ACTA NEUROCHIRURGICA

Acta Neurochirurgica62, 79--85 (1982)

9 by Springer-Verhg1982

Neurosurgical Department and * Neuroradiological Service, University HospitalPadova, Italy

Traumatic

Posterior Fossa Haemorrhage

in C h i l d r e n * *

By

M. Zuccarello, G. C. Andrioli, D. L. Fiore*, P. L. Longatti, K. P a r d a t s c h e r * , and P. Zampieri With 4 Figures

Summary We report ten cases of post-traumatic posterior fossa haemorrhage occurring in children. All patients were studied by CT scan. Five had an intracerebellar haemorrhage, three a brain stem haemorrhage, and two an extradural haematoma. In four cases we have found the coexistence of supratentorial and infratentorial haemorrhagic lesions. The incidence of posterior fossa haemorrhage in children, the importance of linear occipital fracture, the clinical course, the conservative or surgical treatment, and the prognosis are discussed.

Keywords: Head injury; posterior fossa haemorrhages; children; CT scan. Introduction T r a u m a t i c haemorrhages in the posterior cranial fossa are relatively rare 3, ~, and were considered an u n c o m m o n consequence of head i n j u r y in children in the p r e - C T era, because some were not diagnosed. The availability of c o m p u t e d t o m o g r a p h y (CT) has allowed more extensive studies on the location and characteristics of the h a e m o r rhage lesions 1, ~, s, 10, 11, 1~-17 It seems t h a t t r a u m a t i c posterior fossa haemorrhages are less infrequent t h a n was previously thought. Posterior fossa h a e m a t o m a m a y be epidural, subdural, or intraparenchymal. ** This paper was presented at the 7th International Congress of Neurological Surgery, Miinchen, 12-18 July 1981. 0 0 0 1 - 6 2 6 8 / 8 2 / 0 0 6 2 / 0 0 7 9 / 8 01.40

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We have reviewed our experience with this entity, and now report the impact of CT on the management of posterior fossa injury at the Neurosurgical Department of Padua. Materials and M e t h o d s At the Neurosurgical Department of Padua, more than 500 children have been investigated from July 1978 to May 1981. The patients were studied with an Ohio Nuclear Delta 25 scanner with an 8 mm collimator. Blood in the posterior fossa, as shown by increased attenuation either in the extraaxial or intraaxial compartment, was identified in 10 patients (20/o = l~ Parenchymal injuries were more frequent than extraaxial haematomas. A classification of these injuries and their frequency is given in Table 1. Table 1. Frequency of Types of Posterior Yossa Trauma in Children Epidural haematoma Subdural haematoma Cerebellar injury Brain stem injury Total

2 5 3 10

Epidura! Haematomas The incidence of epidural haematomas (EDH) in the posterior cranial fossa ranges from 4 to 7% of all epidural haematomas. This lesion may be particularly prevalent in children 18. In our series of patients operated on for E D H 14 were children, and the incidence of posterior fossa epidural haematomas was 14~ (2/14); seventy-six patients were adult, in whom the incidence of E D H in the posterior cranial fossa was 10~ (8/76). In our cases the mechanism of injury was direct occipital trauma. An occipital fracture was identified in two cases. Our two children with E D H had "lucid intervals" prior to deterioration, but were comatose on admission. The diagnosis was made by CT scan, and a concomitant, frontal, contralateral supratentorial lesion was present in one case. The two patients were operated on by sub-occlpital craniectomy immediately after CT examination, and both made good recoveries

(Fig. i). Cerebellar Injury This occurs rarely in head trauma, and then usually from a direct blow to the occiput, or exceptionally as a contracoup injury 9, 18. Reports of haematoma within the cerebellum following trauma are rare. Schneider et aI. 12 reported four cases due to occipital trauma, Fisher 3 two fatal cases, Gurdjian 4 two cases, and Wright 18 six cases. More recently Tsai et al. iv reported 14 cases, 2 in children. In our series of patients we were able to find three cases. The incidence of cerebellar injury compared with the total number of brain contusions in children is 12~ (5/41, which is higher than that found in adults (I~ = V3"29). The first patient struck the back of her head when she fell from a tricycle on to the sidewalk. She was not immediately unconscious, but a few hours later

