. M. Altamonte. T. Capuzzo
Neurochiru rgia 35 (1992) Tab 1 CaseJage
sex/year
Neurclogical tindings
Skull fracture
Examinaticn
Associated lestons
on Clscanning
Interval between trauma and surgical
Clinical conditton between admission and surgery
Outcome
treatment l/ llyrs M/1972 2/1Oyrs M/1974 3/54yrs F/1979
Comal Horizontal nystagmus Coma JI Anisocoria R> L; lefthemiparesis: bilat.Babinski sign
+
Anglography
10 days
Unchanged
Good recovery
+
Angiography
Less than 24hrs
Unchanged
Good recovery
8 days
Unchanged
Good recovery
Cl scan
Coma I Slight right hemiparesis Alert
+
ct scan
Cema l
+
ct scan
Alert
+
Alert. headache. slightdivergentstrabismus, slight papilloedema
+
ct scan Angiography cr scan
8116yrs
Alert,
M/1982
headacheslightstlf neck Coma 11 stltt neck +
Cf scan Angiography Cf scan
Coma l
+
ct scan
1l/16yrs MI1983
Coma 11, left hemipa resis +
Cf scan
12/24yrs
Coma 111, decerebrate rigidity Comal
+ +
er scan er scan
Coma l
+
ct scan
Alert. headache Coma I, divergent strabismus Alert, headache, anisocoria L > R, stift neck
+
ct scan
4/16yrs M/1980 5/58yrs F/1981 6/16yrs F/1981 7/13yrs F/1981
9/15y rs
M/1982 1O/15yrs M/1983
M/1985 13/23yrs M/ 1985 l4/56yrs F/1986 15/56yrs MI1986 16/24yrs M/1986 17/48yrs F/1986
CT scan
l eft temporal contusion
Lett temporallacerocontusion
Less than 24hrs 4 days
Deterioration after 16hrs Good recovery (coma I, bilateral papilloedema) Unchanged Good recovery
14 days
Unchanged
Good recovery
9 days
Unchanged
Good recovery
23 days
Unchanged
Good recovery
Unchanged
Death
Left fronte-temporal Less than contusion 24hrs Left frontal and temp2 days orc-occrpitallacerocontusions righttemporallacero-contuston Less than 24hrs Bilateral Few hours
Ieft
CTscan
tceses No. 6 and 10) . CT scan demonst rated in all patien ts a lenticula r shaped area of h igh increased den s ity adiace nt to th e inne rtable of the posteri or fossa : dis loeation and/o r distorti on of th e fourth ventr icle was present in 10 cases. The sup ratento r ial vent ricles were foun d to have an incr eased vclu me in a single case only (ease No. 8); see Figs. 2. 6 .
Surgery a nd Resu lts All the pati ents ofthis series und erwent surgica! treatment. According to other num er ous aut hors (3. 7. 10, 18,26,28) th e patient s are group ed as follows: 9 acute cases (patients who underwent surgery within the first 24 hours: cases No. 2, 4, 9, 11,12 ,1 3,14 ,15 ,1 6); 6subac ute cases (patien ts who underwent surgery within the first ten days: cases No. 1, 3, 5, 7, 10, 17); 2 ch ronic cases (patienls who underwent surg ery after ten days: cases No. 6 and 8).
