:Acta . . N6urochlrurglca
Acta Neurochir (Wien) (1995) 135:32-37
9 Springer-Verlag 1995 Printed in Austria
Acute Traumatic Posterior Fossa Subdural Haematomas M. Borzone, C. Rivano, M. Altomonte, and M. Baldini Institute of Neurosurgical Clinic, University of Genoa, Genoa, Italy
Summary Acute Posterior Fossa Subdural Haematoma (PFSDH) caused by trauma is a clinical rarity: only 13 cases have been encountered in the literature. Three consecutive personal cases of PFSDH are presented. Two of them are respectively the sixth and the seventh surgically treated cases with success. Among the 16 cases 60% had a sudden clinical worsening within 24 hours. Seven cases had an occipital fracture. Of the thirteen cases operated upon 11 (85%) were in a state of deep coma. The surgical mortality was 46%. One patient had a good recovery (Grade 5) and six a moderate disability (Grade 4) on the Glasgow Outcome Scale. We conclude that surgical treatment must always be carried out even in patients presenting in an agonal state. Keywords: Head injury; infratentorial subdural haematoma; posterior cranial fossa; subdural haematoma.
Introduction Acute traumatic Posterior Fossa Subdural Haematomas (PFSDHs) are very rare [5, 8]. We were able to find in the literature only 13 cases of PFSDH [1-3, 6-9], excluding those in the newborn. In the Neurosurgical Institute of Genoa from 1990 three patients with PFSDH have been surgically treated. They account for 0.3% of all acute subdural haematomas operated on within the last 22 years. Two of them represent the sixth and the seventh patient operated on with success.
Material, Methods and Results (Personal Series) Case 1 A 48-year-old man, who incurred severe head trauma in the occipital region, was referred in a state of deep coma with a Glasgow coma score of 3. He was respiratorily dependent, and unresponsive to painful stimuli. There was bilateral mydriasis, extremities were flaccid, and plantar responses absent. CT scan performed immediately showed a left occipital depressed fracture reaching the foramen magnum and a right PFSDH. The fourth ventricle was compressed and the posterior fossa cisterns appeared completely obliterated (Fig. 1). CT scanning also revealed left temporo-pari-
etal contusion haemorrhages with a left temporo-occipital hypodense area, and a thin right fronto-temporo-parietal subdural haematoma with contralateral shift of midline structures. The patient underwent surgical treatment by a suboccipital approach: a thin right extradural haematoma and a large PFSDH were removed. In spite of surgery the patient died the following day. Case 2 A 47-year-old man was admitted in a drowsy state following head trauma in the occipital region. Pupils were myotie and light reflexes were barely elicited. Bleeding from the auditory canal and nystagmus on left lateral gaze were present. Right plantar response was absent. CT scan, immediately performed, showed a left PFSDH and a forward and contralateral shift of the fourth ventricle, spontaneously hyperdense. Right perimesencephalic cisterns were obliterated and the brain-stem was compressed on its left side (Fig. 2). Multiple supratentorial right frontal cerebral contusions with lateral ventricle compression were also found. During this examination the patient suddenly worsened into a state of deep coma, becoming respiratorily dependent and unresponsive to painful stimuli. Corneal reflexes were absent. At surgery, a left linear occipital fracture was encountered, and through a left suboccipital craniectomy a large PFSDH was removed and a few bleeding veins of the cerebellar surface were coagulated. During the post-operative course the patient progressively improved. On the 19th day after trauma, he underwent additional surgical treatment because of a supratentorial right frontal hygroma. A check CT showed the complete evacuation of the PFSDH, and the patient was discharged two months later with mild left-sided dysmetria. Case 3 A-16-year-old boy, who suffered a severe head trauma, was referred in a decerebrate state with GCS 4; pupils were myotic, and light reflexes and plantar responses were absent. X-ray films demonstrated an occipital comminuted fracture on right side. CT scan showed a right PFSDH associated with an extradural blood collection (Fig. 3) and small frontal cerebral contusions. The patient had altered blood coagulation (Quick's rate 33%). A right suboccipital craniectomy was performed and the extradural and subdural haematomas in the posterior fossa were removed. During the postoperative course the patient developed a CSF leakage which required surgical treatment. At discharge three months later he was disoriented and mild right sided dysmetria persisted.
