Retroclival epidural haematoma: a diagnosis to suspect. Report of three cases and review of the literature

Pediatric retroclival hematomas

BACKGROUND

Traumatic retroclival hematomas (RCHs) are infrequent occurrences among the pediatric population. The existing body of research pertaining to these hematomas primarily consists of case reports or small case series, which do not provide adequate guidance for managing this condition.

OBJECTIVE

This study aims to present a report on four cases of RCHs. Additionally, we aim to conduct a systematic review to consolidate the existing literature on pediatric RCHs.

METHODS

The authors conducted a systematic review in accordance with the PRISMA and CARE guidelines. A multivariate logistic regression model was developed to evaluate the potential impact of various clinical variables on clinical outcomes. The study also documented four of our cases, one of which was a rare occurrence of spontaneous subdural RCH.

RESULTS

A total of 62 traumatic RCHs have been documented in the literature. We documented three cases of traumatic RCHs and one case of spontaneous RCH. A systematic analysis of 65 traumatic RCHs was performed. Of trauma cases, 64.6% demonstrated craniocervical junction instability with 83.3% ligamentous involvement. Thirty-five patients were males. 50.7% were aged between 5 and 9 years. Cranial nerve palsies occurred in 29 patients (27 had abducent palsy), 26 of which resolved within 6 months of trauma. 23.5% underwent surgery, and 76.5% were conservatively managed. Surgeries targeted hematomas, hydrocephalus, or craniocervical instability. Approaches to hematomas included transclival and far/extreme lateral suboccipital approaches. Clinical outcome was good in 75.4% and intermediate or poor in 24.6%. Logistic regression suggested an association between craniocervical junction injuries and poor or intermediate outcomes (OR 4.88, 95% CI (1.17, 27.19), p = 0.04).

CONCLUSION

Pediatric RCHs are mostly traumatic and extradural. Children between 5 and 9 years old are most vulnerable. Craniocervical junction injuries, mainly ligamentous, are common in RCHs and are associated with intermediate or poor outcomes. Cervical MRI could be important in cases of trauma to rule out ligamentous injuries of the craniocervical junction. The small size of RCHs should not exempt the careful assessment of craniocervical junction instability. Cranial nerve palsies are common and usually resolve within 6 months. Conservative treatment is typical unless brainstem compression, hydrocephalus, or craniocervical junction instability exists.

Retroclival epidural hematoma: A rare location of epidural hematoma, case report, and review of literature

Retroclival epidural hematoma in adults is uncommon. Although most cases are associated with craniocervical trauma, other mechanisms have been reported, such as coagulopathy, vascular lesions, and pituitary apoplexy. We report two adults diagnosed with retroclival epidural hematoma. One patient was an 89-year-old male with leukemia and thrombocytopenia who sustained a fall and developed a traumatic retroclival epidural hematoma with brainstem compression; surgery could not be performed due to his clinical condition and he died 5 days later. The other patient was a 78-year-old female with atrial fibrillation who developed a spontaneous retroclival epidural hematoma as a result of warfarin use; she was treated conservatively with anticoagulant reversal and methylprednisolone and was subsequently discharged without neurological deficit. Retroclival hematomas are primarily treated conservatively due to the difficulty of surgical approach. The bleeding mechanism and dural and venous anatomy of this region tend to limit hematoma expansion.