Deterioration after 48hrs Moderate (coma 11, anisocoria R> L, Vlleft disability crantel nerve palsy Unchanged Unchanged
Moderate disability Death
Few hours
Unchanged
Good recovery
Less than 24hrs Few hours
Unchanged
Good recovery
Unchanged
Good recovery
Few hours
Unchanged
Good recovery
2 days
Unchanged
Good recovery
A suboccipital cra niectomy un der gene ra l anesthes ia in pron e position was performed an d PFEDH was evacuated in eac h cas e. PFEDHs were encounte red in 11 cases on the right side and in the reamaining 5 on the left; in one case (No. 12) PFEDH was bilater al. A tear of the lateral sinus was found an d sutur ed in three cases (No. 5. 8 and IIl. ln ten cases (No. 2, 3, 4, 5, 7, 9, 10, 11, 15, 16) the cra niectomy was enlarged to th e supratentoria l region becaus e the hematom a , which was displacin g the lateral sinus forward s, was extending in an upwar d dir ection , as reported in Iiteratur e (7, 10,26). In eac h case the posterior fossa subdural space was investigated through a small dur al incision. Ther e were two post-operative death s. The first case (No. 12) died two hours after surgery becau se of a pneumomediasti num and A R.D.S., present (on pla in radi ograms) before intervention. The second one (case No. 9) und erwen t surgery 6 hr s afte r traum a . Eight hours
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44
Neurochirurgia 35 (1992)
Traumatte posterior Jossa extradural hematamas
45
Fig. 2a
Fig. 2b
later he was alert and obeyed orders . At the sixteenth postoperative hour , he suddenly went into a deep coma with decerebrat e rigidity and respiratory failure. An immediate CT scan control demonstrated a PFEDH controlateral to the previous one. During examination, respiratory arrest, generalized flaccidity and bilater al non responsive mydriasis occurred. The patient was no Ionger thought suitable for further surgery, and died five days after injur y. At discharge the patients were grouped according to the Glasgow Outcome scale: good recovery 13 cases, modera te disability 2 cases . Discussion
Accordingtoother authors(l , 5,6,9 , 10, 15, 19, 20, 21, 26, 28), CT scan has markedly improved our ability to det ect a PFEDH . In fact, in our ser ies, before the advent of the CT scan the incidence of PFEDHs was 1.4 % (2
Fig.2 c
Fig.3 Case 10: tA, B) InitialCl scan: normal featuresotthe posteriorfossa. (C, D) Cl scan contrcl pe rtormed 31 hou rs later: evident PFEDH in the right side.
Fig.3a
Fig.3b
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Fig.2 Case 7:Cl scanshows a lettPFEDH reachingthe occipital region (A, BI.SagittalCl scan reconstruction(C).
Rioano. c.. M. Borzone. M. Altan/ollte. 7: Cap uzzo
Neurochirurgia 35 (992)
Fig. 3d
Fig. 3c
Fig.4
Case 12:
cr scan showsa massivebilateral PFEDH extendingon the right side in the superiet cuts. Forward displacement of the tourth ve ntricle.
cases out of a total of 138 EDHs); after the CT sca n Introduction a higher inciden ce of 4 .8 % was found (15 ca ses out ofa tot a l of292 EDHs). As reporled by other a uthors (2, 14 ,25 ), PFEDHs a re more fre quent in th e first two de ca des of Iife: this fact can be expla ine d by the rich ness of dip loe and du ra l blood supply in infa nts (4, 25) and by the higherfre quency of the occipita l fract ures in childhood (1 1). The role of the ocei pita l injury in the developmenl of PFEDH is weil documented in Dur ser ies as we ll as in the other (1.7 . 10,24, 25,26 ,2 7, 28).
A PFEDH may occur som etime after trauma, giving rise to a sud den clinica l worse ning as shown in ca se No. 10 . The role of supraten torial associated lesions in afTecting the clinical picture of this patient wa s definitely demonstrated by the first Cl' scan, where no abno rmal posterior fossa features were evident. The wo rsen ing of the patient's clinical cou rse was duc to a PFEDH . as show n by a fur th er CT scan perfor med 48 hours aft er injury (Ta ble 1). In chronic cases witho ut life-threate ning signs, it may be useful over and above CT seanning to per-
The interval between posterior head trauma and the ineid ence of PFEDH is variab le. In case s No. 2, 9 , 12 , 14 and 16 th er e was probab ly a rapid ons et of development of PFEDH a fter hea d injury, as de monslrated by th e signs of a life threatening lesion. In only one of these cases (No. 9), CT scan showed a fronto temporal cerebral contusion which could afTect consci ousnes s soon after trauma.
form an angiographie study in order to obtain further diagnostie data. Indeed. eve n if not frequ ent. delayed posttraumatie hem atomas ean be cause d by intrac rania l aneurism lParkinson D. comment in Zuccarello et al., 19 81) . Coneomitant supratentorial lesic ns. frontal and/or temporal cerebral contusions, as reported in Iiteratu re (7, 10 , 23 . 24, 25 , 26 , 27, 28) were cons iste ntly
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46
N eurochiru rgia 35 (1992)
Trauma tte posterior fo ss a ex tradura l he ma tomas 11
Mortality (%)
Author Before Cl scan le Count and Apfelbach McKenzie Herren and Zeller Campbell et a1. Hooper Petit Dutaill iset at Fisher and Kim Wright After Cl scan Stoneet aL Zuccarello et aL
Garza-Mercado Roda et al. Ammirati andl omita Presentreport
1920 1938 1950 1953 1954 1956 1958 1966
8 3 2 5 7 6 8 6
0 0 0 4 4 2 7 4
100 % 100 % 100 % 20% 42.8 % 66.6 % 12.5 % 33.3 %
1979 1981 1983 1983 1984 1987
4 8 6 3 4 17
4 7 6 3 4 15
0% 12.5 % 0% 0% 0% 11.8 %
12 13
14
15 16
li
18
lq 20
observed in 4 pati ent s on CTsca n. Amongthese, case No. 10 presented multipl e and bilateral as sociated cere bral lesions. According to Zuccarello et al., 1981 , the se cerebral contusions can be due to a contracoup mechanism. In our series the mortality (12 %) and mor bid ity (13 %) correspond to th e widest one reported in literature after the advent of CT sca n (Tab!e 2).
