Posterior fossa epidural hematomas: a review and synthesis

Traumatic posterior fossa extradural hematoma in children: a meta-analysis and institutional experience of its clinical course, treatment and outcomes

Posterior fossa extradural hematoma (PFEDH) is rare but has a greater incidence amongst children. It is also associated with a rapid deterioration. The aim of this study was to present the management of PFEDH through our institutional experience and a meta-analysis. A retrospective single institution review of all children from 2004 to 2024 who underwent craniotomy for PFEDH was undertaken. The collected variables included: demographics, type of trauma, clinical findings, computed tomography findings, and clinical course. A systematic review using Ovid Medline, Ovid Embase, and Cochrane Central Register of Controlled Trials (CENTRAL), and meta-analysis were performed. Nineteen children with PFEDH who underwent surgery were identified. All 19 (100%) patients benefited from good Glasgow Outcome Scale (GOS) score 4-5, and there were no incidences of in-hospital mortality. From the systematic review, 391 patients, across twenty-four studies and our series, were included. A total of 308 were treated with surgery, whereas 83 patients were treated conservatively. A comparative meta-analysis was not performed as the two groups were deemed too heterogeneous in clinical characteristics. Instead, single-arm meta-analyses were performed. The pooled incidence of patients initially under conservative management requiring surgery was 9.90% (95%CI 1.61;22.21%, I2 = 35.2). The incidence of good functional outcomes in patients managed surgically and conservatively were 93.68% (95%CI: 88.69;97.57%, I2 = 0.0%), and 99.99% (95%CI: 96.53;100%, I2 = 0.0%), respectively. Overall pooled of mortality in patients managed surgically and conservatively were 0.57% (95%CI: 0.00;2.87%, I2 = 0.0%) and 0.00% (95%CI: 0.00;1.18%, I2 = 0.0%). Overall, our study reiterates that pediatric PFEDH is uncommon, and patients often present atypically. Based on our institutional experience and extrapolating data from our meta-analysis of the wider literature, neurosurgical intervention is a reliable therapeutic option with good clinical outcomes.

Operative versus non-operative management of posterior fossa epidural hematoma: A systematic review and meta-analysis

BACKGROUND

Posterior fossa epidural hematoma (PFEDH) is rare, occurring in less than 3% of head injuries. It can be managed either operatively or non-operatively. Management guidelines date from 2006, without recent updates providing class III evidence.

METHOD

We searched PubMed and other databases for English language observational studies up to 2021 that compared the two treatment approaches for PFEDH and.

RESULTS

Twenty-four of the 350 references, for involving 874 patients, met the study criteria. Conservative management showed higher GOS 5 scores and lower mortality. GCS 13-15 patients were more prevalent in the conservative group. Surgical cases often involved ventriculomegaly/compression, hydrocephalus or contusion.

CONCLUSION

The study shed light on surgical versus conservative PFEDH management, although evidence is sparse. Generally, conservative methods showed better initial outcomes, and should be preferred. However, respect of individual patient traits and Brain Trauma Foundation guidelines is crucial: conservative management may not suit all cases. To enhance the evidence base, RCTs are important for optimal PFEDH management. Bridging this gap can substantially improve patient outcomes and clinical decision-making, emphasizing the need to consider both the available evidence and patient-specific factors for effective guidance.

Surgical management of supratentorial and infratentorial epidural hematoma in Korea: three case reports

Supratentorial and infratentorial epidural hematoma (SIEDH) is a rare but life-threatening complication following traumatic brain injury. However, the literature on SIEDH is sparse, consisting only of a few small series. Prompt diagnosis and the application of appropriate surgical techniques are crucial for the rapid and safe management of SIEDH. Herein, we present three cases of SIEDH treated at our institution, employing a range of surgical approaches.

Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review

BACKGROUND

Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage.

METHODS

We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon.

RESULTS

Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002).

CONCLUSIONS

The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.

Supra- and infra-tentorial subacute extradural hematoma

Extradural hematoma (EDH) is a rare but serious complication of brain injury. The supra- and infra-tentorial EDH is even rarer and only a few articles focusing on this topic have been published. The clinical manifestations are nonspecific but early diagnosis of supra- and infra-tentorial EDH and prompt treatment are mandatory to avoid complications. We report this case of a supra- and infra-tentorial subacute EDH on a 4 years old child.

Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature

OBJECTIVE

Epidural haematoma (EDH) most commonly occurs in the supratentorial area, particularly in the temporal region, of the brain. Posterior fossa epidural haematoma (PFEDH) is less frequently observed, accounting for only 1.2% to 12.9% of all EDH cases. Because of the non-specific symptoms and the potential for rapid and fatal deterioration in children, an early computed tomography (CT) scanning is necessary for all suspicious cases. The aim of the present study was to share the experience of 48 cases and review the literature concerning PFEDH.

