Traumatic posterior fossa haemorrhage in children

Prognostic and morphological factors in pediatric cerebellar contusions

Background

Although uncommon, cerebellar contusions are associated with significant morbidity and mortality. Literature is lacking in the prognostic and morphological factors relating to their clinical picture and outcomes, especially within children. The objective of this study is to evaluate prognostic and anatomic factors in the clinical picture of cerebellar contusions, including effacement of the 4th ventricle and cisterna magna.

Methods

This is a retrospective chart review over 11 years across two medical centers. Patients included were under 18 years who presented with a cerebellar contusion. Patients were stratified within the study group based on discharge Glasgow outcome scale (GOS) and reviewed for prognostic factors contributing to outcome. Mid sagittal area of the 4th ventricle and cisterna magna were measured using magnetic resonance imaging and compared within the groups.

Results

A total of 21 patients met the study criteria, of which 16 (76.2%) were male, with an average patient age of 8.65 years. Poor outcome at discharge (GOS <4) was associated with decreased admission Glasgow coma scale (P = 0.003), admission motor response (P = 0.006), pupil reactivity (P = 0.014), presence of concomitant subarachnoid hemorrhage (P = 0.010), contusion volume (P < 0.001), and decreased area of the cisterna magna (P = 0.012). Patients with poor outcomes were also more likely to require surgical intervention (P = 0.042).

Conclusion

There are multiple prognostic factors associated with the overall outcome following cerebellar contusions. The rate of good outcomes in this study was superior to that in previous studies in adults.

Traumatic intracerebellar haematoma: To operate or not to operate?

BACKGROUND

Pure cerebellar haematoma of traumatic etiology, without associated posterior fossa sub- or epi-dural haematomas is a rare entity and has been reported to have a poor outcome. We report 23 patients with traumatic intracerebellar haematoma. We sought to study the pattern of such presentations and assess the factors which could be associated with their outcome.

METHODS

A retrospective review of prospectively collected data for all patients who were admitted for the management of traumatic intracerebellar haematoma at Rajendra Institute of Medical Sciences, Ranchi, India provided data for the 23 consecutive patients admitted for aforesaid over a seven-year study period. Medical records, diagnostic imaging and operative notes were reviewed for all patients. We divided the patient pool in to two groups based on their GCS score at the time of presentation - Group A (GCS > 7) and Group B (GCS ≤ 7). The association of different allied factors was studied and statistically analyzed. The relevant medical literature was also reviewed.

RESULTS

Most Group B patients were found to be associated with poor outcome at hospital discharge. The overall incidence of poor outcome in our study was 69.56%. GCS score at time of admission, allied supratentorial lesions, advanced age, condition of fourth ventricle and chest infection were found to be important factors which could be associated with poor outcome.

CONCLUSION

Surgery in patients with the mentioned risk factors remains debatable and should be approached cautiously. Larger multi-institutional and meta-analytic studies are required to study and statistically establish the factors which might be associated with poor outcome in these patients. An algorithm which may be used in the management of traumatic intracerebellar haematoma patients is proposed.

Posterior fossa epidural hematomas in children: clinical experience with 40 cases

OBJECT

Traumatic posterior fossa epidural hematoma (PFEDH) is rare, but among children it may have a slightly higher incidence. With the widespread use of CT scanning, the diagnosis of PFEDH can be established more accurately, leading to an increased incidence of the lesion and possibly to a better patient prognosis. This study presents 40 pediatric cases with PFEDH.

METHODS

The authors assessed the type of trauma, clinical findings on admission, Glasgow Coma Scale scores, CT findings (thickness of the hematoma, bone fracture, compression of the fourth ventricle, and ventricle enlargement), type of treatment, clinical course, and prognosis. Early postoperative CT scans (within the first 6 hours) were obtained and reviewed in all surgical cases.

RESULTS

Twenty-nine patients underwent surgery and 11 patients received conservative therapy and close follow-up. All patients fared well, and there was no surgical mortality or morbidity.

