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

Prevalence, morphology, morphometry and associated clinical implications of mastoid emissary veins: narrative review

The mastoid emissary vein connects the posterior auricular vein to the sigmoid sinus and varies in size, number, location, and course, resulting in clinical complications. This study was conducted in response to the vast clinical implications associated with this vein. The aim of this review is to highlight and describe the prevalence, varied morphology, and morphometry of the mastoid emissary vein, how these varied parameters cause clinical complications, and how these can be rectified and avoided. A literature survey was conducted using various databases and different terms related to mastoid emissary vein were used to search the literature. Pitfalls related to surgery in the vicinity of this vein and their remedies were elucidated. The literature search revealed that the prevalence, morphology, and morphometry of mastoid emissary veins vary immensely and are responsible for morbidity and mortality. Pre-operative identification of mastoid veins is thus essential and so multidetector computed tomography of the temporal bone should be scheduled before planning surgery.

Abdelkarim A, Syed AZ, Orhan K. Morphometric and morphological evaluation of mastoid emissary canal using cone-beam computed tomography

OBJECTIVES

This study aimed to determine mastoid emissary canal's (MEC) and mastoid foramen (MF) prevalence and morphometric characteristics on cone-beam computed tomography (CBCT) images to underline its clinical significance and discuss its surgical consequences.

METHODS

In the retrospective analysis, two oral and maxillofacial radiologists analyzed the CBCT images of 135 patients (270 sides). The biggest MF and MEC were measured in the images evaluated in MultiPlanar Reconstruction (MPR) views. The MF and MEC mean diameters were calculated. The mastoid foramina number was recorded. The prevalence of MF was studied according to gender and side of the patient.

RESULTS

The overall prevalence of MEC and MF was 119 (88.1%). The prevalence of MEC and MF is 55.5% in females and 44.5% in males. MEC and MF were identified as bilateral in 80 patients (67.20%) and unilateral in 39 patients (32.80%). The mean diameter of MF was 2.4 ± 0.9 mm. The mean height of MF was 2.3 ± 0.9. The mean diameter of the MEC was 2.1 ± 0.8, and the mean height of the MEC was 2.1 ± 0.8. There is a statistical difference between the genders (p = 0.043) in foramen diameter. Males had a significantly larger mean diameter of MF in comparison to females.

CONCLUSION

MEC and MF must be evaluated thoroughly if the surgery is contemplated. Radiologists and surgeons should be aware of mastoid emissary canal morphology, variations, clinical relevance, and surgical consequences while operating in the suboccipital and mastoid areas to avoid unexpected and catastrophic complications. CBCT may be a reliable imaging diagnostic technique.

Two pediatric cases of epidural hematoma in the posterior fossa with extension along the sigmoid sinus groove: MR evaluation

To discuss the computed tomography (CT) and magnetic resonance (MR) findings of posterior fossa epidural hematoma (PFEDH) mimicking sinus thrombosis, we present two pediatric cases with the PFEDH extending along the sigmoid sinus groove evaluated by MR imaging (MRI) and MR venography (MRV). T2-weighted coronal MRI can diagnose both patency of the sigmoid sinus and epidural hematoma extending along the sinus groove. Phase-contrast MRV (PC-MRV) is also useful to evaluate the flow state in the dural sinuses but it should be diagnosed carefully whether low visualization of the dural sinus means only functional flow impairment or organized occlusion due to thrombus. To avoid an unnecessary anticoagulant therapy that may worsen epidural hematoma, it is important to recognize the pitfall that PFEDH extending along the sinus groove is easy to misdiagnose for a dural sinus thrombosis.

A review of extraaxial developmental venous anomalies of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, venous varices or aneurysmal malformations, and enlarged emissary veins

This paper is a narrative review of extraaxial developmental venous anomalies (eDVAs) of the brain involving dural venous flow or sinuses: persistent embryonic sinuses, sinus pericranii, enlarged emissary veins, and venous varices or aneurysmal malformations. The article highlights the natural history, anatomy, embryology, imaging, clinical implications, and neurosurgical significance of these lesions, which the authors believe represent a continuum, with different entities characterized by distinct embryopathologic features. The indications and surgical management options are discussed for these individual intracranial pathologies with relevant illustrations, and a novel classification is proposed for persistent falcine sinus (PFS). The role of neurointervention and/or microsurgery in specific cases such as sinus pericranii and enlarged emissary veins of the skull is highlighted. A better understanding of the pathophysiology and developmental anatomy of these lesions can reduce treatment morbidity and mortality. Some patients, including those with vein of Galen malformations (VOGMs), can present with the added systemic morbidity of a high-output cardiac failure. Although VOGM is the most studied and classified of the above-mentioned eDVAs, the authors believe that grouping the former with the other venous anomalies/abnormalities listed above would enable the clinician to convey the exact morphophysiological configuration of these lesions, predict their natural history with respect to evolving venous hypertension or stroke, and extrapolate invaluable insights from VOGM treatment to the treatment of other eDVAs. In recent years, many of these symptomatic venous malformations have been treated with endovascular interventions, although these techniques are still being refined. The authors highlight the broad concept of eDVAs and hope that this work will serve as a basis for future studies investigating the role of evolving focal venous hypertension/global intracranial hypertension and possibilities of fetal surgical intervention in these cases.

Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature

OBJECTIVE

Epidural haematoma (EDH) most commonly occurs in the supratentorial area, particularly in the temporal region, of the brain. Posterior fossa epidural haematoma (PFEDH) is less frequently observed, accounting for only 1.2% to 12.9% of all EDH cases. Because of the non-specific symptoms and the potential for rapid and fatal deterioration in children, an early computed tomography (CT) scanning is necessary for all suspicious cases. The aim of the present study was to share the experience of 48 cases and review the literature concerning PFEDH.

METHODS

A retrospective analysis was conducted for 48 paediatric cases diagnosed with PFEDH and admitted to Yuying Children's Hospital of Wenzhou Medical University from January 2010 to August 2015. The clinical features and outcomes were analyzed and compared with previous literature.

RESULTS

Seventeen patients were surgically treated in this series and 31 patients received non-operative treatment. The outcomes were good in 46 patients, evaluated using the Glasgow outcome score (GOS), while mild disability was observed in one patient, and only one case showed severe disability. There were no cases of mortality in this series.

CONCLUSION

Posterior fossa epidural haematoma is relatively rare compared with supratentorial epidural haematoma. Early and serial CT scans should be performed for all suspicious cases. The criteria for the surgical treatment of paediatric patients with PFEDH were concluded. The overall prognosis was excellent in paediatric patients.

Unusual, Acute, and Delayed Traumatic Torcular Herophili Epidural Hematoma Causing Malignant Encephalocele During Surgery: A Case Report

Patient: Male, 40

Final Diagnosis: Traumatic torcular herophili unusual acute and delayed epidural hematoma

Symptoms: Coma

Medication: —

Clinical Procedure: Craniotomy

Specialty: Neurosurgery

Traumatic Posterior Fossa Extradural Hematoma: Experience at Level I Trauma Center

INTRODUCTION

Posterior fossa extradural hematoma (PFEDH) is rare among the traumatic brain injury and represent about 4-7% cases of all EDHs. This rare condition is rapidly fatal unless identified and intervened timely. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome.

MATERIALS AND METHODS

This study was conducted at Level I trauma center at All India Institute of Medical Sciences, New Delhi, India. Hospital medical records were reviewed from September 2007 to June 2015. There were 856 cases of acute EDHs and of these 69 cases had PFEDHs. Records of patients with PFEDHs were reviewed for the mode of injury, Glasgow Coma Scale (GCS) at admission, imaging, type of intervention, outcome, and follow-up. GCS was assessed at 6 months and 12 months follow-up. Pertinent literature is reviewed.

RESULTS

Of these 69 patients, 51 were males and 18 females. The mean age of patients was 28.6 years (range 4-43 years). Forty-three patients had GCS 15 at admission, and only 4 of them had admission GCS <8. Mean EDH volume was 29.2 ml. Sixty-six patients were operated, three managed conservatively. Sixty-seven patients were discharged, of which, 56 (81.1%) had GCS 15. Two patients died. Most common associated injuries were long bone fractures (18, 26.1%) followed by blunt injury thorax (11, 15.9%). Mean follow-up duration was 69.2 months (range 6-94 months). At 6 months follow-up, 61 (88.4%) patients had good recovery (Glasgow Outcome Score [GOS] 5) and at 12 months, 62 (89.8%) had GOS 5.

CONCLUSION

PFEDH are rare. They are usually associated with occipital bone fractures and may also have a supratentorial hematoma. It may be rapidly fatal due to the expansion of hematoma and compromise of the posterior cranial fossa space leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early diagnosis and emergent evacuation lead to good outcome.

