Acute subdural hematoma of the posterior fossa

Case reports

Acute subdural hematoma of the posterior fossa

A case report and a review of the relevant literature.

Chr. Raftopoulos*, Ch. Reuse* *, C. Chaskis*, and J. Brotchi”

Introduction

In this paper we will describe the clinical presentation, pathogenesis and outcome of Oper- ated Acute Subdural Hematoma of the Post- erior Fossa (OASDH-PF) as reported in literature, illustrated with a personal case.

Our approach of this pathology has led us to choose between various definitions (Table 1) often imprecise or even uncited in some articles. The variable outcome of each type (acute, subacute, chronic, simple, complicated) of subdural hematoma and the inconstant prognosis link- ed to the age of the patient requires precise definitions for every term used.

First, according to McLaurin and Tutor’, an acute subdural hematoma (ASDH) is a subdural hematoma requiring surgery within 24 hours after trauma. Other authors, however, do not nec- essarily agree completely with this definition, as shown in Table 1. We will consider this variance in the definition later in the discussion.

Next, like Jamieson and Yelland’, we distinguish two types of ASDH: the Simple Acute Subdural Hematoma (SASDH) and the Com- plicated Acute Subdural Hematoma (CASDH). The latter is caused by brain laceration and contusion, sometimes associated with an intraparenchymal hematoma3 and occasionally with

Summary

Acute subdural hematoma of the posterior fossa (ASDH-PF) is a clinical rarity with a poor prognosis in teenagers or adults (mortality rate: 71%). We report the third case operated upon with success. The relevant literature is analysed and the characteristics of ASDH-PF are discussed, particularly in connection with the patient’s age.

Key words: Subdural hematoma, posterior fossa, head injury.

avulsion of the bridging vessels to the longitudi- nal, sphenoparietal or superior petrosal sinus- es4. Thus in this group (CASDH) we also in- clude cases with intraparenchymal hematomas. In contrast, SASDH are exclusively produced by tearing or avulsion of these bridging vessels without direct brain lesion.

Not having found a recent analysis focusing on acute subdural hematoma of the posterior fossa in children as well as in adults, knowing the rarity of this pathology’ and the importance for the prognosis of the delay between the trauma and the operation6 not considered for this local- isation, our favorable case has prompted this case report and the following survey of the literature.

Departments of Neurosurgery* and Intensive Care * * Erasmus Hospital, lJniversit.5 Libre de Bruxelles, Brussels, Belgium. ,

Address for correspondence and reprint requests: Chr. Raftopoulos, Department of Neurosurgery, Erasmus Hospital, Universitt! Libre de Bruxelles, 1070 Brussels, Belgium.

Accepted 14.11.88

Clin Neural Neurosurg 1990. Vol. 92-1

57

Table 1. Important variation exists in the literature regard- ing the definition of Acute Subdural Hematoma (ASDH).

1. When fresh brain injury is observed

1942 Munro

2. When emergency surgery is required during: a. the first week 1956 Echlin & al b. the first 3 days 1960 McKissock

& al 1962 Rosen-

bluth & al 1972 Jamieson

& Yelland c. the first 2 days 1971 Ransohoff

& al d. the first 24 hours 1961 McLaurin

& Tutor

Case report

An l&year-old man was thrown backwards by a car while crossing a street, hitting his occiput. He was in deep coma immediately, bleeding from his left auditory canal and from a posterior scalp wound raised by an underlying scalp hematoma. He was rapidly transferred to our in- stitution. The score on the Glasgow coma scale one hour after trauma was poor with only 4 (El, M2, Vl) and no signs of lateralisation. Pupils were in tight myotic and the vestibulo-ocular reflexes were abolished. A right subcapital hu- meral fracture was present.

Fig. 1. Computerized Tomography showing left cerebellar lesion underlying an Acute Subdural Hematoma of the Post- erior Fossa (ASDH-PF). The fourth ventricule is collapsed. There is a right frontal laceration.

Cerebral computed tomography (CT) showed subdural hematoma (SDH) in the posterior fossa due to a left cerebellar contusion-laceration with a collapse of the fourth ventricle (Fig. l), thus being a complicated acute subdural hematoma (CASDH) according to our criteria defined above. This lesion was associated with a right frontal contusion and two scalp hematomas: a large one in the left occipital area and smaller one in the right parietal area.

An hour and a half after the trauma, he was in the emergency operating room where the first surgical act consisted in a left occipital ventricular puncture followed by left craniectomy of the posterior fossa. A subdural hematoma under pressure was evacuated, revealing a left cerebellar contusion-laceration. This lesion was re- sected and the operation ended with the suture of the occipital scalp wound.

The patient remained in the intensive care unit for one month. CT performed after 3 days showed the complete disappearance of the subdural hematoma in the posterior fossa (SDH- PF) (Fig. 2), appearance of delayed contusional lesions in the left frontal area, extension of the right frontal contusion and a right parietal fracture at the level of the small scalp hematoma which had not been previously detected. Four days after surgery a new intracranial pressure monitor was set in place in the right frontal horn to relieve persistent intracranial hypertension.

