Acute Posterior Fossa Epidural Hematomas in Children

Abstract

\s=b\ Epidural hematoma in the posterior fossa is a rare clinical entity requiring immediate surgical intervention to prevent rapid and fatal deterioration. This diagnosis should be considered in children with occipital head trauma who have altered sensorium and evidence of compression of structures within the posterior fossa. Such a clinical setting demands close neurologic observation in a facility where contrast studies and neurosurgical intervention are available. The absence of an occipital skull fracture or the presence of normal pulse rate and blood pressure should not influence the decision. Lumbar puncture is absolutely contraindicated. (Am J Dis Child 131:690-692, 1977) Epidural hemorrhage in the poste¬ rior cranial fossa is an uncom¬ mon consequence of head injury in children. The diagnosis can be elusive early in its course and may become ohvious only after considerable clin¬ ical deterioration. Surgical interven¬ tion is expected to result in complete neurologic recovery despite severe preoperative deficit. The three chil¬ dren who are the subject of this report illustrate the variety of presentations and the results of appropriate man¬ agement. REPORT OF CASESCase 1.-A 3-year-old girl sustained a blunt occipital injury in falling from a high chair. She was dazed for less than five minutes, appeared normal for two hours, and then progressed to semicoma. Evalua¬ tion five hours after injury revealed absence of verbal response to command or painful stimuli, but she had appropriate symmetric motor response and normal cranial nerve function. Skull roentgeno¬ grams disclosed a vertical linear right oc¬ cipital fracture extending to the foramen magnum. Eight hours after injury, she was symmetrically hyporeflexic with bilateral Babinski responses and normal vital signs. Fundoscopic and cranial nerve examina¬ tion remained normal except for dimin¬ ished Bell phenomena. A fluctuant swelling over the right occipital area was noticed. Vertebral angiography 12 hours after injury demonstrated a significant retrocerebellar mass to the right of midline with extravasation of contrast material adja¬ cent to the fracture line just above the foramen magnum (Fig 1). Immediate right suboccipital craniectomy revealed an ex¬ tensive epidural hematoma. A bleeding vessel at the rim of the foramen magnum required control.After 24 hours of agitated disorienta¬ tion, the patient improved rapidly. She was walking and talking within three days, and she was neurologically normal three weeks after operation. Fig 1.-Case 1. Left, Lateral projection of the right vertebral angiogram, arterial phase. Choroidal point of posterior inferior cerebellar artery (single large arrow) is displaced slightly forward. Note small globular collection of extravasated contrast material just within posterior skull (two smaller arrows) in close relationship to a durai artery, most posterior of identifiable vessels. Right, Right vertebral angiogram, Towne projection, arterial phase. Choroidal point and distal segment (arrows) of posterior inferior cereb...

Traumatic Epidural Hematoma in Children

“…5 In addition, the abundance of diploic and dural vascularization in areas of rapid bone growth might explain both the varied locations of epidural hematoma and the high incidence of venous epidural hematoma in children. 2 Our findings do not corroborate previous reports regarding the rarity [18][19][20][21][22][23][24][25][26] and poor prognosis of posterior cranial fossa acute epidural hematoma. 15,10,23,[27][28][29][30] In fact, we found six of these lesions, and all had good recovery after hematoma evacuation.…”

Epidural Hematomas of the Posterior Fossa in Children

“…Character istically, membranous high density is observed along the medial margin of the biconvex low-density area, which is enhanced by contrast study [1,15]. These findings can be observed within 2 days after trauma.…”

“…It is well known that epidural hematomas in the posterior fossa are more common in children than in adults [1,5,14,16]. This is explained by the fact that the dural sinus is easily torn by fracture because of firm adherence of the dura to the inner table of the skull [4], In our 3 cases, bleeding points were not definite, but a fracture line in 1 case and separa tion of the surface of the dura from the inner table of the skull in the other 2 cases seemed to be the sources of bleeding.…”

Posterior Fossa Extradural Haematomas

“…In fact, the incidence in children was lower compared with published data, with only 2 of our 24 patients below the age of 18. The more frequent occurrence of PFEDHs in children is explained by the higher incidence of occipital fractures, greater amount of diploe and richer dural blood supply [2,14,23,27,52] . Rivano et al [49] reported an association between occipital fracture and PFEDHs in 8 of 9 teenagers younger than 17, who constituted 41 % of all his patients with PFEDHs.…”