21
22
23
24
The impr oved surgical outeome is dellnetly related to betterment of diagnosti c neuro radiologieal pro cedure following the introdu ction of CTscan. In our serie s immediate CT scanning in acute cas es or serial CT scans perform ed in sub acute or ehro nic cases allowed pati ent s to und ergo surgical trea tment almost alw ays before the appea ranee of lile-th reatening signs.
25
26 27
28
c..
E. B. Hendr ick. A. R. Hudson: Th e sig niflcance ofskull fra ctu res in ehildre n. Rad iology 101 (l 971 ) 151-155 Herren. R. Y.. W. E. Zeller: Extra d ural hematomas of the posterior fossa . Arch. Surg., Chicago 60 (1950) 953-956 Hocper. R. S.: Extradu ral he morrhages of posteri or fossa . Brit. J . Surg . 42 (19 54) 19- 26 Jamieson. K. G.: Angiographic demon stration of th e bleedlng point in a posterior fossa ext radu ral hematoma . J . Neurosu rg . 36 (1972) 644 - 64 5 Jamieson, K. G.. J. D. N. Yelland: Ext radu ra l hematomas. Report of 167 ca ses . J . Neurosurg . 29 (1968) 13- 23 Le Count. E. R.. C. W. Apfelb ach: Pathologie anatomy of traumatic fra ctures of cra nia l bones and concomitant braln injuries. J . Amer. Med. Ass . 74 (1920) 501-5 11 AJe Kenzie. K. G.: Extradural haem orrh age . Brit. J . Surg . 26 (938) 346-365 Meredith. 1. A1.: Extradura l h aemorrh age in the posterio r fossa. Diagn osis a nd t reatmont wit h areport of two surgically treated patients. Am. J . Surg. 102 (1961) 524-53 1 Merino De viltas ante. 1.. J. M. Taveras: Compute rized tomography (CT) in acute head t rau ma . AJ R 126 (1976) 765-778 Mort. K.. J. Handa. 11. Munem itsu. N. Hasnimoto, N. Kojima: Epidu ral hemato mas on the pos te rior fossa in ehildren. Ch ilds Bra in 10(1983) 130 - 140 Moseley./. F.. E. Zilkha: The role ofcomputeri zed ax ial tomography (EMI scan ningl in the dia gnosis an d rnanagernent of'cra n lo-ce re bra l trauma . J . Neu rc rad lol. 3 (976) 277-296 Perot. P.. R. Btluer. A. Wong: An arte rial posteri or fossa ext radural hematom a de monstrated by the vertebra l angi ography . Case report. J . Neurosurg. 26 (1967) 255-260 Petit Dutaillis, D.. G. Guiot, B. Pertuiset, Y. Le Besne rois: Reflexions sur les hematomes extradurau x de la fosse po sterl eu re d 'a pr es u ne se rie de 6 observations. Neu roch iru rg ie 2 (1956) 221- 222 Reigh. E. E.. T. 1. O'Connet: Extrad ur al hematoma ofthe posterlor fossa with conc om ita nt supratentorial su bdural hematoma . Report of a ease and re view of the literature. J . Neu rosurg. 19 (1962) 359 -364 Roda, G. M.• D. Gtmenez. A. Perez-Hiqueras. M. G. Blaz ouez. M. Perez-Aloarez: Posteri or fossa epidu ra l h em atomas. A review a nd synthes is. Surg. Neurol. 19 (1983) 419-424 Stone , J. L..I.. Shaffer. R. G. Ramsep. R. A. Moody: Epidu ra l hem a tomas of'the poste rior fossa . Surg . Neu ro l. 11 (1979) 419-424 wriatu. R. L.: Tra umatic h em a tomas of the posterior cranial fossa . J. Neurosurg. 25 (1966) 402 -409 Zuccarello. M.. K. Pardatsc her, G. C. Andrtott. D. L. Flore. R. kun coti, P. Cert etttni. Epidur a l h em a tom as ofthe posterior era nia l fossa . Neuro surgery 4 (1981) 434-437
Haruocd-Nash. D.