METHODS

A retrospective analysis was conducted for 48 paediatric cases diagnosed with PFEDH and admitted to Yuying Children's Hospital of Wenzhou Medical University from January 2010 to August 2015. The clinical features and outcomes were analyzed and compared with previous literature.

RESULTS

Seventeen patients were surgically treated in this series and 31 patients received non-operative treatment. The outcomes were good in 46 patients, evaluated using the Glasgow outcome score (GOS), while mild disability was observed in one patient, and only one case showed severe disability. There were no cases of mortality in this series.

CONCLUSION

Posterior fossa epidural haematoma is relatively rare compared with supratentorial epidural haematoma. Early and serial CT scans should be performed for all suspicious cases. The criteria for the surgical treatment of paediatric patients with PFEDH were concluded. The overall prognosis was excellent in paediatric patients.

The profile of blunt traumatic infratentorial cranial bleed types

Infratentorial traumatic intracranial bleeds (ICBs) are rare and the distribution of subtypes is unknown. To characterize this distribution the National Trauma Data Bank (NTDB) 2014 was queried for adults with single type infratentorial ICB, n = 1,821: subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), epidural hemorrhage (EDH), and intraparenchymal hemorrhage (IPH). Comparisons were made between the groups with statistical significance determined using chi squared and t-tests. SDH occurred in 29% of patients, mostly in elderly on anti-coagulants (13%) after a fall (77%), 42% of them underwent craniotomy, their mortality was the lowest (4%). SAH was the most common (56%) occurring mostly from traffic related injuries (27%). Furthermore, 9% of them had a severe head injury Glasgow Coma Scale ≤8 (GCS), but had the lowest Injury Severity Score (ISS, median 8) as well as a short hospital length of stay, 5.1 ± 6.2 days. These patients were most likely to be discharged to home (64%). They had the lowest mortality (4%). EDH was the least common ICB (5%), occurred in younger patients (median age 49 years), and it had the highest percentage of associated injuries (13%). EDH patients presented with the poorest neurological status (26% GCS ≤8, ISS median 25) and were operated on more than any other ICB type (55%). EDH was the highest mortality (9%) ICB type and had a low discharge to home rate (58%). IPH was uncommon (10%). Infratentorial bleeds types have different clinical courses, and outcomes. Understanding these differences can be useful in managing these patients.

Unusual, Acute, and Delayed Traumatic Torcular Herophili Epidural Hematoma Causing Malignant Encephalocele During Surgery: A Case Report

Patient: Male, 40

Final Diagnosis: Traumatic torcular herophili unusual acute and delayed epidural hematoma

Symptoms: Coma

Medication: —

Clinical Procedure: Craniotomy

Specialty: Neurosurgery

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

Retroclival epidural hematoma secondary to a longitudinal clivus fracture

Retroclival epidural hematomas (RCEDH) make part of posterior fossa epidural hematomas (PFEDH) and represent an extremely rare entity not always easily diagnosed with computerized tomography (CT) due to beam hardening artifacts. The authors present a case of a child-to our knowledge-the first reported until now-featured the rare combination of a longitudinal clivus fracture associated with concomitant epidural hematoma treated conservatively with favorable outcome of the patient.

Epidural hematomas of the posterior cranial fossa

Object

The authors present their experience in the management of posterior fossa epidural hematoma (PFEDH), which involved an aggressive diagnostic approach with the extensive use of head computerized tomography (CT) scanning.

Methods

The authors treated 43 cases of PFEDH in one of the largest health centers in Brazil. Diagnosis was established in all patients with the aid of CT scanning because the clinical manifestations were frequently nonspecific. Cases were stratified by clinical course, Glasgow Coma Scale score, and their radiological status. Based on clinical and radiological parameters the patients underwent surgical or conservative management.

Conclusions

Compared with outcomes reported in the available literature, good outcome was found in this series. This is primarily due to the broad use of CT scanning for diagnostic and observational purposes, which, in the authors' opinion, led to early diagnosis and prompt treatment.

Retroclival extradural hematoma is a magnetic resonance imaging diagnosis

An epidural hematoma of the clivus is reported in a 16-year-old boy after a motor vehicle accident. The diagnosis was made by magnetic resonance imaging. Only five similar cases have been reported in the literature. The patient was treated conservatively and recovered without neurological deficits. The mechanism of injury and formation of the hematoma in this region are discussed.

