Chronic extradural hematomas of the posterior cranial fossa

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Chronic Extradural Hematomas of the Posterior Cranial Fossa Carlo Bellotti, M .D ., Massimo Medina, M .D ., Salvatore Barrale, M .D .,

Giuseppe Oliveri, M .D ., Andrea Voci, M .D .

Francesco Ettorre, M .D ., Carmelo Sturiale, M .D ., and

Neurosurgery Division, Ospedale Civil, S . Croce, Cunco, and Neurosurgery Division, Ospedale Maggiore, Novara, Italy

Belloni C, Medina M, Barrale S, Olivcri G . hnorre F, Snuiale C . Chronic extradural hematomas of the posterior cranial fossa. Surg Neurol 1987 ;2' :580-h . Voci A .

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 . Chronic extradural hematma ; Head injury ; Posterior cranial fossa ; Computed tomography KEY WORDS :

Chronic hematomas are rare [3,8,17,29,31,36,39] . In 1914, Turnbull [38] reported on the first case to receive surgical treatment in which a chronic extradural hematoma simulating a posterior fossa tumor about 8 months after an injury was found . Subsequent reports came from Guthkelch [12], Bonnal {4], Christophe [71, Campbell ct al [5], Hooper [17], Petit-Dutaillis et al [31], and W right [ 39 ] . Anderson[ I ] reported on a case diagnosed by ventriculography and Aronson and Ransohoff [2] reported a case diagnosed by pneumoencephalography . Jamieson [20] diagnosed a case by vertebral angiography and Parkinson et at [29] diagnosed a case using a double free interval . The most recent reports are those of Stone et al [36], Cordobcs et al [8], and Garza-Mercado [ 111 . Our seven cases of chronic extradural hematoma of the posterior cranial filssa have been observed for the past 6 years .

Case Reports Extradural hematomas of the posterior cranial fossa account for about 4 r-[2 it of all extradural hemaromas {9,11,16,17,21,23,25,27,41] . They are classified as acute, subacute, and chronic according to the evolution of the clinical pattern, which in turn depends upon the bleeding time and individual tolerance to compression . There is some disagreement regarding the definition of chronic : some authors confine the term to cases operated on more than 13 days after the injury [ 18], whereas others set the limit at 3 days [26,35] . In all our cases the interval between injury and onset of neurological deficits was at least 13 days and therefore, all of these hematomas comply with the requirement of Iwakuma and Brunngraber (181 .

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Cute I

This 17-year-old boy suffered a head injury with brief loss of consciousness following a fall . He was well for about 15 days and then complained of headache and diplopia due to a deficit of the sixth cranial nerve on the right . On admission he was alert and presented with bilateral papilledema and coarse fluctuations bilaterally in the Romberg test, along with sixth cranial nerve deficit . Skull x-ray revealed no fracture . The next (lay (20 days after the injury) a left carotid artery angiography showed a fair degree of hydrocephalus . lodoventriculography demonstrated triventricular hydrocephalus with rightward displacement of the fourth ventricle . Occipital craniotomy and left suboccipital craniectomy (22 days after the accident) allowed the removal of a suprasubtentorial extradural hematoma and revealed a fracture line above the tentorium not shown on the x-ray . Both papilledema and bilateral cranial nerve VI deficit regressed after 15 days . nn9o-iol9/87/$ i .su



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Case 2

An 11-year-old girl suffered a slight head injury with brief loss of consciousness that did not require hospitalization . About 13 days later she complained of decreased visual acuity in both eyes . Alert and cooperative on admission, the patient presented with papilledema in both eyes but no other neurological deficits . A skull x-ray excluded fracture lines . An emergency computed tomography (CT) scan demonstrated the presence of a chronic extradural hematoma in the posterior cranial fossa on the left side with a ring of enhancement around it . On the same day she underwent a left suboccipital craniectomy with removal of the hematoma . The bleed had been due to a lesion found on the left transverse sinus . The postoperative course was uneventful .