Referen ces Ammirati. M.• T. Tomita: Posterior fossa epidu ra l hemato ma d ur ing ch ildhood . Neurosu rgery 14 (1984) 541-544 2 Arkins. T. J.• 1. E Me t.ennan. K. R. Winston. R. D. S trand. Y. Suzuku: Acut e posterior fossa ep idu ra l hem atom as in children .Am. J. Dis . Ch ild 13 J 11 9 771690 - 692 3 Campbeil. E, R. D. withfieid. R. Greenwood: Extradu ra l he matomas ofposterio r fossa . An n. Surg. 138 (1953) 509-5 20 4 Cnoux. M ., F. Ortsott. 1. C. Peragot: Extradural hemato mas in chl ldren. Child Bra in 1 ( 975) 337-347 5 Cordobes, F.. R. D. Loöato. 1. J. Rioae et ul.: Observations on 82 patie nts wlth ext radu ra l hem a toma. Comparison of results befo re a nd afte r the adve nt of computerized tomography . J . Neu rosu rg . 54 119811179- 186 6 Dublin. A. B.. B. N. French, 1. AI. Rennick: Com puted tomog raphy in head trauma . Rad iology 122 (1977 ) 365-369 Fischer. R. G.. 1. K. Ktm: Com plications in posterior fossa due to occipital trauma. The ir ope rability. JAMA 167 (1958) 176-1 82 s Fishgold. 11. . P. Mtühis: Obnu bilations, comas et stu pe urs . Etude elec troe ncephalog raphlque s . EEG Clin. Neu rophisiel. Supp!. 11 (1959) 1-1 26 Y Prencn. B. N.. A. B. Dublin: The value of compute rized tom ography in th e men agemen t of 1 000 consecu tive head inj uries . Surg. Neuro!. 7 1197711 71 -183 1ll Garza -Mercado. /1.: Extra dural he mato ma of t he posterior cra nial fossa . Report of' seve n cases wit h su rvtval. J. Neurosurg. 59 (1983 ) 664-672 I
Prof Dr. C. Riouno Istituto dt Clinica Neu roch irurgica de li Univer sita Osp. San Marti no - Pad . 2 Viale Benedetto XV 16132 Genova/ltalia
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Tab .2
47
Traumatic posterior fossa extradural hematomas Rioano, C; M. Borzone. M. A ltomon te, T. Capuzzo Neurosu rgica l Clinie ofthe Univers ity ofGenova
Clinical Findi ngs Sum mary This series of 17 cc nsec utive patien ts wh o under-
Tra umatische Extrad urale Hä matome der Fossa cra nii pos terior 17 Fälle operierter Epidura lhä matome der hintere n Schädelgrube. trauma tischen Urs pru ngs , werden beschri eben . Die klinischen und neuror ad iologische n Befund e we rden dargelegt und diskuti er t. Die Bedeu tun g der Computertomographie für die genaue DiagnosesteIlung und dadurch bedin gte Senkung der Morbidität s- (13 % ) und Mort alitätsrate (12 %) wird durch die Autoren hervorgeh oben. Key-Word s Computed tomogra phie scanning - Extradura l hem atom a - Head injury- Posterior cra nial fossa Spac e-occupying lesion
we nt s urge ry in the Neuros ur gica l Clinie oft he Unive rs ity of Gcn oa from 1972 to 1986 because of'tra umatic PFEDII, eonsist of 11 male s and 6 femal es . ag e ran ging from 10 to 58 (mea n: 28 yea rs}. Nine patie nts we re less than twen ty years old. Thc others werc three in the third decade , one in the flfth deca de and four in the sixt h
(Table 1). In eac h patie nt , c1 inical a nd/ or ra diologica l evid encc ofa blow in the occipital regio n was prcsc nt. At physical exam ina tion altered conscious ness. localizing neu rological signs , intracrani al hypert cnsion and meni ngea l irr ita tion were found . These findings we rc ra ndo mly joi ned in all thc patlen ts (F a ble 1). At the time ofs urge ry six patients wer e alert. while thc level of conscious ness of the renrainder was ass essed aeeord ing to Fish gold -Mathis 0 9591 eoma scale as follows : I degre e eoma (7 eases l. II degree coma (3 cases). III degr ee coma (1 ca sel.