Extradural hematoma of the posterior cranial fossa

Fourteen cases of an extradural hematoma of the posterior fossa (EDHPF), are presented and the clinical and radiological finds are described. The onset of symptoms was acute in 10 patients and subacute in the other 4. Hematomas occurred in the younger age groups with a clear male predominance. Nine cases had suffered a blow to the head. A fracture of the occipital bone was seen in 86% of the patients. The bleeder could be identified in 10 cases, and in 6 of these the source was a bleeding transverse sinus. The overall mortality was 14.2%, but only patients with an acute course died (20%). All subacute cases survived. This study revealed that the most important factors influencing mortality were late diagnosis and late treatment. Coexisting intracranial lesions had no influence on mortality. According to the literature, there has been a certain decrease in mortality in the acute and subacute course patients since the introduction of computed tomography (CT) scanning. Emphasis is placed on the importance of occipital soft-tissue swelling and occipital fracture as clues to the possible presence of extradural hematomas, and of using the CT in all such patients even if no clinical symptoms are present.

Epidural hematoma of the clivus. Case report

This 8-year-old boy presented with a rare case of epidural hematoma of the clivus and atlantoaxial dislocation caused by a hyperflexion injury sustained in a traffic accident. Magnetic resonance (MR) imaging demonstrated an epidural hematoma in the posterior fossa that compressed the pons and medulla. On admission, the patient was confused and had bilateral abducens palsy. He was treated conservatively, and 6 months after admission, the epidural hematoma on the clivus had disappeared on MR imaging and the bilateral abducens palsy was cured. Only two such cases have been reported in the literature. In this report, the authors discuss the mechanism of hematoma formation in this region of the brain.

Traumatic extradural hematomas of the posterior fossa in children

The most favorable type of traumatic intracranial bleeding in childhood is the extradural hemorrage (EDH). The posterior fossa location is less frequent than the supratentorial site. In the period from January 1989 to January 1994 we treated 2,372 patients with craniocerebral trauma; 31 had extradural hematomas (1.3%); 3 of them were located in the posterior fossa (9.7%): 1 boy and 2 girls aged from 6 to 16 years. The traumatic mechanism was an occipital fall in all cases. Diagnosis was made by computed tomography scan (CT). Two of them had a rapidly deteriorating course. The three patients were operated on without mortality and there was no morbidity. The role of CT in the early detection of lesions and prompt surgical evacuation may reduce the mortality and morbidity from this lesion. The interaction between these factors is discussed.

Posterior fossa extradural hematomas in children: report of nine cases

Extradural post-traumatic posterior fossa hematoma is a rare condition estimated to complicate about 0.13% of all craniocerebral injuries, and represents 5.8% of the entire group of extradural hematomas in our records. Nine cases of posterior fossa extradural hematomas are presented. The clinical picture was dominated by headache, vomiting, and gait ataxia. An occipital fracture was seen in 77.7% of the patients. In all cases, the diagnosis was made by computed tomography. The postoperative evolution was good.

Pathogenesis and biomechanics of traumatic intracranial haemorrhages

Intracranial haemorrhage is frequently seen by the general pathologist in the context of neural trauma. Thus, the differential diagnosis, pathogenesis and biomechanics are of practical interest in the routine work. Extradural haematomas are produced when branches of the middle meningeal vessels are lacerated. They are commonly located in the temporal fossa, and other intracranial haematomas may be present. Skull fractures occur in a high percentage of cases and play a key role in the pathogenesis of this type of bleeding. Acute subdural haematomas commonly arise from tearing of the bridging veins. They are often located in the temporal and frontal regions, and the morbidity and mortality are related to the extent of the underlying brain damage. The visco-elastic behaviour of the bridging veins and their lack of reinforcement by arachnoid trabecula in the subdural space explains why they tear under high rates of acceleration during trauma. Subacute and chronic subdural haematomas are weakly correlated with trauma. The less striking onset of symptoms may be related to the rate of blood accumulation and the capacity of the brain to accommodate the mass effect of the bleeding. Intracerebral haematomas are probably due to the direct rupture of the intrinsic cerebral vessels. The mortality rate shows no correlation with location, but those located in the basal ganglia are compatible with a good recovery when occurring in isolation. Traumatic subarachnoid haemorrhage, when in isolation, is usually associated with evidence of injury elsewhere, such as the neck muscles or the ligamentary system of the cervical spinal column. It may be secondary to intraventricular bleeding due to tearing of the tela choroidea, or associated with contusions.

Traumatic extradural haematomas in pediatric age group

A series of 75 children with traumatic extradural haematomas operated on at our Department between 1982 and 1988 were analysed in detail. The overall mortality rate was 17%. CT scan constituted a valuable tool for an early and correct diagnosis, and the mortality rate declined to 9% in the post-CT era. The outcome was found to be predominantly affected by the preoperative neurological status, by the duration of the time interval between onset of coma and surgical intervention, and mainly by the presence of associated brain lesions.