Case 3

This 5-year-old boy suffered a mild head injury with brief loss of consciousness for which hospitalization did not seem necessary . Headache and vomiting occurred I week later and left cerebellar hemisyndrome after 14 days, for which the child was admitted immediately . On admission he was alert' and presented with a bilateral Babinski sign and left cerebellar hemisyndrome . Skull x-ray revealed no fracture . An emergency CT scan demonstrated the presence of a chronic extradural hematoma in the left posterior fossa. An emergency left suboccipital craniectomy was performed with removal of the chronic extradural hematoma, which was caused by damage to the left transverse sinus . The postoperative course was uneventful .

A

Case 4

This 18-year-old boy suffered a head injury without loss of consciousness . After 3 days he complained of severe nuchal headache and vomiting but showed no focal deficits . Skull x-ray revealed a left occipital fracture . He was hospitalized 20 days after the injury because of diplopia due to left cranial nerve VI deficit and partial deficit of the third cranial nerve on the left . Fundus oculi examination revealed bilateral papilledema . CT scanning 27 days after the injury showed a patch in the shape of a biconvex lens surrounded by a thin hyperdense band in the left posterior cranial fossa, which was attributed to a chronic occipitocerebellar extradural hematoma to the left of the midline (Figures 1A and B) . On the same day he underwent left occipital craniotomy and suboccipital craniectomy with removal of the chronic hematoma. The diplopia improved within a few days and his postoperative course was excellent .

B

Figure

I . (A and B) Case 4 . Chronic extradural hematoma on the right side of the posterior cranial fossa with suprateniorial expansion . Note the peripheral ring of enhancement .

Case 5

This 36-year-old man suffered a head injury with loss of consciousness . On admission he was stuporous but free from focal neurological deficits . An x-ray of the skull revealed a right temporal fracture . Consciousness gradually improved in the days that followed . On day 16 he complained of headache and deficit of the inferior branch of the seventh cranial nerve on the right . A CT



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verse sinus) was removed . The bleeding had been due to section of a small branch of the meningeal vein under the left lambdoid suture . The postoperative course was excellent . Case 7

Figure 2 . Ca' . S d11l e, o/ ihrmn, evmdrn'ul he atnma to th n oe,ipital region to the right of the midline extruding into the po tertor cranial fmta .

A 2-year-old boy suffered a head injury with loss of consciousness following a fall . He was conscious on admission and had no focal neurological deficits . An x-ray of the skull revealed a right occipital fracture . After 14 days the child began to complain of modest nuchal headache, and on day 15 a CT scan showed a thin layer of epidural hematoma in the occipital region to the right of the midline and extending into the posterior cranial fossa (Figure 2) . Following antiedemic therapy the headache regressed completely . As the patient had no focal neurological deficits or intracranial hypertension and as the hematoma was small, it was decided not to operate . Successive CT scans showed complete resorption of the blood collection . The subsequent course was excellent . Discussion

scan taken 25 days after the injury revealed a subthecal layer with curved margin in the right posterior cranial fossa, probably due to a chronic extradural hematoma with a mass effect on the fourth ventricle and a fair degree of supratentorial ventricular dilatation . There was also a large hypodense area in the left temporoparietal region typical of contusion . On the same day right suboccipital craniectomy was performed with removal of the chronic epidural hematoma of the right posterior cranial fossa . The operation disclosed a right occipital fracture not detected by x-ray . The postoperative course was good . Case 6 This 15-year-old boy suffered a head injury with loss of consciousness . He was stuporous in the days that followed and developed diplopia due to a deficit of right cranial nerve VI 13 days after the injury . Skull x-ray showed a left occipital fracture . On admission the patient presented with bilateral papilledema and right cranial nerve V I deficit . A CT scan revealed a chronic extradural hematoma of the left occiput with subtentorial expansion and slight mass effect on the ventricular axis and on the fourth ventricle . On the same day a left occipital craniotomy-suboccipital craniectomy was performed in which a large, chronic extradural hematoma in the left occipital region with subtentorial expansion into the left posterior cranial fossa (visualization of the avulsed trans-

