Traumatic Pediatric Posterior Fossa Extradural Hematomas: A Tertiary-Care Trauma Center Experience from India

Abstract

Introduction: Traumatic posterior fossa extradural hematomas (PFEDH) are rare lesions constituting <10% of all extradural hematomas. Reliance on clinical findings alone is not recommended as these are nonspecific; for all suspicious cases, it is advisable to conduct a CT scan. Only a handful of pediatric studies have been reported analyzing the outcome of such lesions. The aim of our study was to analyze outcomes for children with PFEDH managed at our apex trauma center. Materials and Methods: We conducted a retrospective analysis of pediatric patients (≤18 years) admitted with a diagnosis of traumatic PFEDH from January 2008 to February 2014. Results: Of 22 patients, 16 were managed surgically (group 1) and 6 conservatively (group 2); 1 failed conservative treatment (due to an increased EDH volume). Mean age was 11.7 years (range 2-18 years). Falls were the most common cause of injury. Vomiting and loss of consciousness were the most frequent presenting features. There were 18 mild, 2 moderate and 2 severe head injuries. The mean volume of EDH was 37.1 ml (range 18-100 ml) and 10.3 ml (8-16 ml) in the operative and conservative subgroups, respectively. Occipital bone fracture was seen in 16 cases with supratentorial extension in 11. Four complications were noted in 3 cases. Mean follow-up duration was 25.1 months (range 3-34 months). Except for 1 patient, all had excellent outcomes. There was no mortality. Conclusions: Traumatic pediatric PFEDHs are rare. Both the clinical status of the patient and the volume of the hematoma need to be assessed before deciding on surgery. Most cases have associated occipital bone fractures and around half have supratentorial extension; these need to be carefully assessed preoperatively. Torrential venous bleeding can be a major problem due to rupture of the adjacent sinuses. Timely intervention is crucial for achieving good outcome, keeping in view a low threshold for surgical evacuation. Although not innovative, this second-largest case series provides additional data and contributes to the existing literature on such lesions in pediatric patients.

Pediatric Extradural Hematoma: A Report of 34 Cases

“…Paucity of pure temporal hematoma during infancy and early childhood have been reported in the literature and was explained by the lake of indentation of the middle meningeal artery in the temporal bone (13) . Similarly, posterior fossa location was reported in one patient (2.9%), which is less than the rate previous literature (4.2) (17) , and have been attributed to the more firm attachment between dura and posterior cranial fossa compared to anterior and middle fossae (25) . Associated skull fractures were observed in 61.7% of our patients.…”

Trephination mini-craniectomy for traumatic posterior fossa epidural hematomas in selected pediatric patients

“…PFEDH could be of particular danger due to direct brain stem compression. 15 Occipital bone fractures are quite common (80%) in pediatric PFEDHs 5 , 13 and PFEDHs are more likely to have a venous origin (venous sinus, venous vessels or diploic veins in bone) by bone fractures than arterial origin. 40 Hydrocephalus or ventricular dilation is uncommon in pediatric PFEDHs and its presence might indicate the existence of severe mass effect in the posterior fossa and thus usually associate with poor prognosis.…”

“… 40 Hydrocephalus or ventricular dilation is uncommon in pediatric PFEDHs and its presence might indicate the existence of severe mass effect in the posterior fossa and thus usually associate with poor prognosis. 5 , 13 We presented here the clinical data on the successful application of trephination mini-craniectomy in 7 pediatric patients. The surgical procedures were fast and simple and satisfactory clinical outcomes were achieved.…”

“… 7 , 16 , 17 , 46 Lately, Prasad et al. 13 suggested a PFEDH volume >20 mL and/or fourth-ventricle mass effect with/without ventriculomegaly should be surgically treated, while Senceret et al. 5 recommended a PFEDH with thickness <5 mm could be followed up conservatively.…”

“… 11 The diagnosis of EDH has become easier with the increased availability of computed tomography (CT) facilities. 12 Although some patients have been successfully treated with conservative approach, 5 , 13 most studies support timely management of PFEDH by surgical intervention in children. 5 , 7 , 14 , 15 , 16 , 17 For EDH, standard craniotomy is routinely used to remove the hematomas.…”