M. Borzone et al.: Acute Traumatic Posterior Fossa SDHs
33
Fig. 1. (A-C) Case 1. Axial CT scan shows left occipital depressed fracture and right PFSDH which appears as a retrocerebellar high density flat-convex shaped area, similar to an epidural blood collection
Fig. 2. (A-C) Case 2. On axial CT views a left concavo-convex retrocerebellar hyperdense area is clearly demonstrated, which represents the typical aspect of PFSDHs. The fourth ventricle is hyperdense and contralaterally shifted
Discussion 1) Features of PFSDHs ( P e r s o n a l C a s e s and R e v i e w o f the L i t e r a t u r e ) a) C l i n i c a l F e a t u r e s T h e m a i n features o f the three patients in our series and o f the thirteen cases r e p o r t e d in l i t e r a t u r e are
s u m m a r i z e d in T a b l e 1. W e h a v e here e x c l u d e d the five n o n - a c u t e cases o f J a m i e s o n [47] o w i n g to lack o f data. O f the 16 cases, 12 w e r e m a l e s and 4 f e m a l e s , age r a n g i n g f r o m 3 to 84 ( m e a n : 32 years). In 60% o f these patients a s u d d e n c l i n i c a l w o r s e n i n g was e n c o u n t e r e d . E x c l u d i n g F i s h e r ' s patient, w h o was
parietal
occipital
drowsy
coma bilat, myosis, hypert. 4 limbs
stuporous
6/44yrs M/1965 Wright
7/22yrs F/1965 Wright
8/52yrs F/1980 Tsai
alert
3 / 6 yrs F/1961 Es~idge
5/84 yrs alert M] 1964 Ciembronewicz
drowsy stiff neck
2/51 yrs M/1958 Fisher
temporooccipital
occipital
deep coma
1/4 yrs F/1958 Fisher
RX Skull fracture
4/47 yrs alert M/1964 Ciembronewicz
Neurological findings
Case/Age Sex/Year Author
Table 1. Clinical Picture
CT scan
Examination
right
bilat.
right
right, extending to C2 level
right?
left
bilat?
Side of haematoma
right cerebellar haemorrhage, mild hydrocephalus
thin SDH in anterior & middle fossa
Associated lesions on CT scanning
few hours
few hours
2 days
few hours
few hours
1 day
1 day
no operation
Interval between trauma and surgical treatment
SDH: 60 cc. above 35 cc. below tentorium
Findings at surgery
30 cc. of SDH
worsened in few h coma, decerebrate state
worsened after 1 h coma, bilat myosis, decerebrate state
worsened after 2 days coma
SDH mm 8 thick
SDH mm 3 thick, bilat, cerebellar contusion
worsened after 6 b 40 cc. of deep coma, apnoeic, bi- SDH lat myosis, areflexic hydrocephalus
worsened after 1/2 h coma, anisocoria L >R areflexic, flaccid
worsened progressively: SDH cm 1.5 corneal reflexes absent thick flaccid, bilat Babinski
worsened after 24 h coma
Clinical conditions between admission and surgery
moderate disability
died 2 h after surgery
died 3 days after surgery
died 4 hours after surgery
died 20 hours after surgery
moderate disability
good recovery
died 1 day later
Outcome
GCS 10, bilat, myosis, nystagmus
GCS 4, occipital bilat, myosis, hypert. 4 limbs
15/47yrs M/1992 Personal
16/16yrs M/1993 Personal
occipital
GCS 3, bilat. mydriasis, flaccid
14/46yrs M/1992 Personal
occipital
GCS 10
13/16yrs M/1991 Stone
few hours
