Double lucid interval in patients with extradural hematoma of the posterior fossa

Traumatic epidural hematoma in children

The purpose of this study was to investigate the characteristics of childhood acute epidural hematoma and to report our experience in recent years. A series of 35 patients below the age of 15 years treated for acute epidural hematoma at our institution between June 1991 and December 2000 was analyzed in detail. Pediatric epidural hematoma presents both age-related and atypical features when compared with epidural hematoma in adults. In selected cases, prompt surgical evacuation of the hematoma results in an excellent outcome. Outcomes seem to be directly related to the patient's preoperative neurologic status and the presence of associated intracranial lesions.

Traumatic extradural haematomas in pediatric age group

A series of 75 children with traumatic extradural haematomas operated on at our Department between 1982 and 1988 were analysed in detail. The overall mortality rate was 17%. CT scan constituted a valuable tool for an early and correct diagnosis, and the mortality rate declined to 9% in the post-CT era. The outcome was found to be predominantly affected by the preoperative neurological status, by the duration of the time interval between onset of coma and surgical intervention, and mainly by the presence of associated brain lesions.

Subacute traumatic extradural haematomas of the posterior fossa: a clinicopathological entity of the 5- to 10-year-old child

The subacute form of posterior fossa extradural haematoma, which presents a few days after minor occipital trauma, is a distinct clinicopathological entity that occurs most commonly in the 5- to 10-year-old child. Five cases are presented and the literature is reviewed since the advent of computed tomography.

Nonsurgical treatment of posterior fossa epidural hematoma

The recommended treatment for posterior fossa epidural hematoma has been prompt surgical evacuation. We report 2 patients who were treated conservatively. Both patients were younger than 10 years of age and developed subacute symptoms and signs. Serial computed tomography demonstrated complete resolution of the hematomas and no development of hydrocephalus during nonsurgical treatment. They recovered well without any neurologic deficits. In order to evaluate an indicative factor for nonsurgical treatment in young children with posterior fossa epidural hematoma, we review both of our patients and 36 well-documented patients from the literature, all of whom were younger than 10 years of age. The results demonstrate that the development of hydrocephalus is a critical factor in clinical progression. Nonsurgical management can be applied in these circumstances until spontaneous resolution of the hematoma unless early signs of medullary compression appear acutely after head trauma or serial computed tomography demonstrates the development of hydrocephalus followed by medullary compression.

Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961

Twenty patients with an epidural haematoma of the posterior fossa (EPIPF) among a total number of 359 patients with an epidural haematoma are reported (5.6%). Nine patients obtained a good outcome, four patients had a moderate disability and seven patients died (mortality 35%). Mortality of the acute cases was 50%, of the subacute cases 20%. In general, the clinical features were uncertain. Sixteen cases showed an occipital skull fracture or diastasis of the lambdoid suture respectively. A total number of 127 cases with EPIPF from the literature since 1961 was studied. The mortality in the CT-diagnosed group ran to 21.7% and to 25.9% in the group without CT. None of the patients showing a subacute course died when the diagnosis was made by CT, in the group without CT, however, four patients out of 11 subacute cases died. Head injured patients with an occipital trauma should therefore undergo CT scanning to detect a surgically significant lesion before clinical deterioration occurs.

Extradural haematoma of the posterior fossa. Twelve years experiences with CT-scan

18 cases of an extradural haematoma of the posterior fossa (EDHPF) are presented and the clinical and radiological findings are demonstrated. The onset of symptoms was acute in 10 patients and subacute in the other 8 patients. The overall mortality was 22%, but only acute course patients died (40%). All subacute cases survived. The most important factors influencing mortality were the level of consciousness immediately before the operation and the presence of hydrocephalus prior to surgery. Other coexisting intracranial lesions had no influence on mortality but on the quality of survival. Compared with the literature there is a certain decrease in mortality in the subacute course patients since the introduction of computed tomography.

Chronic extradural hematomas of the posterior cranial fossa

During the past 6 years, seven patients with chronic extradural hematomas have been observed at these hospitals. All had a history of occipital injury. Occipital fracture was demonstrated in five cases (by skull x-ray in three cases, at operation in two). The diagnosis was obtained by computed tomography scan in six cases and by iodoventriculography in one. One patient had an associated cerebral lesion, namely, a contralateral temporoparietal contusion. The interval between injury and operation ranged from 27 to 13 days with a mean of 19 days. Only one patient was not operated on, because he was free from symptoms and the hematoma was small. The course was excellent in all seven cases.