Neuroradiological Findi ngs All pati ent s had a plain skull Xvray. A fra ctu re in the occip ital regte n \vas found in 13 cases (8 1 %1. Hight verte bral a ngiography was perfo r med as the onlv neuro radio logica l pr ocedur e in two pa tie nts before CT sca n beca me ava ilable. With this procedure it ls poss ible to show a PPEDH in for m of a retrocerebella r avascula r area with a fotwa rd and down,va rd dis placcrncn t of arteries an d possible detach men t of vcn ous sinuses aw ay from calva rium. Cont ra st medium ext ravasation from men ingeal vessels. as reported by other authors (14. 22J. was never observed. CT sca n alone wa s performed in 13 pat ients. while in two cases both CT scan and verte bra l a ngiograp hy we ro ca rried out. Pre-operative CT scan was repeated two and thr ee times res pectively in two cases
Extrad ural hematomas (EIlHs) are the probab ly most common tr aumati c space-occupying lesions in th e posterior fossa, According to literatu re dat a (2.7 .2 5. 27) the incid en ce of th e Posteri or Fossa Extradural Hematoma (PFEDH) rang es from 1.2 % to 12 .9% of all extra dura l hematomas. PFEDHs and associated suprate ntorial lesions have been mor e easily identified since the introduction of th e CT scan. 17 consec utive cases of PFEDH and their clinical picture and tr eatment are discussed.
Neurochlrurgta 35 ( 992) 43-4 7 © Georg Th ieme Verlag Stuugart New York
Fig. 1 Gase 2: Right vertebral angiogra phy pertormec through brachial artery (venousphase, lateral view): avascufarareawithtorward displacement ofthe venous structures.
Downloaded by: University of Pennsylvania Libraries. Copyrighted material.
17 cas es of operat ed Posterior Fossa Epidural Hem atomas (PFEDH) of tra umatic origin are reporte d. C1inical an d neuro radiological findings are pr esent ed and discussed . Authors emphasize the imp ortan ee of' C'I sean in determi nin g a more pr ecise diagnosis and the related imp rovement in the morhid ity (13 %) and mo rt ality (12 %) rates.
Rivano. C, M. Borzone. M. Altamonte. T. Capuzzo
Neurochiru rgia 35 (1992) Tab 1 CaseJage
sex/year
Neurclogical tindings
Skull fracture
Examinaticn
Associated lestons
on Clscanning
Interval between trauma and surgical
Clinical conditton between admission and surgery
Outcome
treatment l/ llyrs M/1972 2/1Oyrs M/1974 3/54yrs F/1979
Comal Horizontal nystagmus Coma JI Anisocoria R> L; lefthemiparesis: bilat.Babinski sign
+
Anglography
10 days
Unchanged
Good recovery
+
Angiography
Less than 24hrs
Unchanged
Good recovery
8 days
Unchanged
Good recovery
Cl scan
Coma I Slight right hemiparesis Alert
+
ct scan
Cema l
+
ct scan
Alert
+
Alert. headache. slightdivergentstrabismus, slight papilloedema
+
ct scan Angiography cr scan
8116yrs
Alert,
M/1982
headacheslightstlf neck Coma 11 stltt neck +
Cf scan Angiography Cf scan
Coma l
+
ct scan
1l/16yrs MI1983
Coma 11, left hemipa resis +
Cf scan
12/24yrs
Coma 111, decerebrate rigidity Comal
+ +
er scan er scan
Coma l
+
ct scan
Alert. headache Coma I, divergent strabismus Alert, headache, anisocoria L > R, stift neck
+
ct scan
4/16yrs M/1980 5/58yrs F/1981 6/16yrs F/1981 7/13yrs F/1981
9/15y rs
M/1982 1O/15yrs M/1983
M/1985 13/23yrs M/ 1985 l4/56yrs F/1986 15/56yrs MI1986 16/24yrs M/1986 17/48yrs F/1986
CT scan
l eft temporal contusion
Lett temporallacerocontusion
Less than 24hrs 4 days
Deterioration after 16hrs Good recovery (coma I, bilateral papilloedema) Unchanged Good recovery
14 days
Unchanged
Good recovery
9 days
Unchanged
Good recovery
23 days
Unchanged
Good recovery
Unchanged
Death
Left fronte-temporal Less than contusion 24hrs Left frontal and temp2 days orc-occrpitallacerocontusions righttemporallacero-contuston Less than 24hrs Bilateral Few hours
Ieft
CTscan
tceses No. 6 and 10) . CT scan demonst rated in all patien ts a lenticula r shaped area of h igh increased den s ity adiace nt to th e inne rtable of the posteri or fossa : dis loeation and/o r distorti on of th e fourth ventr icle was present in 10 cases. The sup ratento r ial vent ricles were foun d to have an incr eased vclu me in a single case only (ease No. 8); see Figs. 2. 6 .
