Traumatic epidural haematoma of the posterior fossa in childhood: 16 new cases and a review of the literature

A series of 16 children (nine males, seven females) with traumatic epidural haematoma of the posterior fossa (TEHPF) is presented. All patients had a history of mild to moderate trauma to the occiput. The causes were falls in 15 and traffic accident in one case. Four of the 16 cases had depressed fractures of the occipital bone. Surgical intervention was performed in all cases. In 14 patients the outcome was good, one patient had moderate disability and one died. Our study revealed that early diagnosis and urgent surgical intervention may give the patient a chance of total recovery and craniotomy with haematoma evacuation is an appropriate surgical technique as in the case of supratentorial extradural hematoma.     

Traumatic epidural haematoma of the posterior cranial fossa

A posterior fossa epidural haematoma (EDH) is uncommon and the diagnosis is difficult because the clinical symptoms are non-specific. Therefore, a computed tomography scan is important for the early diagnosis and management. Thirty-four patients with a posterior fossa EDH were admitted between 2001 and 2008. A retrospective analysis of the clinical and radiographic findings with regard to outcome and prognostic factors was carried out. The Glasgow Coma Scale (GCS) score on admission was recorded to be: one in 3-5, five in 6-8, six in 9-12 and 22 patients in 13-15. The admission GCS score was the most valuable prognostic factor. Among the 28 patients with a GCS score of more than 9, 27 patients survived with good results; for the six patients with a GCS score of less than eight, two patients had good recovery and four patients had unfavourable outcome. The 15 patients that were conservatively treated and 14 out of the 19 patients surgically treated had a good recovery. Among the other surgically treated patients, two were moderately disabled, two remained in a vegetative state and one died (overall mortality 2.9%). An occipital fracture was present in 28 cases. Six patients with a diastatic fracture of the lambdoid suture had a more complicated venous sinus injury requiring early surgery compared to those with a simple linear fracture. The patients admitted with associated intracranial injuries, such as a contrecoup injury including subdural haemorrhage or traumatic subarachnoid haemorrhage had a poor outcome. The initial GCS score on admission and the presence of associated intracranial injuries were important factors associated with the patient prognosis. A diastatic fracture of the lambdoid suture was associated with complicated venous sinus injuries making surgery more difficult.     

Traumatic epidural hematomas of the posterior cranial fossa

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.     

Traumatic acute subdural haematomas of the posterior fossa: clinicoradiological analysis of 24 patients

Background. We report 24 patients with a traumatic acute subdural haematoma of the posterior fossa managed between 1997 and 1999 at 8 Italian neurosurgical centres. Method. Each centre provided data about patients clinico-radiological findings, management, and outcomes, which were retrospectively reviewed. Findings. A poor result occurred in 14 patients (58.3%). Ten patients (41.7%) had favourable results. Patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (12/24 cases; GCS score, 8), the outcome was favourable in 75% of cases. In Group 2 (12/12 cases; GCS score, <8), the outcome was poor in 91.6% of cases. Nineteen patients underwent posterior fossa surgery. Factors correlating to outcome were GCS score, status of the basal cisterns and the fourth ventricle, and the presence of supratentorial hydrocephalus. Multivariate analysis showed significant independent prognostic effect only for GCS score (P<0.05). Interpretation. acute posterior fossa subdural haematomas can be divided into two distinct groups: those patients admitted in a comatose state and those with a moderate/mild head injury on admission. Comatose patients present usually with signs of posterior fossa mass effect and have a high percentage of bad outcomes. On the contrary, patients admitted with a GCS of 8 or higher are expected to recover. In these patients the thickness of the haematoma (<1cm) seems to be a guide to indicate surgical evacuation of the haematoma.     

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

Summary Background. The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Method. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). Findings. The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diplo? (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 ± 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4–5) and 8 (26.7%) had poor results (GOS 1–3). Conclusions. Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.     

Interhemispheric subdural haematomas: seven cases and review of the literature

Interhemispheric subdural haematoma (ISH) is a rare complication of head injury with only 19 cases reported since 1940, but it may also occur spontaneously (three cases). In both circumstances, clotting disorders are frequent (six cases). We have recorded seven cases (five traumatic, two spontaneous). Classically ISH is due to tearing of bridging veins or cortical contusions. In one of our cases, it was due to arterial bleeding from a pericallosal branch. CT scan shows that ISH may extend above the tentorium and on the hemispheric convexity. Mortality is high (35%). The best operative procedure is parasagittal craniotomy. Chronic interhemispheric subdural haematomas also occur.     

