Biphasic ventricular dilatation following posterior fossa subdural hematoma in the full-term neonate

Neonatal Spontaneous Bilateral Posterior Fossa Chronic Subdural Hematoma and Obstructive Hydrocephalus with a Successful Outcome: A Case Report

Background

Chronic supratentorial subdural hematoma is uncommon in neonates but accounts for most neurosurgical procedures in neonatal age. However, its occurrence in the posterior fossa is extremely rare. It can be caused by instrumental delivery, coagulation abnormality, hypoxic insult, and various structural abnormalities. Furthermore, spontaneous onset has been reported only in a few case reports.

Case Presentation

A twenty-nine-day-old male neonate presented with failure to suck for three days duration associated with vomiting. Imaging showed bilateral posterior fossa chronic subdural hematoma and obstructive hydrocephalus. Bilateral burrhole craniostomy and hematoma evacuation was done which resulted in an excellent outcome.

Conclusion

Posterior fossa chronic subdural hematoma is extremely rare in the neonatal period. It can be caused by various possible etiologic agents; however, rarely it can occur spontaneously. Management with suboccipital burrhole craniostomy and hematoma evacuation can result in a good outcome. Intraoperative monitoring and management with an experienced anesthesiology team are indispensable for a good outcome.

Study Setting

Pediatrics neurosurgery ward, St Peter's Comprehensive Specialized Hospital, Addis Ababa, Ethiopia.

Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors

PURPOSE

To retrospectively evaluate the prevalence of neonatal intracranial hemorrhage (ICH) and its relationship to obstetric and neonatal risk factors.

MATERIALS AND METHODS

Pregnant women were recruited for a prospective study of neonatal brain development; the study was approved by the institutional review board and complied with HIPAA regulations. After informed consent was obtained from a parent, neonates were imaged with 3.0-T magnetic resonance (MR) imaging without sedation. The images were reviewed by a neuroradiologist with 12 years of experience for the presence of ICH. Medical records were prospectively and retrospectively reviewed for selected risk factors, which included method of delivery, duration of labor, and evidence of maternal or neonatal birth trauma. Risk factors were assessed for relationship to ICH by using Fisher exact test statistics.

RESULTS

Ninety-seven neonates (mean age at MR imaging, 20.8 days +/- 6.9 [standard deviation]) underwent MR imaging between the ages of 1 and 5 weeks. Eighty-eight (44 male and 44 female) neonates (65 with vaginal delivery and 23 with cesarean delivery) completed the MR imaging evaluation. Seventeen neonates with ICHs (16 subdural, two subarachnoid, and six parenchymal hemorrhages) were identified. Seven infants had two or more types of hemorrhages. All neonates with ICH were delivered vaginally, with a prevalence of 26% in vaginal births. ICH was significantly associated with vaginal birth (P < .005) but not with prolonged duration of labor or with traumatic or assisted vaginal birth.

CONCLUSION

Asymptomatic ICH following vaginal birth in full-term neonates appears to be common, with a prevalence of 26% in this study.

Conservative management of spontaneous posterior fossa subdural hematoma in a neonate

Symptomatic intracranial hemorrhage in term neonates is uncommon, and is usually secondary to trauma, coagulation disorders and/or hypoxia. Posterior fossa hemorrhage in the neonate is a rare neurosurgical emergency and is usually associated with the same etiological factors. Diagnosis is with computed tomography and magnetic resonance imaging. We present a spontaneous posterior fossa subdural hematoma in a term neonate and discuss conservative management.

[Posterior fossa hemorrhage in newborns following vaccum extractor delivery]

AIM

To emphasize the risk of posterior fossa hemorrhage in newborns following vacuum extraction.

PATIENTS AND METHODS

Over a period of 26 months (September 1996-December 1998), seven patients who underwent delivery with the vacuum extractor had symptoms of brain stem compression, related to posterior fossa hemorrhage. They were referred to the neonatal intensive care unit. Some parameters had been analyzed: gestational period, delivery circumstances, gestational age, parameters of newborn, indications of vacuum extraction and other paraclinical investigations (biological and radiological).

RESULTS

Ultrasound scan revealed intracranial hemorrhage in five cases of seven; mean time of diagnosis was 10 hours of age. All patients presented symptoms of brain stem compression. Mean period of follow-up was 22 months: six of seven patients had a normal neurodevelopment. One patient had a cerebellar ataxia, another one a palsy of the IIIrd cranial nerve.

CONCLUSION

Analyses of posterior fossa by ultrasound scan should be made for newborns delivered by vacuum extractor, especially if they had symptoms of brain stem compression.