Fig. 2. Computerized Tomography performed 3 days after the operation, showing a more transversal section of the brain than figure 1. demonstrating the disappearance of the Subdural Hematoma (SDH), and a smaller cerebellar laceration with a still collapsed fourth ventricule.

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It was removed five days later. The patient was kept on hyperventilation for the next 13 days. During this stay in the Intensive Care Unit a left pleural collection appeared, requiring surgical drainage and antibiotherapy.

His condition improved progressively. A month and a half later our patient was able to walk with aid. Two months later, he walked alone and his neurological status showed only mildly impaired gait without cerebellar symp- toms, a right moderate central facial paresis and also a moderate decrease of visual acuity of the left eye. From a neuropsychological standpoint, his understanding was slowed and his speech slurred.

In the post-operative period, 3 CTs were made at regular intervals. The ventricular dila- tion observed one month after the trauma remained unchanged on the subsequent CT. The Evans’ index remained at 0.34.

The follow-up at 5 months after trauma showed obesity due to bulimia, a positive Rom- berg’s sign and an unchanged acuity of th’e left eye (3110). His understanding and his speech were improved.

Discussion

We have studied the literature which especially concerned the impact of surgery in the treat- ment of ASDH-PF. However before presenting the operative series an autopsy series published by Vance in 19277 must be borne in mind. It reports 507 autopsies of severely head injured patients and concludes that subdural hemor- rhages of posterior fossa are ‘rather rare and most of them insignificant’, conclusions quite imprecise.

Our first discussion concerns the definition of ASDH. Different definitions of ASDH are giv- en in literature. If we study Table 1 we notice that the time between injury and operation is not only the basis for the definition, but also a parameter that varies. The shortest time interval, i.e. 24 hours, is proposed by McLaurin and Tutor in 1961’ as Rosenbluth et al. in 19628, Ransohoff et al. in 19719 and Jamieson and Yel- land in 1972’set the interval at 2 or 3 days, while Echlin considered an ASDH as requiring surgery during the first weeklo. Since an SDH requiring surgery 24 hours or more after trauma

has a better prognosis than the one requiring surgery during the first 24 hours, the definition of Acute SDH of McLaurin & Tutor’, i.e., a hematoma requiring surgery during the first 24 hours after trauma, seems appropriate. Review- ing reported cases of ASDH-PF, we did not find any series dealing specifically with this type of SDH-PF.

Literature6, however, outlines the importance of the delay between trauma and surgery.

Another observation is the frequent finding of the existence of parenchymal laceration associated to ASDH. The information necessary to distinguish ‘Simple’ ASDH (SASDH) from ‘Complicated’ ASDH(CASDH) is often not available. Yet this difference is useful because the prognosis of SASDH is somewhat better (63%) than of CASDH (77%)*.

Let us now consider particularly SDH of the Posterior Fossa and outline some characteristic facts: rarity, confusing clinical presentation, frequent association with contrecoup supratentorial complications, variable prognosis according to the population considered and mortality higher than of supratentorial SDH. A review of the literature has led to one table concerning all SDH-PF reported in the literature (Table 2)“-23,5~*4‘*7,*,~,*9,30. Only 33 operated SDH_PF

(ASDH-PF) were reported, mentioning the patients age and the delay between trauma and surgery. Among them, only 7 acute SDH-PF were reported, all in the teenage or adult population. The first case of ASDH-PF operated on with success was reported by Childe et all7 in 1953. The case operated on with success reported by Neisser and Pollack in 1904ll was not an acute case, for the operation was performed more than 10 days after trauma. Our case is the 8th operated case belonging to the teenage- adult group reported in the literature and only the 3rd operated on with success. With regard to the global frequency of SDH-PF compared with all intracranial SDH we have found one case of SDH-PF for 62 SDH in the series of Munro13, two cases of SDH-PF out of 389 cases of SDH in the series of McKissock et aP’, 3 out of 535 cases in the series of Ciembroniewic? and 2 other cases out of 553 in the series of Jamieson and Yelland in 19722. Thus there are only 8 SDH-PF observed in 1539 SDH (0,52%). The explana- tion of the rarity of the SDH-PF is twofold (Fig.