Extradural haematoma of the posterior fossa: A report of eight cases and a review of the literature

Summary The authors review the literature and present 8 cases of extradural haematoma of the posterior fossa operated from 1979 to 1985 at the Neurosurgical Clinic of the University of Pavia.Emphasis is placed on the importance of an early diagnosis of the symptoms which are often ignored due to the absence of specific clinical signs.The authors recognize a substantial improvement in results because of the recent introduction of CT scanning facilities which permit an early and precise diagnosis of this traumatic pathology.     

Bilateral posterior fossa epidural hematoma--report of two cases.

Two cases of posttraumatic bilateral posterior fossa epidural hematoma are presented. Such hematomas are extremely rare, but can be surgically cured. Computed tomography helps to establish the diagnosis and determine the neurosurgical treatment.     

Meningeal melanocytoma of the posterior fossa: case report and literature review

BACKGROUND: Meningeal melanocytomas are rare primary melanotic tumors of the leptomeninges. According to our review of the literature, just 22 cases of meningeal melanocytoma (MM) of the posterior fossa have been previously reported. Some aspects related to diagnosis, radiological appearance, histopathologic features, and management are discussed in this paper. CASE DESCRIPTION: We describe the case of a 42-year-old female presenting with severe headache, nausea, and vomiting. Computed tomography and magnetic resonance imaging demonstrated a posterior fossa lesion that was surgically treated. Histopathologic examination showed a highly cellular melanocytic neoplasm with numerous dark pigments in the cytoplasm. Immunoperoxidase staining S-100 protein and HMB 45 demonstrated immunoreactivity for both, confirming the diagnosis of MM. CONCLUSIONS: In conclusion, MMs are rare histologically benign tumors that can be cured by complete surgical resection alone, which should be the goal of the treatment. These lesions, although rare, should be considered in the differential diagnosis of tumors of the posterior fossa.     

Traumatic rupture of the tibialis posterior tendon after ankle fracture: three cases and a review of the literature

We report three cases of complete traumatic tibialis posterior tendon rupture which occurred after ankle fracture. Diagnosis was established at surgery. Repair of the non-degenerative tendon was achieved during the procedure for osteosynthesis of the malleolar fracture. Fractures healed a few months after surgery. The posterior tibialis muscle tendon functioned plantar arch was normal, except in one patient with multiple injuries who died in intensive care thirteen days after the accident. Although exceptional, injury of the tibialis posterior tendon should not be overlooked after ankle fracture. These injuries become apparent only at surgery for the malleolar fracture since pain hinders clinical examination. Primary suture best guarantees a good functional outcome. Residual pain, deficit in active inversion of the foot, modified medial longitudinal arch, or progression to planovalgus are retrospective diagnostic signs.     

Traumatic clivus epidural hematoma: case report and review of the literature

BACKGROUND: Traumatic clival epidural hematoma is an extremely rare reported entity. CASE DESCRIPTION: We describe the case of a 26-year-old woman involved in a car accident who presented with a Glasgow Coma Scale score of 13, bilateral abducens palsy, bilateral numbness on the mandibular territory of the trigeminal nerve, and left hypoglossal palsy. Radiological examinations revealed a clival epidural hematoma. The patient was managed conservatively, with clinical improvement of her neurological condition. This is the first traumatic clival epidural hematoma reported in an adult. From a review of the literature, we found only 8 cases. CONCLUSION: The pathophysiology of these hematomas is still a subject of debate; occipitoatlantoaxial ligamentous instability may play a role in it. In one third of the cases, bilateral cranial nerve palsies were associated. Apparently, they have a benign outcome.     

Traumatic abdominal wall hernia--four cases and a review of the literature

OBJECTIVE: To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. METHOD: Retrospective review of blunt abdominal trauma cases over a 6-month period. RESULTS: Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery. CONCLUSION: This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.     