Surgery a nd Resu lts All the pati ents ofthis series und erwent surgica! treatment. According to other num er ous aut hors (3. 7. 10, 18,26,28) th e patient s are group ed as follows: 9 acute cases (patients who underwent surgery within the first 24 hours: cases No. 2, 4, 9, 11,12 ,1 3,14 ,15 ,1 6); 6subac ute cases (patien ts who underwent surgery within the first ten days: cases No. 1, 3, 5, 7, 10, 17); 2 ch ronic cases (patienls who underwent surg ery after ten days: cases No. 6 and 8).
Deterioration after 48hrs Moderate (coma 11, anisocoria R> L, Vlleft disability crantel nerve palsy Unchanged Unchanged
Moderate disability Death
Few hours
Unchanged
Good recovery
Less than 24hrs Few hours
Unchanged
Good recovery
Unchanged
Good recovery
Few hours
Unchanged
Good recovery
2 days
Unchanged
Good recovery
A suboccipital cra niectomy un der gene ra l anesthes ia in pron e position was performed an d PFEDH was evacuated in eac h cas e. PFEDHs were encounte red in 11 cases on the right side and in the reamaining 5 on the left; in one case (No. 12) PFEDH was bilater al. A tear of the lateral sinus was found an d sutur ed in three cases (No. 5. 8 and IIl. ln ten cases (No. 2, 3, 4, 5, 7, 9, 10, 11, 15, 16) the cra niectomy was enlarged to th e supratentoria l region becaus e the hematom a , which was displacin g the lateral sinus forward s, was extending in an upwar d dir ection , as reported in Iiteratur e (7, 10,26). In eac h case the posterior fossa subdural space was investigated through a small dur al incision. Ther e were two post-operative death s. The first case (No. 12) died two hours after surgery becau se of a pneumomediasti num and A R.D.S., present (on pla in radi ograms) before intervention. The second one (case No. 9) und erwen t surgery 6 hr s afte r traum a . Eight hours
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44
Neurochirurgia 35 (1992)
Traumatte posterior Jossa extradural hematamas
45
Fig. 2a
Fig. 2b
later he was alert and obeyed orders . At the sixteenth postoperative hour , he suddenly went into a deep coma with decerebrat e rigidity and respiratory failure. An immediate CT scan control demonstrated a PFEDH controlateral to the previous one. During examination, respiratory arrest, generalized flaccidity and bilater al non responsive mydriasis occurred. The patient was no Ionger thought suitable for further surgery, and died five days after injur y. At discharge the patients were grouped according to the Glasgow Outcome scale: good recovery 13 cases, modera te disability 2 cases . Discussion
Accordingtoother authors(l , 5,6,9 , 10, 15, 19, 20, 21, 26, 28), CT scan has markedly improved our ability to det ect a PFEDH . In fact, in our ser ies, before the advent of the CT scan the incidence of PFEDHs was 1.4 % (2
Fig.2 c
Fig.3 Case 10: tA, B) InitialCl scan: normal featuresotthe posteriorfossa. (C, D) Cl scan contrcl pe rtormed 31 hou rs later: evident PFEDH in the right side.
Fig.3a
Fig.3b
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Fig.2 Case 7:Cl scanshows a lettPFEDH reachingthe occipital region (A, BI.SagittalCl scan reconstruction(C).
Rioano. c.. M. Borzone. M. Altan/ollte. 7: Cap uzzo
Neurochirurgia 35 (992)
Fig. 3d
Fig. 3c
Fig.4
Case 12:
cr scan showsa massivebilateral PFEDH extendingon the right side in the superiet cuts. Forward displacement of the tourth ve ntricle.
cases out of a total of 138 EDHs); after the CT sca n Introduction a higher inciden ce of 4 .8 % was found (15 ca ses out ofa tot a l of292 EDHs). As reporled by other a uthors (2, 14 ,25 ), PFEDHs a re more fre quent in th e first two de ca des of Iife: this fact can be expla ine d by the rich ness of dip loe and du ra l blood supply in infa nts (4, 25) and by the higherfre quency of the occipita l fract ures in childhood (1 1). The role of the ocei pita l injury in the developmenl of PFEDH is weil documented in Dur ser ies as we ll as in the other (1.7 . 10,24, 25,26 ,2 7, 28).
