Traumatic Posterior Fossa Extradural Hematoma: Experience at Level I Trauma Center

Abstract

Introduction: Posterior fossa extradural hematoma (PFEDH) is rare among the traumatic brain injury and represent about 4-7% cases of all EDHs. This rare condition is rapidly fatal unless identified and intervened timely. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome.

Materials and methods: This study was conducted at Level I trauma center at All India Institute of Medical Sciences, New Delhi, India. Hospital medical records were reviewed from September 2007 to June 2015. There were 856 cases of acute EDHs and of these 69 cases had PFEDHs. Records of patients with PFEDHs were reviewed for the mode of injury, Glasgow Coma Scale (GCS) at admission, imaging, type of intervention, outcome, and follow-up. GCS was assessed at 6 months and 12 months follow-up. Pertinent literature is reviewed.

Results: Of these 69 patients, 51 were males and 18 females. The mean age of patients was 28.6 years (range 4-43 years). Forty-three patients had GCS 15 at admission, and only 4 of them had admission GCS <8. Mean EDH volume was 29.2 ml. Sixty-six patients were operated, three managed conservatively. Sixty-seven patients were discharged, of which, 56 (81.1%) had GCS 15. Two patients died. Most common associated injuries were long bone fractures (18, 26.1%) followed by blunt injury thorax (11, 15.9%). Mean follow-up duration was 69.2 months (range 6-94 months). At 6 months follow-up, 61 (88.4%) patients had good recovery (Glasgow Outcome Score [GOS] 5) and at 12 months, 62 (89.8%) had GOS 5.

Conclusion: PFEDH are rare. They are usually associated with occipital bone fractures and may also have a supratentorial hematoma. It may be rapidly fatal due to the expansion of hematoma and compromise of the posterior cranial fossa space leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early diagnosis and emergent evacuation lead to good outcome.

Keywords: Extradural hematoma; posterior fossa; surgery; trauma.

Figure 1

(a) Another patient with posterior fossa extradural hematoma straddling the transverse sinus showing the infratentorial part, (b) supratentorial part of extradural hematoma in the same patient as in Figure 2a, (c) postoperative scan of patient in Figure 2a showing complete evacuation

Figure 2

(a) Preoperative computed tomography showing posterior fossa extradural hematoma with compression of the fourth ventricle and dilated temporal horns, (b) preoperative scan of patient in Figure 1a showing upstream hydrocephalus, (c) bone window showing occipital bone fracture, (d) postoperative scan showing complete evacuation of extradural hematoma

Figure 3

(a) Another patient's scan showing posterior fossa extradural hematoma and left sided frontotemporal acute subdural hematoma and bilateral frontal contusions and subarachnoid hemorrhage, (b) postoperative scan of patient in a showing evacuation of posterior fossa extradural hematoma and left-sided acute subdural hematoma and bilateral frontotemporal decompressive craniectomy