Prevalence of Petrosquamosal Sinus and Its Clinical Significance: Radiologic Study and Meta-analysis

OBJECTIVE

The petrosquamosal sinus (PSS) is clinically important as it represents a potential hemorrhagic hazard during neurosurgical procedures. This double-approach radiologic study and meta-analysis aimed to assess the imaging characteristics of the PSS on computed tomography (CT) and systematically analyze its prevalence to improve imaging accuracy and assist in neurosurgical management.

METHODS

The retrospective radiologic study included CT scans of 388 patients aged 18 years or older. All patients with any visible intracranial pathologies or history of head trauma were excluded. To identify articles eligible for inclusion in our meta-analysis, an extensive search was conducted through PubMed, Embase, ScienceDirect, Web of Science, and CNKI. Data extracted included investigative method, prevalence of the PSS among subjects, ethnicity, gender, side, laterality, and mean diameter. The extracted data were pooled into a meta-analysis with a random-effects model.

RESULTS

The radiologic study showed that the PSS was visualized in 25.5% of the sides examined, that it was slightly more common among females (27.5%) than males (23.8%) and on the left (21.7%) than the right (29.4%). Its mean diameter was 1.14 ± 0.58 mm. The meta-analysis revealed that the overall prevalence of the PSS in the population is 11.1%, that it is more common in females (27.4%) than males (17.6%), and that a unilateral PSS is more common (78.2%) than a bilateral one (21.8%).

CONCLUSIONS

As a PSS is present in about one tenth of the population, it is important to consider the possibility that it is present when undertaking neurosurgical procedures and to assess preoperative CT scans to avoid complications.

Sinus pericranii, petrosquamosal sinus and extracranial sigmoid sinus: Anatomical variations to consider during a retroauricular approach

Lateral and sigmoid sinus malformations are uncommon and dangerous anatomical variations that surgeons may encounter when performing a retroauricular approach. We report three cases of rare temporal bone venous sinus anomalies seen in patients who underwent cochlear implant surgery. The first patient had a diagnosis of CHARGE syndrome and presented a bilateral persistent petrosquamosal sinus with sigmoid sinus agenesis, which made mastoidectomy for cochlear implantation difficult. The second patient presented an anomalous venous lake in the occipital region, which communicated the left dural venous sinuses with a conglomerate of pericranial vessels in the left nuchal region, also consistent with left sinus pericranii. The third patient presented with an extracranial sigmoid sinus that produced a troublesome bleeding immediately after the muscular-periosteal flap incision was performed.

Anatomy and pathology of the cranial emissary veins: a review with surgical implications

Emissary veins connect the extracranial venous system with the intracranial venous sinuses. These include, but are not limited to, the posterior condyloid, mastoid, occipital, and parietal emissary veins. A review of the literature for the anatomy, embryology, pathology, and surgery of the intracranial emissary veins was performed. Detailed descriptions of these venous structures are lacking in the literature, and, to the authors', knowledge, this is the first detailed review to discuss the anatomy, pathology, anomalies, and clinical effects of the cranial emissary veins. Our hope is that such data will be useful to the neurosurgeon during surgery in the vicinity of the emissary veins.

Trephine craniotomy for evacuation of posterior fossa extradural hematoma

Extradural hematomas (EDH) commonly occur in the supratentorial region where these are evacuated by trephine or craniotomy. Posterior fossa EDH (PFEDH) account for 4% to 12.9% of all cranial EDH and the standard method for evacuation of PFEDH involves a suboccipital craniectomy. Use of a trephine craniotomy for evacuation of PFEDH has not yet been described. This is the first report describing our experience in 8 patients with PFEDH where a sub occipital trephine craniotomy was used for evacuation of PFEDH. Eight patients with PFEDH were operated at our institution using a trephine for making a sub occipital craniotomy. Park bench position was used in all patients. The procedure was safely and expeditiously completed with no significant peri-operative complications related to the procedure. Operative time was comparatively shorter than for traditionally described procedures. Replacing the bone flap also avoids any scope for the possibility of occurrence of the sinking skin flap syndrome. We think that using a trephine for making a sub occipital craniotomy for evacuation of PFEDH is a feasible and safe option. There is no added risk of venous sinus injury. Replacing the bone flap helps to restore the normal anatomy. Use of central and peripheral dural hitch sutures in patients of traumatic PFEDH is feasible and avoids any possible reaccumulation of hematoma.

Posterior fossa extradural hematoma: our experience and review of the literature

BACKGROUND

Posterior fossa EDH is an uncommon entity, accounting for only 4% to 12.9% of all EDHs It has a characteristic clinical presentation, which if detected can be life-saving.