Extradural hematoma of the posterior cranial fossa. Report of seven cases with survival

Extradural posttraumatic posterior fossa hematoma is a rare condition estimated to complicate about 0.3% of all craniocerebral injuries, and represents 4% to 12.9% of the entire group of extradural hematomas. Seven cases of posterior fossa extradural hematoma (PFEDH) are presented. There were four males and three females. One case occurred in an adult, the remaining six cases in patients 16 years of age or younger, two of whom were infants. In each case the hematoma resulted from a blow to the posterior part of the head. Each patient showed local evidence of trauma to the scalp, and a radiographic appearance of an occipital linear fracture crossing the path of the torcular Herophili or the transverse sinus. The clinical picture varied. Three patients suffered immediate transient unconsciousness. Three others suffered sudden respiratory arrest after a seemingly stable course of several hours in the hospital, but responded well to resuscitation maneuvers. Computerized tomography scans were obtained in three patients; in three others no specialized neurodiagnostic studies were feasible; in one patient, precise diagnostic documentation was achieved by Conray ventriculography. All seven patients were operated on and all survived. Two patients had associated surgical intracranial lesions: an underlying subdural hygroma of the posterior fossa in one, and a contralateral supratentorial temporal subdural hematoma in the other. Six patients have returned fully to their previous activities. One patient is steadily improving.

Extradural haematoma in children. Primary and secondary lucid intervals

Twenty-six cases of extradural haematoma in children were reviewed over a 10-year period. The incidence of extradural haematoma was 3.3/1000 patients admitted to hospital with head injuries. Of 26 patients, 23% had no skull fracture and, in a further 8%, the fracture was not radiographically detectable. Twenty-three per cent of patients showed papilloedema, and 50% exhibited a fixed dilated ipsilateral pupil. In 62% of patients, there was no initial loss of consciousness; in a further 19%, impairment of consciousness was brief or doubtful. The lucid interval lasted three hours or less in one-third of patients; 24 hours after injury, the level of consciousness had declined in 73% of patients. Of particular interest was the occurrence of a secondary lucid interval, definite and dramatic in 8% of patients, and definite, but slight, in a further 12%. All patients made a good recovery, except one, who died from massive pulmonary fat embolism.

Posterior fossa epidural hematomas: a review and synthesis

The authors report three patients with posterior fossa epidural hematomas and analyze 80 additional cases in the accessible literature. They occur in the younger age groups with a clear male predominance (3.6 to 1). The loss of consciousness at the time of impact and just before surgical intervention have both proved to be factors indicating a poor prognosis. The clinical symptoms and signs were classified in three general types: increased intracranial pressure, brainstem dysfunction, and cerebellar disturbances. A fracture of the occipital bone was seen in 84.2% of the patients. The source of bleeding often remained undetermined, although a tear of the dural sinuses was a most frequent finding. An associated intracranial lesion was found in 39.7% of the cases, this being another factor indicating a poor prognosis. The overall mortality was 26.5%, while the surgical mortality was only 11.5%. Excellent results were achieved in 65% of the cases.

Traumatic extradural haematomas in children: experience with 62 cases

Sixty-two children with traumatic extradural haematomas are considered According to the clinical history presented--often atypical--and to the grade of neurological impairment, patients have been divided into different clinical groups. Nearly 50% of patients sustained a minor injury, and 26% did not lose consciousness after trauma. Twenty-four per cent of patients did not show fractures on skull X-rays. Atypical location of the haematoma was noted in 22 cases, mainly in the anterior fossa (19 cases). Sixty patients were operated on, while two patients were conservatively treated, owing to the limited size of the haematomas and to the absence of neurological deficits. Associated brain lesions were discovered at surgery in 40% of cases. The overall mortality rate has been 17%, the operative mortality rate 14%. The morbidity rate has been 6%, with 3% of patients presenting severe disability. Morbidity and mortality have been shown to be affected by age--with better prognosis in patients under 10 years of age, by the clinical history presented, by the preoperative conditions, and, mainly, by the presence of associated brain lesions. As regards location, frontal haematomas have shown a better prognosis and a slower course than convexity haematomas. Finally, prognosis of extradural haematomas in children has improved to some extent in the last years with the advent of the CT scan, possibly due to speed and accuracy of diagnosis.

Epidural haematoma: pathophysiological significance of extravasation and arteriovenous shunting. An analysis of 35 patients

35 patients with epidural bleeding operated on at Rikshospitalet, Oslo, during the period 1965-1980 had preoperative angiography with visualization of the external carotid artery. Twenty-one patients had extravasation of contrast medium from meningeal arteries. Seventeen of the 21 had also shunting of contrast medium from meningeal arteries to meningeal or diploic veins, while 20 of the 21 also had bled from a ruptured meningeal artery at operation. It was further found that of 20 patients who deteriorated after trauma 18 had an epidural arteriovenous shunt or extravasation. Conversely, of 15 patients who improved after trauma 12 had no evidence of a shunt. The strong correlation between the clinical course and the occurrence of extravasation supports previous experimental and clinical data, indicating the epidural arteriovenous shunt to be a major factor in the pathophysiology and the outcome of epidural bleeding.

Traumatic posterior fossa haemorrhage in children

We report ten cases of post-traumatic posterior fossa haemorrhage occurring in children. All patients were studied by CT scan. Five had an intracerebellar haemorrhage, three a brain stem haemorrhage, and two an extradural haematoma. In four cases we have found the coexistence of supratentorial and infratentorial haemorrhagic lesions. The incidence of posterior fossa haemorrhage in children, the importance of linear occipital fracture, the clinical course, the conservative or surgical treatment, and the prognosis are discussed.