Torticollis secondary to posterior fossa and cervical spinal cord tumors: report of five cases and literature review

Torticollis is either congenital or acquired in childhood. Acquired torticollis is not a diagnosis but rather a sign of an underlying disorder. The causes of acquired torticollis include ligamentous, muscular, osseous, ocular, psychiatric, and neurologic disorders and may be a symptom of significant abnormalities of the spinal cord and brain, such as spinal syrinx or central nervous system neoplasia. Torticollis is rarely considered to be an initial clinical presentation of posterior fossa and cervical spinal cord tumors. We report five cases of pediatric tumors with torticollis at the onset: an astrocytoma originating from the medulla oblongata, another presumptive astrocytoma of the spinal cord located between C1 and C6 cervical vertebrae (not operated), an ependymoma located throughout the whole cervical spinal cord extending into the bulbomedullary junction, an astrocytoma originating from the bulbus and extending into the posterior fossa, and another case of a eosinophilic granuloma located extradurally through the anterior and posterior portions of the vertebral bodies from C3 to C7 producing the collapse of the sixth cervical vertebra. All five cases were seen in children, aged between 3 and 12 years. All these cases reflect the misinterpretation of this neurological sign and the lack of association with the possibility of spinal or posterior fossa tumor. This delay in the diagnosis of these diseases led to progressive neurological deterioration and to the increase in the tumor size, which made surgical intervention difficult and the prognosis unfavorable. Although torticollis secondary to tumors is rarely seen, it is necessary to be kept in mind in the differential diagnosis.     

Sequestrated lumbar intervertebral disc in the posterior epidural space: a report on two cases and review of the literature.

BACKGROUND: Posterior epidural migration is an interesting but rare path taken by a prolapsed intervertebral disc fragment. There are only seven cases reported of a similar migration of the disc fragment in the lumbar spine. PURPOSE: To diagnose the unusual presentation and interpretation of the sequestrated disc in the posterior epidural space. STUDY DESIGN: Case report. METHODS: Two cases of migration of the sequestrated disc into the posterior epidural space are presented. In one patient there was weakness of the ankle dorsiflexors, foot invertors, and toe extensors of the left foot, with sensory loss over the back of the calf and over the lateral three toes. The left ankle jerk was also absent. However, in the other case, there was no objective evidence of neurological deficit distally. RESULTS: Gadolinium magnetic resonance imaging scans showed ring enhancement preoperatively. Biopsy of the specimen taken from surgery confirmed it to be sequestrated disc fragment. CONCLUSION: Diagnosis of posterior epidural migration of the sequestrated discs may be difficult. It may present with subtle clinical features even though the disc transgresses through numerous anatomic restraints including the nerve roots in such cases.     

The CT criteria for conservative treatment — but under close clinical observation — of posterior fossa epidural haematomas

Summary In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than 10 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30 ml in the latter. That means a PFEDH of 10 ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision     

Traumatic lumbosacral dislocation: four cases and review of literature

Diagnosis, physiopathology, and treatments of four patients with traumatic lumbosacral dislocations are described. This is a rare but severe lesion of the lumbosacral junction that usually occurs in patients with multiple trauma. It often is not thought of and the diagnosis may be missed. Evidence of lumbosacral dislocation should be examined and confirmed by computed tomography scans in patients with multiple fractures of transverse lumbar processes, asymmetric lumbosacral joints on frontal images, or slipping of L5 over S1 on lateral images. Treatment consists of reduction of the dislocated and fractured parts, lumbosacral arthrodesis, a posterolateral graft, and posterior instrumentation. Instrumentation may be short, extending from L5 to S1, or long, from L4 to S1, depending on the extension of the lesion. In some cases, reduction can be done intraoperatively, when the L4-S1 instrumentation is inserted, provided L5 transpedicle screws are pulled posteriorly. It usually is preferable to explore the vertebral canal to ensure that there is no disc lesion compressing the dura before proceeding with reduction. Compression of the dura could be avoided with a preoperative magnetic resonance imaging scan on which a lesion of the L5-S1 disc is sought. Additional interbody vertebral arthrodesis should be considered when the L5-S1 disc is affected severely. This lesion should be looked for preoperatively with a magnetic resonance imaging scan and intraoperatively by exploring the canal. This can be done at the time of the posterior surgery or during a second anterior surgical procedure.