Of the 195 cases of extradural hematoma treated here to date, seven were cases of chronic extradural hematoma of the posterior cranial fossa (3 .6C! ) . These lesions are more frequent in the young and this is probably related to the fact reported by HarwoodNash et al [141 that about 3041 of cranial fractures in children are of the occipital region . According to Choux et al [6} the great wealth of blood vessels of the diploe and dura in children favors the onset of these lesions . Our data support this observation, as 86C of our patients were under the age of 18 . In all the cases examined the salient and constant feature was occipital trauma . An occipital fracture was proven radiologically in three patients and was found at operation in two, while in the other two no fracture was found either radiologically or surgically . Thus, occipital fracture was present in 7WG of the cases . Absence of fracture is especially frequent in children and may be explained by a sudden deformation of the bone with rapid return to its original shape due to the great elasticity of the child's skull . The hematoma is, as a rule, caused by bleeding of the transverse sinus, confluens sinuum, or mastoid emissary vein, whereas in cases in which no sure source of hemorrhage can be detected diploic bleeding may be responsible [5] . The source of bleeding was not determined in three of our cases (43%) ; in two, a lesion of the left transverse sinus was present and in one other case an interruption of a small meningeal vessel had occurred at the left lambdoid suture .



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The venous or diploic bleeding may, according to some authors [15,19,371, account for the chronicity of some cases and the late onset of symptoms, although acute courses are reported in many patients with extradural hematoma of the posterior cranial fossa due to venous bleeding (23) . Arterial bleeding has been reported in only a few cases of extradural hematoma of the posterior cranial fossa [5,20,30,34,36] . The symptom-complex is marked by an intracranial hypertension syndrome, sometimes accompanied by cerebellar disturbances and signs of brainstem dysfunction (attacks of decerebration with respiratory disturbances but no alteration of consciousness) . Signs of cranial nerve VI, X, and XI involvement are often present . Cranial nerve Ill involvement is less frequent ; however, when it is present, it is due to compression by transtentorial cerebellar hernia, according to Jamieson [211 . At the time of admission, four patients (57%) presented with no disturbances of consciousness and the other three had modest disturbances of vigilance . Papilledema was present in four patients . The cranial nerves most affected were V I (43%) and III (14 .3%) . Only one patient had a cerebellar hemisyndrome . CT scanning is definitely the most rapid and precise aid to early diagnosis and helped appreciably to improve the prognosis [9,10,28,36,41 ] . Carotid and vertebral angiography, on many occasions, supplies only indirect signs of the lesion (hydrocephalus, interruption of the transverse sinus, displacement of blood vessels of the posterior fossa), and in only a few cases with certain projections is it possible to visualize the hematoma [22,23,36) . In one case reported by Jamieson [20], vertebral angiography demonstrated leakage of contrast medium from the occipital branch of the vertebral artery . Perot et al [30) also reported a case of leakage of contrast medium from a laceration of the meningeal branch of the vertebral artery . The characteristic CT image of acute extradural hematoma is a biconvex lensshaped patch, extraaxial, hyperdense with a clear-cut inner margin combined with adjacent hypodensity due to edema or contusion [10) . In chronic extradural hematoma the CT image is marked by the presence of areas with different density values within the hematoma, sometimes slightly increased, sometimes normal, and sometimes slightly decreased with respect to normal brain tissue [40] . Intravenous injection of contrast medium enhances the peripheral ring separating the hematoma from the underlying cortex . For Handa et al [131, the ring of enhancement results from superimposition of the image of the inner membrane of the vascularized hemaroma and of the dura mater over the congested underlying cerebellar cortex . Lanksh et al [24] identify the ring of enhancement with the displaced dura mater .

These different interpretations are probably due to the different stages at which CT is performed . In this study the diagnosis of chronic extradural hematoma of the posterior cranial fossa was supplied by CT scanning in six cases and by iodoventriculographyafter carotid angiography had demonstrated hydrocephalus-in one. lodoventriculography is, however, avoided these days because of the risk of transtentorial cerebellar hernia. In one patient (case 5) the hematoma was accompanied by a patch of contusion in the contralateral temporoparietal region . The hematoma was removed through an occipital craniotomy and a suboccipital craniectomy in the three cases in which it was located above and below the tentorium, whereas in the other three cases in which it was electively localized in the posterior fossa, only a suboccipital craniectomy was performed . One patient (case 7) did not undergo surgery because the hematoma was very small, there were no noteworthy clinical symptoms, and repeated CT scans subsequently showed that the hematoma had been completely resorbed . The interval between injury and operation in the six cases operated on ranged from 13 to 27 days with a mean of 19 days . The postoperative course was trouble-free in all seven cases .