Management and outcomes of posterior fossa subdural hematomas in neonates

OBJECTIVE

To review and analyze a contemporary series of 15 neonates who were treated for posterior fossa subdural hematomas (PFSDHs) during the era of computed tomography and magnetic resonance imaging.

METHODS

A retrospective chart review identified all neonates with PFSDHs for whom neurosurgical consultations were obtained for treatment planning.

RESULTS

There were nine male and six female patients. The mean gestational age was 39 weeks. Nine of the 15 mothers of the patients were primiparous. Instrument-assisted delivery (forceps and/or vacuum extractor) was undertaken for seven patients. The mean birth weight of the infants was 3165 g (range, 2160-3930 g). The mean 5-minute Apgar score was 7.5. Symptoms of PFSDH developed within the first 24 hours of life in 13 neonates. The predominant symptoms and signs were failure to thrive, irritability, seizures, apnea, and bradycardia. Lumbar punctures to rule out central nervous system sepsis were performed in six neonates. Hemograms revealed that six neonates were anemic with low hemoglobins, five had low platelets, and four had abnormal prothrombin and/or partial thromboplastin times at the time of diagnosis. Computed tomography established the diagnosis of PFSDH in all cases. Magnetic resonance imaging was performed for two neonates. The median time to diagnosis by imaging studies was 10 hours after birth. Surgical evacuation of the PFSDHs was performed in eight neonates. Seven neonates were followed conservatively with serial imaging studies. There was no mortality in either treatment group. Follow-up ranged from 2 to 10 years, with a mean of 4.5 years. Functional outcome assessment revealed that seven neonates were neurodevelopmentally normal, three were mildly delayed, two were moderately delayed, and three were profoundly delayed. In addition to traumatic causes of the PFSDHs, three neonates were observed to have coagulation disturbances at birth and one was observed at follow-up to have a posterior fossa medulloblastoma that had bled at birth.

CONCLUSION

PFSDHs are rare but important lesions to diagnose early in the neonatal period. Surgery can be life-saving when performed in a timely manner for signs and symptoms of brain stem dysfunction. A search for an underlying cause predisposing to a PFSDH may, on occasion, reveal a coagulation disturbance or a neoplasm that will require additional therapeutic considerations.

Tentorial subdural hemorrhage in term newborns: ultrasonographic diagnosis and clinical correlates

Tentorial subdural hemorrhage with its supratentorial and infratentorial extensions were diagnosed by cranial ultrasonography and computed tomography in 9 term newborns. Vacuum extraction or forceps delivery was used in 6 patients. Abnormal neurologic manifestations developed after a period of normality in 8 patients. Increased intracranial pressure was the most common presentation. All patients had hemorrhage at the falcotentorial junction near the incisura; 5 also had hemorrhage around the tentorial leaflet. Posterior fossa retrocerebellar subdural hemorrhage developed in 5 patients and posterior interhemispheric subdural hemorrhage developed in 4. All 6 patients who received conservative treatment had normal neurodevelopmental outcomes. Of the other 3 patients upon whom suboccipital craniotomies were performed, only 1 had a normal outcome. Although it localized the tentorial subdural hemorrhage either at the incisura area or at the tentorial leaflet, ultrasonography failed to identify all patients with retrocerebellar or posterior interhemispheric subdural hemorrhage. Parturitional tentorial subdural hemorrhage may not be uncommon. Ultrasonography and computed tomography are complementary in the diagnosis. Surgical decompression of the posterior fossa subdural hematoma is necessary only in the presence of acute hydrocephalus or signs of brainstem compression.

On the management of neonatal tentorial damage. Eight case reports and a review of the literature

From the history of 15 personal patients--8 reported here in extenso--and from 63 patients in the literature with the diagnosis of posterior fossa subdural haemorrhage during life, we discuss the possibility of detecting tentorial damage on computed tomography (CT) and ultrasound (US) scan. The association of a (peri)cerebellar haemorrhage with peritentorial bleeding around the straight sinus and a subdural haemorrhage between both occipital cerebral lobes is suggestive of tentorial laceration(s). Both coronal CT scan and sagittal US scan are very helpful in locating these haemorrhages near the falco-tentorial junction. The conservative management of one of our infants with very extensive but asymmetric posterior fossa haemorrhage, leading to resorptive hydrocephalus, is compared with both surgical and conservative treatment of patients from the literature. Two reasons that warrant neurosurgical intervention are: life-threatening brain-stem compression--as in one of our own patients--and acute obstructive hydrocephalus. Craniotomy of the posterior fossa within the neonatal period does not prevent later-onset resorptive hydrocephalus. The communicating nature of this latter process is adequately demonstrated by lumbar isotope cisternography. Finally, neonatal posterior fossa subdural haemorrhage is one of the many causes of cyst-like structures behind the cerebellum.