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Fig. 1. CT scan shows a left epidural haematoma. The fourth ventricle is displaced towards the right side

Fig. 2. CT scan show an occipital fracture and a left intracerebellar haematoma

lethargy and vomiting began. On admission to our Department she was comatose. Skull X-rays showed no fracture. A C T scan revealed a left cerebellar haematoma (Fig. 2). She was immediately operated on, and she recovered completely. The second patient, a one-year-old child, was struck by a car. On admission she was comatose, but responsive to deep pain with decerebrate posturing. Skull X-rays showed a right occipital fracture. CT scan showed a right cerebellar haemorrhage and CT findings indicative of secondary brain stem injury. The patient deteriorated rapidly, and died before a decompression could be done. The last three patients, victims of vehicle accidents, were not unconscious, and on admission to the hospital they were moderately lethargic, but otherwise the neurological examination was normal. Skull X-rays showed an occipital fracture 6

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Fig. 3. The first CT scan reveals a haemorrhagic density in the left cerebellum (a); the second CT scan seven days later shows no evidence of the lesion (b)

Fig. 4. On CT scan a small right haemorrhagic area is seen in the pons (a), and blood is present in the posterior fossa cisterns and in the fourth ventricle. Brain slices show haemorrhage corresponding to the CT finding (b)

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in all cases and in the CT scan a cerebellar contusion. They were not operated on, but they were submitted to serial CT scan control (Fig. 3). The patients improved spontaneously, and were discharged in good condition. Primary Brain Stern Injury

Before the advent of the CT scan, brain stem injury was usually a postmortem diagnosis. In our experience the mortality rate is 84~ once the CT diagnosis of primary brain stem injury is made. Our three patients had a Glasgow Coma score of less than 7, and decerebrate posturing was present initially in all patients. They died three days after admission (Fig. 4). Discussion

H e a d injuries in children are different from those in adults. A child may appear to be in shock, with generalized pallor and fluctuating vital signs, but much of this m a y be due to fright; since the skull of an infant or young child can readily expand, serious intracranial bleeding in the posterior cranial fossa m a y be accomodated to such an extent that neurological signs are greatly delayed. Clinical evaluation must include history and general physical and careful neurological examination. Skull X-rays m a y be valuable as an adjunct to help clarify CT findings, but in a case of child head trauma the presence of a skull fracture does not greatly increase the risk of intracranial haemorrhage and death. Twenty per cent of skull fractures in our series involved the occipital bone, and less than 4 % were associated with haematomas. Several posterior fossa epidural haematomas have been reported without skull fracture 5, 1% However, in our series both epidural haematomas and four out of five cerebellar injuries were associated with occipital fractures. CT scan has to be considered the primary non-invasive diagnostic procedure of choice to evaluate intracranial sequelae of tramna, and in our experience CT was sufficient to determine accurately the nature and extent of posterior fossa injuries. C T scan not only facilitates the diagnosis of posterior fossa haematomas, but is also able to reveal associated supratentorial haematomas that in the pre-CT scan era could have gone undetected. The prognosis of posterior cranial fossa epidural haematoma is good 6, 7, 18 providing the lesion is recognized and adequate surgical treatment is instituted promptly. We have successfully treated both our cases. This is only partially true in cases of cerebellar haemorrhage an indication for surgery exists whenever hydrocephalus is detected or 6*