Conclusions Neither symptoms nor clinical signs were typical of chronic extradural hematoma in the majority of our cases . A cranial nerve VI deficit and an aspecific intracranial hypertension syndrome (headache, vomiting, papilledema) without cerebellar signs do not specifically suggest this diagnosis . Thus, a history of head injury associated with occipital fracture in the presence of the foregoing symptoms provides the best guidance . However, failure to visualize the fracture radiologically does not rule it out, as shown in four of our cases, in two of which the fracture was found at operation . The source of bleeding could not be determined in three cases but was probably from the margins of the fracture line into the diploe . Since the advent of CT scanning the prognosis of these lesions has been good, provided that they are promptly diagnosed and treated . The factors most likely to affect the prognosis are delayed diagnosis and the presence of associated intracranial lesions . Significant in the latter connection are the data of Reigh and O'Connell [32] and of Roda et al [33], who found associated intracranial lesions in 20% and in 39 .7% of their cases, respectively, and of Zuccarello et al [41], who found such lesions (three hematomas and four cerebral contusions) in as many as seven out of eight cases . Only one of our patients was treated conservatively because



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clinical symptoms were lacking and the hematoma was small and, despite the interesting suggestion of Jackson and Speakman [19] chat some extradural hematomas may be reabsorbed spontaneously, we believe that conservative treatment should be reserved for the very few cases in which there are no clinical symptoms and the hematoma is very small .

References I . Anderson FM . Extradural cerebellar hemorrhage. Review of the subject and report of a case . J Neurosurg 1949 ;6191-6 . 2 . Aronson N, Ransohoff J. Chronic extradural hematoma of the posterior fossa. A case with a diagnostic pneumoencephalographic finding. Neurology 1955 ;5215-7 . 3 . Besson G, Leguyader J, Bagot D'arc M, et Garre H . L'hemarome extra-dural de Ia fosse posterieure . Problemes diagnostiques (10 observations) . Neurochirurgie 1978 ;24 :53-63 . 4 . Bonnal MJ . Hematome exrradural de la fosse ccrebelleuse . Rev Neurol (Paris) 1951 ;85 :439-43 . 5 . Campbell E, Whitfield RD, Greenwood R . Extradural hematomas of the posterior fossa. Ann Surg 1953 ;138 :509-17 . 6 . Choux M, Grisoli F, Peragut JC . Extradural hematomas in children, 104 cases . Childs Brain 1975 ;1:337-47 . 7 . Christophe L Hematome extradural de la fosse ccrebelleuse (discussion) . Rev Neurol (Paris) 1951 ;85 :439-43 .

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20- Jamieson KG . Angiographic demonstration of the bleeding point in a posterior fossa extradural hematoma . Case report. J Neurosurg 1972,36 :644-5 . 21 Jamieson KG, Yelland JDN . Extradural hematoma. Report of 16' cases .1 Neurosurg 1968;29.13-23 . 22 . Koch RL . Glickman MG . The angtographic diagnosis of extradural hematoma of the posterior fossa . AJR 1971 ;112 :289-95 . 23 . Kosary IZ, Goldhammer Y, Lerner MA . Acute extradural hematoma of the posterior fossa . J Neurosurg 1966 ;24 :1007-12 . 24 . Lanksch W, Grumme Th, Kazner E . In: Lanksch W et al, eds . Computed tomography in head injuries . Berlin, Heidelberg, New York : Springer, 1979 :17-32 . 25 . Lemmen I .J . Schneider RC . Extradural hematomas of the posteriorfossa .J Neurosurg 19520 :245-53 . 26. Lie . F, Wustner S . Diagnose, Behandlung and Prognose der traumatischen Hamarnme des Schadelinneren . Acta Neurochir (Wien) Suppl . VIII . Wien :Springer. 1960 . 27 . McKissock W, Taylor JC, Bloom WH, Till K . Extradural haematomas . Observations on 125 cases . Lancet 1960;u :167-72 . 28 . Merino-de Villasanre J, Taveras JM . Computerized tomography (CT) in acute head trauma . AJR (976 ;126 :765-78 . 29. Parkinson D, Hunt B, Shields C . Double lucid interval in patients with extradural hematoma of the posterior fossa . J Neurosurg 197l ;34 :534-6 . 30. Perot P, Ethier R, Wong A . An arterial posterior fossa extradural hematoma demonstrated by vertebral angiography . Case report . J Neurosurg 196? ;26 :255-60 .