few hours right cerebellar haemorrhage, mild hydrocephalus few hours temporo-parietal cont-haemprrhages, fronto-telnp. SDH few hours
few hours
right frontal contusion
frontal contusions
frontal contusionhaemorrhages
left
left
right
left
right
CT scan
CT scan
CT scan
CT scan
CT scan
12/18yrs GCS 4, bilat M/1990 myosis Raftopoulos
few hours
no operation
cerebellar contusion
right
CT scan
combactive
11/24yrs M/1986 St, John
occipital
CT scan
GCS 3, eye deviated to right side
10/17yrs M/1980 Tsai
no operation
cerebellar contusion
right
CT scan
coma, bilat. mydriasis, flaccid, areflexic
Interval between uauma and surgical treatment
Associated lesions on CT scanning
Side of haematoma
Examination
9/22yrs IV[/1980 Tsai
RX Skull fi:acture
Neurological findings
Case/Age Sex/Year Author
Table 1. Continued
worsened after 1 h GCS 3, respiratory dependent, flaccid
worsened after 1 h GCS 3, bilat myosis
worsened after 9 h coma, bilat mydriasis
Clinical conditions between admission and surgery
right posterior fossa extradural haematoma
thin posterior fossa extradural haematoma
at 5th h surgery for fronto-pariet. SDH
few hours after
Findings at surgery
moderate disability
moderate disability
died 1 day after surgery
moderate disability
moderate disability
died 5 days after surgery
died 1 day later
admission
died
Outcome
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M. Borzone et al.: Acute Traumatic Posterior Fossa SDHs
Fig. 3. (A-C) Case 3. Large right retrocerebellar PFSDH associated with a smaller extradural haematoma (arrows). The fourth ventricle is collapsed and posterior fossa cisterns are completely obliterated
Table 2. Series in the Literature Since 1958 Author
Year
No. of cases
Died
Operated cases
Died
1958 1961 1965 1965
2 1 2 2
1 50% 0 0% 2 100% 2 100%
1 1 2 2
0 0% 0 0% 2 100% 2 100%
7
5 71%
6
4 67%
3 1 1 1 3
2 67% 1 100% 0 0% 0 0% 1 33%
1 1 1 1 3,
0 0% 1 100% 0 0% 0 0% 1 33%
9
4 44%
7
2 29%
Before C T scan
Fisher Estridge Ciembroniewicz Wright Total
After C T scan
Tsai St. John Raftopoulos Stone Present report Total
1980 1986 1990 1991 1994
m o r i b u n d and d i a g n o s e d at p o s t - m o r t e m , of the 9 initially c o n s c i o u s patients (3 alert, 1 c o m b a c t i v e , and 5 d r o w s y ) 7 s u c c o m b e d to a state of deep c o m a w i t h i n 30 m i n u t e s to 9 hours, w h i l e the other 2 w o r s e n e d i n 24 hours. Six patients were in a deep c o m a i m m e d i ately after trauma. Therefore all the patients were c o m a t o s e (44% i m m e d i a t e l y , 4 4 % w i t h i n 30 m i n u t e s
to 9 hours, and 12% w i t h i n 24 hours), the m a j o r i t y of t h e m (85%) p r e s e n t i n g i n a state of deep coma. Six patients had bilateral m y o s i s (37%), 3 bilateral m y d r i a s i s (19%) and in one case there was anisocoria. C o r n e a l reflexes were bilaterally absent in four cases, while i n another case the reflex was absent on one side and barely elicited o n the other (33%).