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when a large cerebellar haemorrhage causes brain stem compression with neurological signs of dysfunction. In fact, we have medically treated with success three cases out of five avoiding a surgical procedure in our little patients, indicating that cerebellar injury can be a benign injury. On the other hand, in some individuals it is lifethreatening depending on the size and proximity of cerebellar haemorrhage to the brain stem. In such cases an immediate craniectomy for decompression of the brain stem must be carried out, however, in some cases the brain stem compression may be due to a delayed reaction caused by parenchymal swelling. We recommend also the use of a ventricular tap to reduce the supr~atentorial pressure not only during surgery but also in the postoperative course when cerebellar swelling can cause an acute obstructive hydrocephalus with neurological signs of diencephalic coma. Finally, in the case of brain stem injury the prognosis is obviously very poor; of course, the main CT sign of brain stem injury is the finding of high density area, but obliteration of the posterior fossa cisterns is also a reliable indicator of the lesion and its poor prognosis 17. References 1. Arkins, T. J., McLennan, J. E., Winston, K. R., Strand, R. D., Suzuki, Y., Acute posterior fossa epidural haematomas in children. Am. J. Dis. Child 131 (1977), 690--692. 2. Dublin, A. B., French, B. N., Rennick, J. M., Computed tomography in head trauma. Radiology 122 (1977), 365--369. 3. Fisher, R. G., Kim, J. K., Sachs, E., jr., Complications in posterior fossa due to occipitaI trauma--their operability. JAMA 167 (1958), 176--182. 4. Gurdjian, E. S., Surgical treatment of patients with head injury. Presented at 14th annual meeting of Congress of Neurological Surgeons, Bal Harbour, Florida, November 18, 1964. 5. Harwood-Nash, D. C., Hendrick, E. B., Hudson, A. R., The significance of skull fractures in children: A study of 1,187 patients. Radiology 10i (1971), 151--155. 6. Herren, R. Y., Zeller, W. E., Extradural haematomas of the posterior fossa. Arch. Surg. 60 (1950), 953--956. 7. Lemmen, L. J., Schneider, R. C., Extradural haematoma of the posterior fossa. J. Neurosurg. 9 (1952), 245--253. 8. Miiller, H. R., Wiithrich, R., Wiggli, U., Hiinig, R., Eke, M., The contribution of computerized axial tomography to the diagnosis of cerebellar and pontine haemorrhage. Stroke 6 (1975), 467--475. 9. Olin, M. S., Young, H. A., Schmidek, H. H., Contrecoup intracerebelIar haemorrhage: Report of a case. Neurosurgery 3 (1980), 271--273. 10. Parkinson, D., Hunt, B., Shields, C.: Double lucid interval in patients with extradural haematoma of the posterior fossa. J. Neurosurg. 34 (1971), 534--536. 11. Pressman, B. P., Kirkwood, J. R., Davis, D. O., Posterior fossa haemorrhage localization by computerized tomography. JAMA 232 (1975), 932--33.

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12. Schneider, R. C., Craniocerebral trauma. In: Correlative Neurosurgery (Kahn, E. A., Bassett, R. C., Schneider, R. C., Crosby, E. C., eds.), pp. 275--326. Springfield, Ill.: Charles C Thomas. 1955. 13. Stone, J. L., Schaffer, L., Ramsey, R. G., Moody, R. A., Epidural haematomas of the posterior fossa. Surg. Neurol. 11 (1979), 419--424. 14. Tsai, F. Y., Huprich, J. E., Gardner, F. C., Segall, H. D., Teal, J. S., Diagnostic and prognostic implications of computed tomography of head trauma. J. Comput. Assist. Tomogr. 2 (1978), 323--331. 15. Tsai, F. Y., Huprich, J. E., Further experience with contrast-enhanced CT in head trauma. Neuroradiology 16 (1978), 314--317. 16. Tsai, F. Y., Quinn, M. F., Itabashi, H. H., Teal, J. S., Ahmadi, J., Segall, H. D., The role of computed tomography in the evaluation of head trauma. Excerpta Medica Extract 6 (1979), 2--13. 17. Tsai, F. Y., Teal, J. S., Itabashi, H. H., Huprich, J. E., Hieshima, G. B., Segall, H. D., Computed tomography of posterior fossa trauma. J. Comput. Assist. Tomogr. 4 (1980), 291--305. 18. Wright, R. L., Traumatic haematomas of the posterior cranial fossa. J. Neurosurg. 25 (1966), 402--409. 19. Zuccarello, M., Pardatscher, K., Andrioli, G. C., Fiore, D. L., Iavicoli, R., Cervellini, P., Epidural haematomas of the posterior cranial fossa. Neurosurgery 8 (1981), 434--437. Authors' address: Dr. M. Zuccarello, Neurosurgical Department University Hospital, Via Giustiniani 5, 1-35100 Padova, Italy.