8 . Cordobes F, Lobato RD, Amor T, Lamas E. Epidural haemaroma of the posterior fossa with delayed operation . Report of a "chronic" case. Aces Neurochir(Wien) 1980 ;53 :275-81 . 9 . Cordobes F, Lobato RD, Ribas JJ, Munoz MJ, Chillon D, Portillo JM, Lamas E . Observations on 82 patients with extradural hematoma Comparison of results before and after advent of computerized tomography . J Neurosurg 1981 ;54 :179-86 .

31 . Petit-Dutaillis D, Guiot G, Pertuiset B, Le Besnerais Y . Les hematomes extra-duraux de la fosse ccrebelleuse Presse Med 1956 ;64 :521-4 .

10 . Dublin AB, French BN, Rennick JM . Computed tomography in head trauma . Radiology 1977 ;122 :365-9 . 11 . Garza-Mercado R . Extradural hematoma of the posterior cranial fossa. Report of seven cases with survival . J Neurosurg 1983 ;59. 664-72 . 12 . Guthkelch AN . Extradural hemorrhage as a cause of cortical blindness . J Neurosurg 1949 ;6:180-2 . 13 . Handa J, Handa H, Nakano Y . Rim enhancement in computed tomography with chronic epidural hematoma . Surg Neurol 1979,11 : 217-20. 14 . Harwood-Nash DC, Hendrick Ell, Hudson AR . The significance of the skull fracture in children . Radiology 1971 ;101151-5 . 15 . Hirsh LF . Chronic epidural hematomas . Neurosurgery 1980 ;6: 508-12 . 16 . Hooper R. Observations on extradural haemorrhage . Br J Surg 1959 ;47 :71-87 . 17 . Hooper RS . Extradural haemorrhages of the posterior fossa . Br J Surg 1954 ;42 :19-26 . 18. Iwakuma T, Brunngraber C . Chronic extradural hemaromas . A study of 21 cases . J Neurosurg 1973 ;38 :488-93 . 19 . Jackson IJ, Speakman TJ . Chronic extradural hematoma . J Neurosurg 1950 ;7 :444-7 .

33 . Roda JM, Gimenez D, Perez-Higueras A, Blazquez MG, PerezAlvarez M . Posterior fossa epidural hematomas: a review and synthesis . Surg Neurol 1983 ;19 :419-24 .

32 . Reigh EE, O'Connell TJ . Extradural hematoma of the posterior fossa with concomitant suprarentorial subdural hematoma . Report of a case and review of the literature . J Neurosurg 1962 ;19 : 359-64 .

34 . Saleeby RG, LeFever HE, Harmon JIM . Acute posterior fossa epidural hematoma. Ann Surg 1954 ;140 :748-51 . 35 . Sparacio RR, Khatib R, Chin J, Cook AW . Chronic epidural hematoma J Trauma 1972 ;12 :435 9. 36 . Stone JL, Schaffer L, Ramsey RG, Moody RA : Epidural hematomas of the posterior fossa . Surg Neurol 1979 ;11419-24 3' . Trowbridge WV, Porter RW, French JD . Chronic extadural hematomas . Arch Surg 1954 ;69 :824-30 . 38 . Turnbull F . Extradural cerebellar hematoma . A case report . J Neurosurg 1944 ;1 321-4 . 39 . Wright RL . Traumatic hematomas of the posterior cranial fossa. J Neurosurg 1966 ;25 . 402 9 . 40. Zuccarello M, Fiore DL, Pardatscher K, Trincia G, Andrioli GC . Chronic extradural haematomas . Acta Neurochir (Wien) 1983 ;67'. 57-66 . 41 . Zuccarello M, Pardatscher K, Andrioli GC, Fiore DL, lavicoli R, Cervellini P . Epidural hematomas of the posterior cranial fossa . Neurosurgery 1981 ;8 :434-7 .