Posttraumatic retroclival acute subdural hematoma: Report of two cases and review of 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.

Traumatic retroclival hematoma complicated with hyponatremia and delayed traumatic intracranial hematoma in an adult: A case report

Intracranial hematoma is a common variety of brain insults in trauma. However, posterior fossa hematoma in the retroclival location is quite unusual. There are limited numbers of case reports regarding traumatic retroclival hematoma. Some are managed with surgery in this condition. We present a traumatic retroclival hematoma in a 34-year-old gentleman who sustained brain trauma in a motor vehicle accident. His condition was further complicated by hyponatremia and delayed traumatic intracerebral hematoma in a distant location. The only symptom he had later was severe headache which could be attributed to delayed traumatic intracerebral hematoma and hyponatremia. He was managed conservatively and discharged on the 12th day from the hospital.

Pediatric Retroclival Epidural Hematoma in the Acute Trauma Setting: A Sign of Tectorial Membrane Stripping Injury

OBJECTIVE. A traumatic retroclival epidural hematoma is a rare imaging finding of severe cervical flexion-extension injury in the pediatric population. The purpose of our study was to identify pediatric patients with a retroclival epidural hematoma, record the hematoma size and extent, and examine the major craniocervical ligaments for injury. MATERIALS AND METHODS. Pediatric patients who suffered a retroclival epidural hematoma were identified retrospectively using the keywords "clivus," "epidural hematoma," and "retroclival" included in head CT reports between 2012 and 2019. The cervical and brain MRI examinations for these patients were reviewed for craniocervical ligament injury by two certified neuroradiologists. Detailed descriptions of patient injuries were recorded along with demographic information, clinical history, patient management, and outcome. RESULTS. Eleven pediatric patients were identified with an acute posttraumatic retroclival epidural hematoma with a mean anteroposterior dimension of 4.4 mm and craniocaudal dimension of 4.3 cm. All patients with a retroclival epidural hematoma who underwent subsequent cervical MRI had a stripping injury of the tectorial membrane (TM). Disruption of additional major craniocervical ligaments on MRI (alar ligament, transverse ligament, longitudinal ligaments, and ligamentum flavum) was relatively rare with the most common associated ligamentous injuries involving the anterior atlantooccipital membrane, apical ligament, and interspinous ligaments. None of the patients suffered a cervical cord or severe intracranial injury. The majority of the patients were managed conservatively with excellent clinical outcomes. CONCLUSION. A posttraumatic retroclival epidural hematoma in the pediatric population is a rare injury often identified initially by head CT and easily overlooked by the radiologist. We propose that a retroclival epidural hematoma in the pediatric population is a direct result of a significant flexion-extension force, with a subsequent stripping injury of the TM from the posterior clivus. Pediatric patients with a posttraumatic retroclival epidural hematoma on initial head CT should undergo a cervical MRI to evaluate the integrity of the TM and other craniocervical ligaments.

Retroclival and spinal subdural hematoma after traumatic brain injury - A case report and literature review

Background

Retroclival hematomas are rare and occur mostly in the pediatric population. They are variously attributed to trauma, apoplexy, and vascular lesions. With motor vehicle accidents (MVAs), the mechanism of traumatic injury is forced flexion and extension. There may also be associated cervical spinal and/or clivus fractures warranting fusion.

Case Description

A 35-year-old male sustained a traumatic brain injury after a fall of 5 m at work. His Glasgow coma scale (GCS) on admission was 13 (M6V3O4). He had no cranial nerve deficits. The brain computed tomography (CT) showed a retroclival subdural hematoma that extended to the C2 level.

Conclusions

Most retroclival hematomas are attributed to MVAs, and cranial CT and magnetic resonance studies typically demonstrate a combination of posterior fossa hemorrhage with retroclival hematomas (intra or extradural). Patients with retroclival hematomas but high GCS scores on admission usually have better prognoses following traumatic brain injuries attributed to MVA. Notable however is the frequent association with additional cervical and/or craniocervical injuries (e.g. such as odontoid fracture) that may warrant surgery/fusión.