METHODS

We sought to study the demographic features of patients with PFEDH and assess the clinical and radiologic predictors of the outcomes of as well as evaluate the various treatment modalities for this disease. We carried out a retrospective analysis of the cases of 61 patients with PFEDH who were admitted to the National Institute of Mental Health and Neurosciences (Bangalore, India) from 1991 through 2002. We analyzed various parameters and applied Fisher's exact test for statistical analysis.

RESULTS

Mostly male individuals were affected with PFEDH. Their GCS score at admission and the presence of hydrocephalus as detected by CT scan determined the outcome of the patients. The children had better outcomes than did the adults. Patients with a good GCS score could be managed conservatively.

CONCLUSIONS

Posterior fossa EDH is rare. The PF is an unfavorable location of a hematoma. Good GCS scores have a favorable prognosis. Children have better outcomes than do adults, and the presence of hydrocephalus on CT scan is an ominous sign.

Cranial CT of the unconscious adult patient

Unconscious patients are frequently referred to radiology departments for computed tomography (CT) of the brain. The objectives of these examinations are to define the underlying cause of impaired consciousness and in some cases to determine the severity of associated brain injury. There is often little history available to guide the clinician or radiologist, particularly in patients referred from the casualty department. In this review, we present the typical CT appearances of adult patients presenting with loss of consciousness for CT examination. We focus on the most common abnormalities that are identified in everyday radiological practice, emphasize important diagnostic signs that may enable a confident diagnosis to be made and discuss when further imaging may be warranted.

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.

Retroclival epidural hematoma secondary to a longitudinal clivus fracture

Retroclival epidural hematomas (RCEDH) make part of posterior fossa epidural hematomas (PFEDH) and represent an extremely rare entity not always easily diagnosed with computerized tomography (CT) due to beam hardening artifacts. The authors present a case of a child-to our knowledge-the first reported until now-featured the rare combination of a longitudinal clivus fracture associated with concomitant epidural hematoma treated conservatively with favorable outcome of the patient.

Retroclival extradural hematoma is a magnetic resonance imaging diagnosis

An epidural hematoma of the clivus is reported in a 16-year-old boy after a motor vehicle accident. The diagnosis was made by magnetic resonance imaging. Only five similar cases have been reported in the literature. The patient was treated conservatively and recovered without neurological deficits. The mechanism of injury and formation of the hematoma in this region are discussed.

Extradural hematoma of the posterior cranial fossa

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological finds are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Epidural hematoma of the clivus. Case report

This 8-year-old boy presented with a rare case of epidural hematoma of the clivus and atlantoaxial dislocation caused by a hyperflexion injury sustained in a traffic accident. Magnetic resonance (MR) imaging demonstrated an epidural hematoma in the posterior fossa that compressed the pons and medulla. On admission, the patient was confused and had bilateral abducens palsy. He was treated conservatively, and 6 months after admission, the epidural hematoma on the clivus had disappeared on MR imaging and the bilateral abducens palsy was cured. Only two such cases have been reported in the literature. In this report, the authors discuss the mechanism of hematoma formation in this region of the brain.

Delayed extradural hematoma after mild head injury: report of three cases

BACKGROUND

Extradural hematoma has been classically considered to be an acute complication of head injury whose maximum development takes place in the minutes following trauma. Delayed extradural hematoma (DEH) is defined on the basis of an exclusively radiologic criterion: epidural hematoma that is not present in the first neuroradiologic examination made after trauma but that appears in sequential neuroradiologic examinations during patient evolution. This is an infrequent complication that usually appears in hypotensive multiple trauma patients or is related to severe head injury with other intracranial lesions.

CASE DESCRIPTION

We present three cases of DEH after mild head injury (GCS > 12) without associated intracranial or traumatic systemic lesions. Therefore, those usually considered to be "protective mechanisms" responsible for delayed development of an extradural hematoma were absent in our three patients. Diagnosis was attained by means of repetition of cranial computed tomography (CT) scan after neurologic impairment was noted. Surgical evacuation of DEH was immediately performed after diagnosis. Postoperative outcome was favorable in two patients who suffered DEH in the supratentorial compartment. One patient who presented a posterior fossa DEH died 3 days after surgery.

CONCLUSIONS

Early diagnosis and immediate treatment have proved to be essential for improving the prognosis of patients affected by DEH. Hospital admission under neurologic observation is recommended for patients who have sustained mild head injury associated with those factors that are related to the development of DEH, including GCS score under 15 or the detection of a skull fracture. Normality of a CT scan does not rule out subsequent appearance of delayed traumatic lesions.