CONCLUSIONS

Based on the data in this large series, the authors conclude that PFEDH in children can be treated in experienced centers with excellent outcome, and there is no need to avoid surgery when it is indicated.

Surgical Management of Posterior Fossa Mass Lesions

RECOMMENDATIONS (see Methodology)

Indications

Timing

Methods

Traumatic intracerebellar hemorrhage: clinicoradiological analysis of 81 patients

OBJECTIVE

We report 81 patients with a traumatic intracerebellar hemorrhagic contusion or hematoma managed between 1996 and 1998 at 13 Italian neurosurgical centers.

METHODS

Each center provided data about patients' clinicoradiological findings, management, and outcomes, which were retrospectively reviewed.

RESULTS

A poor result occurred in 36 patients (44.4%). Forty-five patients (55.6%) had favorable results. For the purpose of data analysis, patients were divided into two groups according to their admission Glasgow Coma Scale (GCS) scores. In Group 1 (39/81 cases; GCS score, > or =8), the outcome was favorable in 95% of cases. In Group 2 (42/81 cases; GCS score, <8), the outcome was poor in 81% of cases. Twenty-seven patients underwent posterior fossa surgery. Factors correlating with outcome were GCS score, status of the basal cisterns and the fourth ventricle, associated supratentorial traumatic lesions, mechanism of injury, and intracerebellar clot size. Multivariate analysis showed significant independent prognostic effect only for GCS score (P = 0.000) and the concomitant presence of supratentorial lesions (P = 0.0035).

CONCLUSION

This study describes clinicoradiological findings and prognostic factors regarding traumatic cerebellar injury. A general consensus emerged from this analysis that a conservative approach can be considered a viable, safe treatment option for noncomatose patients with intracerebellar clots measuring less than or equal to 3 cm, except when associated with other extradural or subdural posterior fossa focal lesions. Also, a general consensus was reached that surgery should be recommended for all patients with clots larger than 3 cm. The pathogenesis, biomechanics, and optimal management criteria of these rare lesions are still unclear, and larger observational studies are necessary.

Acute hydrocephalus in posterior fossa injury

This is the first known report of the use of computerized tomography (CT) scanning to examine acute hydrocephalus in posterior fossa injury. Of the 1802 patients with acute head trauma treated at Funabashi Municipal Medical Center, 53 (2.9%) had suffered injury to the posterior fossa. Of these, 12 patients (22.6%) had associated acute hydrocephalus: nine patients with acute epidural hematoma (AEH) and three with intracerebellar hematoma and contusion (IH/C). There was a significant relationship between cases of AEH with hydrocephalus and supratentorial extension, hematoma thickness of 15 mm or more, and abnormal mesencephalic cisterns. In cases of IH/C, bilateral lesions and no visible fourth ventricle were significant causes of hydrocephalus. According to these results, possible mechanisms of acute hydrocephalus in posterior fossa injury may be as follow: in cases of AEH, hematoma that extends to the supratentorial area compresses the aqueduct posteriorly and causes hydrocephalus; in cases of IH/C, hematoma and contusional lesions may directly occlude the fourth ventricle and cause acute hydrocephalus. Seven patients suffering from AEH with acute hydrocephalus underwent evacuation of their hematoma without external ventricular drainage. In these cases, CT scanning showed that the hydrocephalus improved immediately after evacuation of the hematoma. Two patients suffering from IH/C with hydrocephalus underwent a procedure for evacuation of the hematoma and external ventricular drainage. The authors do not believe that ventricular drainage is necessary in treating posterior fossa AEH. However, both evacuation of the hematoma and ventricular drainage are necessary in cases of IH/C with hydrocephalus to provide the patient with every chance for survival. There was no significant difference in mortality rates when cases of AEH with acute hydrocephalus (0%) were compared with cases of AEH without hydrocephalus (7.7%). The observed mortality rates in cases of IH/C with hydrocephalus and those without hydrocephalus were 100% and 15.4%, respectively; this is statistically significant.