A PFEDH may occur som etime after trauma, giving rise to a sud den clinica l worse ning as shown in ca se No. 10 . The role of supraten torial associated lesions in afTecting the clinical picture of this patient wa s definitely demonstrated by the first Cl' scan, where no abno rmal posterior fossa features were evident. The wo rsen ing of the patient's clinical cou rse was duc to a PFEDH . as show n by a fur th er CT scan perfor med 48 hours aft er injury (Ta ble 1). In chronic cases witho ut life-threate ning signs, it may be useful over and above CT seanning to per-
The interval between posterior head trauma and the ineid ence of PFEDH is variab le. In case s No. 2, 9 , 12 , 14 and 16 th er e was probab ly a rapid ons et of development of PFEDH a fter hea d injury, as de monslrated by th e signs of a life threatening lesion. In only one of these cases (No. 9), CT scan showed a fronto temporal cerebral contusion which could afTect consci ousnes s soon after trauma.
form an angiographie study in order to obtain further diagnostie data. Indeed. eve n if not frequ ent. delayed posttraumatie hem atomas ean be cause d by intrac rania l aneurism lParkinson D. comment in Zuccarello et al., 19 81) . Coneomitant supratentorial lesic ns. frontal and/or temporal cerebral contusions, as reported in Iiteratu re (7, 10 , 23 . 24, 25 , 26 , 27, 28) were cons iste ntly
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46
N eurochiru rgia 35 (1992)
Trauma tte posterior fo ss a ex tradura l he ma tomas 11
Mortality (%)
Author Before Cl scan le Count and Apfelbach McKenzie Herren and Zeller Campbell et a1. Hooper Petit Dutaill iset at Fisher and Kim Wright After Cl scan Stoneet aL Zuccarello et aL
Garza-Mercado Roda et al. Ammirati andl omita Presentreport
1920 1938 1950 1953 1954 1956 1958 1966
8 3 2 5 7 6 8 6
0 0 0 4 4 2 7 4
100 % 100 % 100 % 20% 42.8 % 66.6 % 12.5 % 33.3 %
1979 1981 1983 1983 1984 1987
4 8 6 3 4 17
4 7 6 3 4 15
0% 12.5 % 0% 0% 0% 11.8 %
12 13
14
15 16
li
18
lq 20
observed in 4 pati ent s on CTsca n. Amongthese, case No. 10 presented multipl e and bilateral as sociated cere bral lesions. According to Zuccarello et al., 1981 , the se cerebral contusions can be due to a contracoup mechanism. In our series the mortality (12 %) and mor bid ity (13 %) correspond to th e widest one reported in literature after the advent of CT sca n (Tab!e 2).
21
22
23
24
The impr oved surgical outeome is dellnetly related to betterment of diagnosti c neuro radiologieal pro cedure following the introdu ction of CTscan. In our serie s immediate CT scanning in acute cas es or serial CT scans perform ed in sub acute or ehro nic cases allowed pati ent s to und ergo surgical trea tment almost alw ays before the appea ranee of lile-th reatening signs.
25
26 27
28
c..
E. B. Hendr ick. A. R. Hudson: Th e sig niflcance ofskull fra ctu res in ehildre n. Rad iology 101 (l 971 ) 151-155 Herren. R. Y.. W. E. Zeller: Extra d ural hematomas of the posterior fossa . Arch. Surg., Chicago 60 (1950) 953-956 Hocper. R. S.: Extradu ral he morrhages of posteri or fossa . Brit. J . Surg . 42 (19 54) 19- 26 Jamieson. K. G.: Angiographic demon stration of th e bleedlng point in a posterior fossa ext radu ral hematoma . J . Neurosu rg . 36 (1972) 644 - 64 5 Jamieson, K. G.. J. D. N. Yelland: Ext radu ra l hematomas. Report of 167 ca ses . J . Neurosurg . 29 (1968) 13- 23 Le Count. E. R.. C. W. Apfelb ach: Pathologie anatomy of traumatic fra ctures of cra nia l bones and concomitant braln injuries. J . Amer. Med. Ass . 74 (1920) 501-5 11 AJe Kenzie. K. G.: Extradural haem orrh age . Brit. J . Surg . 