Traumatic extradural hematomas of the posterior fossa in children

The most favorable type of traumatic intracranial bleeding in childhood is the extradural hemorrage (EDH). The posterior fossa location is less frequent than the supratentorial site. In the period from January 1989 to January 1994 we treated 2,372 patients with craniocerebral trauma; 31 had extradural hematomas (1.3%); 3 of them were located in the posterior fossa (9.7%): 1 boy and 2 girls aged from 6 to 16 years. The traumatic mechanism was an occipital fall in all cases. Diagnosis was made by computed tomography scan (CT). Two of them had a rapidly deteriorating course. The three patients were operated on without mortality and there was no morbidity. The role of CT in the early detection of lesions and prompt surgical evacuation may reduce the mortality and morbidity from this lesion. The interaction between these factors is discussed.

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

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.

Posterior fossa extradural hematomas in children: report of nine cases

Extradural post-traumatic posterior fossa hematoma is a rare condition estimated to complicate about 0.13% of all craniocerebral injuries, and represents 5.8% of the entire group of extradural hematomas in our records. Nine cases of posterior fossa extradural hematomas are presented. The clinical picture was dominated by headache, vomiting, and gait ataxia. An occipital fracture was seen in 77.7% of the patients. In all cases, the diagnosis was made by computed tomography. The postoperative evolution was good.

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.

The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study

A prospective study was conducted to validate the retrospective finding that adolescents (11 to 15 years old) with skull fractures were prone to develop acute traumatic intracranial hematoma (ICH). Over a 4-year period, 1178 consecutive adolescents attended the emergency room directly, of whom 760 were discharged well and 418 were admitted. All underwent skull x-ray studies. Immediate computerized tomography (CT) scans were performed in patients with Glasgow Coma Scale (GCS) scores of less than 15, in those with radiological and/or clinical evidence of skull fracture, and whenever clinically indicated. Of the 418 admitted patients, only 26 had skull fractures; 13 of these developed ICH. Four patients without skull fracture developed diffuse brain swelling. The remaining 401 patients were discharged after observation periods of up to 48 hours. Of the 13 patients with ICH, 10 had admission GCS scores of 15; however, four deteriorated rapidly and required urgent operation, and four remained stable but were operated on due to their large ICH. Two required conservative treatment only and both made good recovery. Three patients were in coma (GCS score less than or equal to 8) on admission. One patient had an epidural hematoma and made good recovery after surgery. Two developed delayed ICH after operations for associated systemic injuries despite initial CT showing diffuse brain swelling only, and both died despite evacuation of the ICH. Multivariate analysis showed that skull fracture was the only independent significant risk factor in predicting ICH in adolescents (sensitivity of 100% and specificity of 97%). A routine skull x-ray study is therefore mandatory in all head-injured adolescents and, if a skull fracture is detected, immediate CT may be performed for early detection of ICH.

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.

Delayed epidural hematoma. A review

Since the CT has become the main diagnostic tool in head trauma, more cases of DEDH have become confirmed and published although some have been classified among other entities and under different criteria. This review tries to describe the characteristics of DEDH based on the cases previously published, as well as on three of our own cases. The entity is mainly radiological i.e. appearance of an epidural hematoma in a CT scan following up a previous one which has not shown this pathology. Although not specific, we have found some common features among the cases published. The patients are usually young people. The cause of many injuries is either a fall injury or involvement of a pedestrian in a road accident. Skull fracture under which the DEDH develops is the rule. DEDH is not found in the usual location of the classic epidural hematoma (the temporal fossa). Some of the patients developed DEDH after an earlier neurosurgical operation for evacuation of another traumatic mass lesion for urgent decompression. Others developed DEDH after medical treatment aimed at restoring normal blood pressure or reducing increased ICP. This main group of patients had other associated lesions, mainly intracranial. The others (including our case no. 1) were considered to have a skull fracture associated only with concussion of the brain, as the clinical picture changed or persistent headache developed, another CT scan was indicated and DEDH was then found. This group constitutes those patients in whom the prognosis is expected to be good or excellent. Keeping in mind the necessity for repeated CT scans in this group (we think the number will increase in the future), other patients will benefit from the awareness of the clinician of the importance of this diagnostic tool. CT scan is efficient, accurate and can be repeated at short intervals. It enables a correct diagnosis to be made in nearly 100% of cases of head trauma. Although this liberal use of CT may increase the number of negative scans, it will also increase the number of DEDH's diagnosable at an earlier stage.

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

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.