Isolated traumatic retroclival hematoma: case report and review of literature

BACKGROUND

Retroclival hematomas are a rare entity. The pathology can be categorized into epidural hematoma or subdural hematoma based on the anatomy of the tectorial membrane. Frequently, the etiology is related to accidental trauma, though other mechanisms have been observed, including coagulopathy, non-accidental trauma, and pituitary apoplexy. There have been only 2 prior cases where both epidural and subdural hematoma co-present.

CASE PRESENTATION

An 8-year-old male was involved in a high-speed motor vehicle accident. He presented with a Glasgow Coma Score (GCS) of 14 with bilateral abducens nerve palsies. Computed tomography (CT) revealed a hemorrhage along the dorsum sella, clivus, and dens. Magnetic resonance imaging (MRI) demonstrated the retroclival hematoma in both the subdural and epidural space. At discharge, 19 days after the accident, the abducens nerve palsies had resolved without medical or operative intervention.

CONCLUSION

Retroclival hematoma may present after trauma. Although most cases exhibit a benign clinical course with conservative management, significant and profound morbidity and mortality have been reported. Prompt diagnosis with close observation is prudent. Surgical management is indicated in the presence of hydrocephalus, symptomatic brainstem compression, and occipito-cervical instability.

A major pitfall to avoid: retroclival hematoma due to odontoid fracture

BACKGROUND

Retroclival hematoma (RCH) is a rare occurrence. The hemorrhage is usually small and hidden and can be easily missed on CT scan. Here, we report the association of a RCH with an odontoid fracture.

METHODS

Case report and review of the literature.

RESULTS

We describe a case of a 75-year-old man with a history of squamous cell carcinoma of the tongue base, treated with chemo-radiation. He was on warfarin for atrial fibrillation. He presented to the hospital 6 weeks after falling from standing height, with headache, neck pain, and stiffness. Clinical examination did not show any focal neurologic deficits. INR measured 4 days before admission was 6.0, but therapeutic at 2.4 on the day of admission. CT scan of the head showed a RCH. CT angiogram of the neck unexpectedly showed a type II odontoid fracture with instability of the upper cervical spine and extension of the hematoma to the upper cervical spine. Anticoagulation was reversed with factor IX complex (Bebulin). He underwent C1-C2 fusion without any complications. The immediate post-operative period was unremarkable. Unfortunately, he succumbed to airway obstruction due to mucus plugging 14 days into hospitalization.

CONCLUSIONS

In the appropriate clinical setting, when a RCH is found, further imaging should be considered to rule out fracture of the cervical spine. Odontoid fractures can lead to compression of the spinal cord or lower medulla. To prevent neurologic injury and subsequent complications, prompt recognition of type II odontoid fracture should lead to immediate spine stabilization.

Neuroimaging findings of retroclival hemorrhage in children: a diagnostic conundrum

BACKGROUND

Retroclival hemorrhage in children may occur in three compartments, namely epidural, subdural, and subarachnoid, frequently secondary to trauma. Retroclival epidural hematoma may be associated with ligamentous injury, which may further result in instability at the craniocervical junction. Retroclival subdural hematoma may indicate a sentinel event for traumatic injury elsewhere within the brain or posterior fossa. Retroclival subarachnoid hemorrhage may have severe clinical consequences related to vasospasm.

OBJECTIVE

Neuroimaging is essential in the recognition, localization, and characterization of retroclival hemorrhage into various compartments and for evaluating potential severe clinical consequences such as craniocervical junction instability, underlying traumatic brain injury, and ischemia secondary to vasospasm. The goal of this paper is to discuss the anatomy and biomechanics of the craniocervical junction as well as the neuroimaging findings associated with various compartments of retroclival hemorrhage in children.