26 (938) 346-365 Meredith. 1. A1.: Extradura l h aemorrh age in the posterio r fossa. Diagn osis a nd t reatmont wit h areport of two surgically treated patients. Am. J . Surg. 102 (1961) 524-53 1 Merino De viltas ante. 1.. J. M. Taveras: Compute rized tomography (CT) in acute head t rau ma . AJ R 126 (1976) 765-778 Mort. K.. J. Handa. 11. Munem itsu. N. Hasnimoto, N. Kojima: Epidu ral hemato mas on the pos te rior fossa in ehildren. Ch ilds Bra in 10(1983) 130 - 140 Moseley./. F.. E. Zilkha: The role ofcomputeri zed ax ial tomography (EMI scan ningl in the dia gnosis an d rnanagernent of'cra n lo-ce re bra l trauma . J . Neu rc rad lol. 3 (976) 277-296 Perot. P.. R. Btluer. A. Wong: An arte rial posteri or fossa ext radural hematom a de monstrated by the vertebra l angi ography . Case report. J . Neurosurg. 26 (1967) 255-260 Petit Dutaillis, D.. G. Guiot, B. Pertuiset, Y. Le Besne rois: Reflexions sur les hematomes extradurau x de la fosse po sterl eu re d 'a pr es u ne se rie de 6 observations. Neu roch iru rg ie 2 (1956) 221- 222 Reigh. E. E.. T. 1. O'Connet: Extrad ur al hematoma ofthe posterlor fossa with conc om ita nt supratentorial su bdural hematoma . Report of a ease and re view of the literature. J . Neu rosurg. 19 (1962) 359 -364 Roda, G. M.• D. Gtmenez. A. Perez-Hiqueras. M. G. Blaz ouez. M. Perez-Aloarez: Posteri or fossa epidu ra l h em atomas. A review a nd synthes is. Surg. Neurol. 19 (1983) 419-424 Stone , J. L..I.. Shaffer. R. G. Ramsep. R. A. Moody: Epidu ra l hem a tomas of'the poste rior fossa . Surg . Neu ro l. 11 (1979) 419-424 wriatu. R. L.: Tra umatic h em a tomas of the posterior cranial fossa . J. Neurosurg. 25 (1966) 402 -409 Zuccarello. M.. K. Pardatsc her, G. C. Andrtott. D. L. Flore. R. kun coti, P. Cert etttni. Epidur a l h em a tom as ofthe posterior era nia l fossa . Neuro surgery 4 (1981) 434-437
Haruocd-Nash. D.
Referen ces Ammirati. M.• T. Tomita: Posterior fossa epidu ra l hemato ma d ur ing ch ildhood . Neurosu rgery 14 (1984) 541-544 2 Arkins. T. J.• 1. E Me t.ennan. K. R. Winston. R. D. S trand. Y. Suzuku: Acut e posterior fossa ep idu ra l hem atom as in children .Am. J. Dis . Ch ild 13 J 11 9 771690 - 692 3 Campbeil. E, R. D. withfieid. R. Greenwood: Extradu ra l he matomas ofposterio r fossa . An n. Surg. 138 (1953) 509-5 20 4 Cnoux. M ., F. Ortsott. 1. C. Peragot: Extradural hemato mas in chl ldren. Child Bra in 1 ( 975) 337-347 5 Cordobes, F.. R. D. Loöato. 1. J. Rioae et ul.: Observations on 82 patie nts wlth ext radu ra l hem a toma. Comparison of results befo re a nd afte r the adve nt of computerized tomography . J . Neu rosu rg . 54 119811179- 186 6 Dublin. A. B.. B. N. French, 1. AI. Rennick: Com puted tomog raphy in head trauma . Rad iology 122 (1977 ) 365-369 Fischer. R. G.. 1. K. Ktm: Com plications in posterior fossa due to occipital trauma. The ir ope rability. JAMA 167 (1958) 176-1 82 s Fishgold. 11. . P. Mtühis: Obnu bilations, comas et stu pe urs . Etude elec troe ncephalog raphlque s . EEG Clin. Neu rophisiel. Supp!. 11 (1959) 1-1 26 Y Prencn. B. N.. A. B. Dublin: The value of compute rized tom ography in th e men agemen t of 1 000 consecu tive head inj uries . Surg. Neuro!. 7 1197711 71 -183 1ll Garza -Mercado. /1.: Extra dural he mato ma of t he posterior cra nial fossa . Report of' seve n cases wit h su rvtval. J. Neurosurg. 59 (1983 ) 664-672 I
Prof Dr. C. Riouno Istituto dt Clinica Neu roch irurgica de li Univer sita Osp. San Marti no - Pad . 2 Viale Benedetto XV 16132 Genova/ltalia
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Tab .2
47
