Posterior Fossa Extradural Haematomas: Operate or Conserve?

Abstract

Background: Posterior fossa extradural haematomas (PFEDHs) are an uncommon entity, accounting for only 4 to 12.9% of all extradural haematomas encountered in clinical practice (EDHs). They have a characteristic clinical presentation, which if detected early, can be life saving. Most PFEDHs are operated owing to the imminent propensity of brainstem compression and death. However, a growing number of neurosurgeons, now consider conservative therapy for smaller bleeds. Clear and reliable criteria do not exist, to assist this critical decision-making process. Hence, here with our clinical experience, we attempt to formulate a clinico-radiologic criteria for the management of PFEDHs. When to operate and when to conserve-the jury is still out on this matter. Methods: The clinical and radiological data of patients with PFEDHs admitted to Kasturba Medical College hospital, Manipal between the period of January 2012 and September 2014 were considered to test the efficacy of the criteria proposed. We carried out a retrospective analysis of 12 patients with PFEDH who were admitted during the above said period. A transverse diameter of 4 cms (of the extradural haematoma) was taken as a cutoff for the decision-making process. Results: Of the 12 cases reviewed only 4 were operated with a single mortality. All the operated cases had bleeds of a transverse diameter of >4 cms or had a GCS of less than 13. 46% of bleeds occurred due to occipital bone fracture resulting in a diploic venous ooze or a sinus bleed. Conclusion: PFEDHs are relatively less often encountered in clinical practice. The PF is an unfavorable location for a hematoma. Good GCS scores, at the time of presentation, have a favorable prognosis. Our proposed criteria, for the management of PFEDHs, concluded that all bleeds greater than 4 cms in transverse diameter are to be treated surgically while those with less than 4 cms in diameter are to be managed on the basis of GCS.