M. Borzone et al.: Acute Traumatic Posterior Fossa SDHs
Seven cases were unresponsive to painful stimuli (47%), three patients in a decerebrate state (19%) and another had hypertonus in all extremities. All these clinical signs are referrable to brain-stem compression. b) Radiological Features Eight patients (50%) had skull fractures: 7 in the occipital and one in the parietal region. Before the advent of CT scanning 6 patients were diagnosed at surgery and one at post-mortem. In the last 9 cases the PFSDH was found by means of CT scanning. Computed tomography has proved to be diagnostic. On CT scans acute PFSDH usually appears as a high attenuation retrocerebellar collection in a concavo-convex shape. Complete obliteration of the posterior fossa cisterns, considered as an unfavourable prognostic sign [8], was observed in 5 cases (31%), representing 50% of the CT diagnosed cases. Including the two cases in our series (cases 1 and 3), 60% of the patients with this CT aspect died. Hydrocephalus was encountered in 3 cases only (19%). c) Pathological Findings Usually the source of bleeding is a tear of a cerebellar cortical artery or vein [1], as we found at surgery in two of our cases. In the pre-CT era a tear of the lateral sinus has also been reported [2]. Operative findings and associated lesions shown on CT scan are summarized in Table 1. d) Treatment and Outcome Thirteen patients underwent surgery (81%). Two of them were operated on for a co-existing supratentorial subdural haematoma, and 1 patient (the second in our series) for a supratentorial hygroma. Three patients - case 1 (No. 2 in Fisher's series), and cases 9 and 10 (No. 19 and 20 in Tsai's series) have been conservatively treated, and all of them died: one a few hours after trauma, and two on the following day. Seven patients (46%) survived, presenting on the GOS in one case (14%) with a good recovery, and in six (86%) with moderate disability. In our series the second and the third patient, who developed hydrocephalus and was conservatively treated, presented
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only a mild dysmetria at 16 months and one year follow-up, respectively. Five of the 10 surgical cases reported in literature died: 3 within a few hours, and the remaining two, three and nine days after surgery, respectively. The first of our cases died the day after surgery. The overall mortality rate was 56%: 100% for the non-surgical cases, and 46% for those treated surgically. Comparing the patients surgically treated before and after the introduction of CT scanning, the mortality rate was reduced from 67% to 29% (Table 2).
2) Surgical Management On the basis of favourable results obtained in the five cases (cases No. 2, 3, 8, 12, 13) in the literature [2, 3, 5, 7, 8] and in two of our series, all presenting in extremely poor neurological conditions, we emphasize that prompt surgical treatment should be performed in all patients affected by acute PFSDH, even though moribund, to give them a chance of survival.
References 1. Ciembroniewicz JE (1965)Subdural hematoma of the posterior fossa. J Neurosurg 41:465-473 2. Estridge MN, Smith MA (1961) Acute subdural hemorrhage of posterior fossa. J Neurosurg 18:248-249 3. Fisher G, Kim JK (1958) Complications in posterior fossa due to occipital trauma-their operability. JAMA 167: 176-182 4. Jamieson KJ, Yelland JDN (1972) Surigcally treated traumatic subdural hematomas. J Neurosurg 37:137-149 5. Raftopoulos C, Reuse C, Chaskis C, Brotchi J (1990)Acute subdural hematoma of the posterior fossa. Clin Neurol Neurosurg 92:57-62 6. St John JN, French BN (1986) Traumatic hematomas of the posterior fossa. A clinicopathological spectrum. Surg Neurol 25:457-466 7. Stone JL, Ladenheim E, Wilkinson SB, Cybulski GR, Oldershow JB (1991) Hematoma in the posterior fossa secondary to a tangential gunshot wound of the occiput: case report and discussion. Neurosurgery 28:603 605 8. Tsai FY, Teal JS, Itabashi HH, Huprich JE, Hieshima GB, Segall HD (1980)Computed tomography of posterior fossa trauma. J Comput Assist Tomogr 4:291-305 9. Wright RL (1966) Traumatic hematomas of the posterior cranial fossa. J Neurosurg 25:402-409 Correspondence: Mario Borzone, M.D., Istituto di Clinica Neurochirurgica, Universita' di Genova, Viale Benedetto XV - Osp. San Martino, 1-16132 Genova, Italy.