Subacute traumatic extradural haematomas of the posterior fossa: a clinicopathological entity of the 5- to 10-year-old child

The subacute form of posterior fossa extradural haematoma, which presents a few days after minor occipital trauma, is a distinct clinicopathological entity that occurs most commonly in the 5- to 10-year-old child. Five cases are presented and the literature is reviewed since the advent of computed tomography.

Clivus epidural hematoma. Case report

A rare case of epidural hematoma of the clivus is reported in an 11-year-old girl involved in a traffic accident which caused a severe hyperextension injury. Only one similar case has been reported in the literature. The mechanism for the formation of the hematoma of this region is discussed.

Extradural hematomas of the posterior cranial fossa. Observations on a series of 32 consecutive cases treated after the introduction of computed tomography scanning

A series of 32 patients with posterior fossa epidural hematoma treated after the introduction of computed tomography scanning between 1975 and March 1988 is presented. Sixteen patients harbored "pure" epidural hematomas, whereas 16 had other infratentorial or supratentorial traumatic lesions. Glasgow Coma Scale on admission was 7 or less in 10 patients, 8-12 in 11, and 13-14 in 11. Only six patients had a lucid interval. Thirty patients were treated surgically; two patients with small hematomas were treated conservatively. Overall mortality was 15.6%, with 0% for "pure" and 31.2% for "complicated" posterior fossa epidural hematomas. The value of routine computed tomography scanning is emphasized in cases with occipital skull fracture or when such fracture is found in patients undergoing emergency evacuation of supratentorial hematomas. The pertinent literature is addressed with special regard to the delayed occurrence, associated lesions, and mortality of posterior fossa epidural hematomas and to the role of computed tomography scanning.

Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961

Twenty patients with an epidural haematoma of the posterior fossa (EPIPF) among a total number of 359 patients with an epidural haematoma are reported (5.6%). Nine patients obtained a good outcome, four patients had a moderate disability and seven patients died (mortality 35%). Mortality of the acute cases was 50%, of the subacute cases 20%. In general, the clinical features were uncertain. Sixteen cases showed an occipital skull fracture or diastasis of the lambdoid suture respectively. A total number of 127 cases with EPIPF from the literature since 1961 was studied. The mortality in the CT-diagnosed group ran to 21.7% and to 25.9% in the group without CT. None of the patients showing a subacute course died when the diagnosis was made by CT, in the group without CT, however, four patients out of 11 subacute cases died. Head injured patients with an occipital trauma should therefore undergo CT scanning to detect a surgically significant lesion before clinical deterioration occurs.

Extradural haematoma of the posterior fossa. Twelve years experiences with CT-scan

18 cases of an extradural haematoma of the posterior fossa (EDHPF) are presented and the clinical and radiological findings are demonstrated. The onset of symptoms was acute in 10 patients and subacute in the other 8 patients. The overall mortality was 22%, but only acute course patients died (40%). All subacute cases survived. The most important factors influencing mortality were the level of consciousness immediately before the operation and the presence of hydrocephalus prior to surgery. Other coexisting intracranial lesions had no influence on mortality but on the quality of survival. Compared with the literature there is a certain decrease in mortality in the subacute course patients since the introduction of computed tomography.

Chronic extradural hematomas of the posterior cranial fossa

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.

Traumatic hematomas of the posterior fossa. A clinicopathological spectrum

Eight patients were found to have traumatic hematomas of the posterior fossa during a 6-year period. There were four patients with extradural hematomas, one patient with a subdural hematoma, and four patients with intracerebellar hematomas. In one patient, clinically significant hematomas were found both in the extradural space and in the cerebellum. Clinical or radiologic evidence of skull fracture was present in each case, and computed tomography scans were diagnostic of a posterior fossa hematoma in all cases. In six of the eight patients, there was clinical deterioration prior to surgical treatment, and in three cases, this was abrupt. All patients underwent suboccipital craniectomy. Six patients survived; four made a good recovery. Our experience indicates that early operation is usually indicated for these lesions.

Extradural haematoma of the posterior fossa: a report of eight cases and a review of the literature

The authors review the literature and present 8 cases of extradural haematoma of the posterior fossa operated from 1979 to 1985 at the Neurosurgical Clinic of the University of Pavia. Emphasis is placed on the importance of an early diagnosis of the symptoms which are often ignored due to the absence of specific clinical signs. The authors recognize a substantial improvement in results because of the recent introduction of CT scanning facilities which permit an early and precise diagnosis of this traumatic pathology.

[Pediatric craniocerebral injuries requiring surgical treatment]

A survey is given of the craniocerebral traumas in children necessitating surgical treatment. The particularities of craniocerebral traumas in children are contrasted to those in adult persons. Diagnostic possibilities and consequences of the injury are discussed.