Compression of the posterior fossa venous sinuses by epidural hemorrhage simulating venous sinus thrombosis: CT and MR findings

Axial Convex-Shaped Hematoma was Associated with Poor Curative Effect of Surgical Treatment for Traumatic Posterior Fossa Epidural Hematoma in Children

BACKGROUND

Posterior fossa epidural hematoma (PFEDH) is rare which accounts for just 4-12.9% of all EDH cases. Since its frequently subtle and nonspecific clinical presentation, CT scan has great importance for early diagnosis and treatment of PFEDH. However, indications for surgery depending on the findings of CT image are still controversial.

METHODS

We retrospectively analyzed 40 pediatric cases of PFEDH. Their baseline characteristic, clinical presentation, imaging findings and outcomes were collected and analyzed. The ellipsoid volume equation X × Y × Z/2 was used to measure the hematoma volume. The Glasgow Outcome Scale (GOS) was used to assess the neurologic functional outcome.

RESULTS

A total of 40 pediatric PFEH patients were included with 8 patients having poor outcome and 32 patients having a relatively good prognosis. GCS score showed a significant difference between good and poor outcome groups (p < 0.001). Y value on CT image was significantly bigger in poor outcome group than good outcome group (p < 0.01). Similar results were got in X/Z value (p < 0.05) and Y/Z value (p < 0.01) which reflected the shape of hematoma. A predictive model with Y + X/Z showed the largest area under the ROC curve with a sensitivity of 75.0% and specificity of 93.7%.

CONCLUSIONS

GCS score at admission was closely related to the prognosis of the pediatric patients with PFEDH. The morphometry of PFEDH has a crucial role in judging the prognosis. Axial convex-shaped hematoma was associated with poor curative effect of surgical treatment.

Comparative Therapeutic Effectiveness of Anticoagulation and Conservative Management in Traumatic Cerebral Venous Sinus Thrombosis

BACKGROUND

Consensus is currently lacking in the optimal treatment for blunt traumatic cerebral venous sinus thrombosis (tCVST). Anticoagulation (AC) is used for treating spontaneous CVST, but its role in tCVST remains unclear.

OBJECTIVE

To investigate the characteristics and outcomes of patients treated with AC compared with patients managed conservatively.

METHODS

We retrospectively reviewed patients who presented to a Level 1 trauma center with acute skull fracture after blunt head trauma who underwent dedicated venous imaging.

RESULTS

There were 137 of 424 patients (32.3%) presenting with skull fractures with tCVST on venous imaging. Among them, 82 (60%) were treated with AC while 55 (40%) were managed conservatively. Analysis of baseline characteristics demonstrated no significant difference in age, sex, admission Glasgow Coma Scale, admission Injury Severity Score, rates of associated intracranial hemorrhage, or neurosurgical interventions. New or worsening intracranial hemorrhage was seen in 7 patients treated with AC. Patients on AC had significantly lower mortality than non-AC (1% vs 15%; P = .003). There was no difference in the Glasgow Coma Scale or Glasgow Outcome Scale at last clinical follow-up. On follow-up venous imaging, patients treated with AC were more likely to experience full thrombus recanalization than non-AC (54% vs 32%; P = .012), and subsequent multiple regression analysis revealed that treatment with AC was a significant predictor of full thrombus recanalization (odds ratio, 5.18; CI, 1.60-16.81; P = .006).

CONCLUSION

Treatment with AC for tCVST due to blunt head trauma may promote higher rates of complete thrombus recanalization when compared with conservative management.

Rapid resolution of a traumatic venous epidural hematoma in a 3-year-old child: illustrative case

BACKGROUND

Posterior fossa epidural hematoma rarely occurs in children after traumatic head injury. There is ongoing discussion about appropriate treatment, yet the radiological features regarding the time to resorption of the hematoma or required follow-up imaging are rarely discussed.

OBSERVATIONS

The authors presented the case of a 3-year-old child who was under clinical observation and receiving analgetic and antiemetic treatment in whom near-complete hematoma resorption was shown by magnetic resonance imaging as soon as 60 hours after diagnosis. The child was neurologically stable at all times and showed no deficit after observational treatment. Hematoma resorption was much faster than expected. The authors discussed hematoma drainage via the sigmoid sinus.

LESSONS

Epidural hematomas in children can be treated conservatively and are resorbed in a timely manner.

Traumatic cerebral dural sinus vein thrombosis/stenosis in pediatric patients-is anticoagulation necessary?

INTRODUCTION

Cerebral dural vein thrombosis/stenosis (CDVT/S) is a condition that affects the venous drainage of the brain. Risk factors and causes associated with CDVT/S include systemic risk factors that cause hypercoagulability, or local factors such as head trauma. While consensus is that non-traumatic sinus vein thrombosis should be treated with anticoagulation therapy, treatment of patients with TBI-induced CDVT is not yet established.

METHODS

Retrospective review of clinical data of pediatric patients presented to our medical center from July 2017 to August 2020. Inclusion criteria were age, birth to 18 years, admission due to head trauma, head CT scan with positive traumatic findings, and follow-up in our clinic. Exclusion criteria were a normal head CT on admission and failure to follow-up. Data regarding demographics, clinical presentation, imaging findings, treatment, and status on follow-up were recorded. Study protocol was approved by our institutional ethics committee.

RESULTS

One hundred sixty-two patients were enrolled. Falling accident occurred in 90.1%, a minority suffered from direct head trauma or gunshot wound. Of the patients, 95.1% suffered from mild TBI. Forty-two percent suffered from an associated intracranial injury. Fourteen cases with CDVT were included in the cohort. Linear fractures were significantly correlated with CDVT. Additionally, occipital/suboccipital fractures, associated intracranial injury, and proximity of injury to the sinus were correlated with CDVT. From this group, 12 were treated conservatively; one patient was treated surgically due to EDH. All patients with CDVT were neurologically intact at discharge. Only one patient was treated with therapeutic dose of LMWH. A total of 86.7% of patients with CDVT who were treated conservatively had full recanalization on follow-up imaging. Four patients had CDVS; all were neurologically intact at admission and discharge, and all were treated conservatively and had full recanalization on follow-up.

DISCUSSION

Treatment with ACT is established in pediatric CDVT but not in the sub-group of TBI. While ACT prevents progression of thrombosis, it might cause worsening of extra-axial hemorrhage. In our study, no clinical deterioration was noted with expectant management; thus, we present an algorithm for diagnosis and treatment of trauma-induced CDVT/S in children with frequent clinical and radiologic imaging while avoiding anticoagulation.

CONCLUSION

In most cases, anticoagulation therapy is not necessary in traumatic CDVT/S. Initial expectant management in children is safe. However, each case should be evaluated individually and further studies should be performed.

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.