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Table 2. Subdural hematomas of the posterior fossa (SDH-PF) described in literature

t

1st author + reference number

year Operated SDH-PF (OSDH-PF)

number mortality

< 12 yrs > 12 yrs < 12 yrs > 12 yrs

A SA/Cr C A SAiCr C A SA/Cr C A SAlCr C

Neisser” 1904 Pickeni2 1928 Munro” 1934 SchreiberrJ 1939 Coblerm? 1940 MartinezI 1949 Childeb 1953 Pourpre18 1957 Fisher”* 1958 Nelson” 1959 McKissock2r 1960 Estridge’* 1961 Reighz3 1962 Ciembroniewiczs 1964 Wright24 1965 Pitlyk= 1967 GillesZfi 1970 Carterz7 1971 Jamieson” 1972 Serfontein” 1980 Hadj-Djilani23 1981 Hernansanr?’ 1984

1 1

1

1

2

1 1 I 1

1 1 1

2 li 2 2

1 1 I 1 0

0 1

1 0 1 1 1

0 2

0 0

1 I 0 1 4 1

0 0** 0

2 0 0 0

0 1 1 (I

0 0

0 1

1

1 1 1

Total 0 14 0 7 14 2 0 5 6 I

Mortality (%) 0 71 42.8 50

yrs = years A = acute SA/Cr = subacute and chronic C = complicated

* we omitted one of the four cases reported in this article, because no age was mentioned * * patient died from sepsis, thus the mortality related to the SDH is considered negative + we considered only one of the three cases reported, as the other two cases were low-weight premature infants.

3). First, the traumatic impact must be under the inion in a small nearly horizontal region well protected by muscles. Secondly the most com- mon way to strike this region is a backward fall with the head sufficiently in flexion so that the planum nuchale of the occipital bone becomes parallel to the ground and therefore more ex- posed to be injured (Fig. 3). We observed 2 other facts: firstly the absence of ASDH-PF in very young patients. This can be explained by the elasticity of the cranium because of the un- closed sutures during the first year of life. After this time, once the sutures are closed, the reason

for the lack of SDH-PF is not clear. The second fact is the extreme rarity of ‘complicated’ cases: only 2 in the teenage-adult group (> 12 yrs) are reported and none in the neonate-baby-infant (< 12 yrs) group. Hence our case is the third for the teenage-adult group. This rarity is due to the same reasons as already illustrated in Fig. 3, and to the low energy involved in the neonate head moulding considered as the essential factor in the newborn ASDw0.U**9.

The confusing clinical presentation of the SDH-PF is already well known. As Ciembro- niewicz’ stated: ‘a well-defined syndrome can-

Fig. 3Schematic diagram showing the mechanism of the Acute Subdural Hematoma of the Posterior Fossa (ASDH- PF). The patient is thrown backwards so that his flexed head strikes the ground under the Inion on the Planum Nuchale of the OS occipitale causing cerebellar laceration resulting in a SDH in the Posterior Fossa compressing the brain stem (arrows) and the cerebellum with tonsil herniation (arrows).

not be described’. Nevertheless, a few features must suggest the presence of ASDH-PF: princi- pally the occipital localization of the trauma even without skull fracture, nuchal rigidity and disturban~ of consciousness. In the chronic form, cranial nerve involvement and cerebellar signs are more frequent, This confusing clinical presentation is demonstrated by a very small number of preoperative clinical diagnosis5*“~‘s. So, SDH-PF is often discovered by CT, as in our case.

A frontal right cerebral contusion was present in our patient. Association of a posterior fossa hematoma with a supratentorial contrecoup lesion has already been stressed by Schneider et al. in 195331. They reported four cases of intracerebellar hematoma with associated contrecoup supratentorial contusion or hematoma.

Finally we have observed that the prognosis of SDH-PF varies according to the patient’s age (Table 2).

Due to this fact, we have distinguished the same two populations as before, a group including neonates, babies and infants, the age ranging from the newborn to the age of 12 years and another including teenagers and adults. As showed in Table 2, the mortality rate of SDH- PF in the former group is null, whereas it varies

from 42% to 71% in the latter group. This observation has not been established so far in the literature, since Ciembroniewicz’ concludes in his paper that ‘with immediate surgery excellent recovery is reasonably anticipated’ without reference to the patient’s age! Of the 7 ASDH-PF operated on in the teenager or adult population, only 2 patients survived (mortality rate: 71%). Considering the case we reported, the poor preoperative state, the acute evolution in a adult patient, the association with a cerebellum laceration (complicated) and the very favorable post- operative evolution make it exceptional, compared to the results from the literature.

ASDH-PF in the teenage-adult-group have a mortality rate of 71%. Supratentorial acute subdural hematomas have a mortality rate of 50% (ages mixed)32. The reason of this worse prognosis is probably the low compliance of the posterior fossa compartment (Fig. 3). At this level the ventricular system is limited to the small fourth ventricle as opposed to the supratentorial level which contains the two lateral ventricles and the third ventricle. In addition one should be aware of the immediate nearness of the brain stem, especially the medulla oblongata which, regulates cardio vascular and respiratory func- tions. A rapid increase of SDH volume or brain edema can induce a rapid direct compression of the brain stem with tonsillar herniation and sud- den death, sometimes without obvious change in vital signs, that warn of the impending disas- ter3’.

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Acknowledgements

We would like to thank Mrs. F. Delecluse, M.D., and Mr. M. Vloeberghs, M.D., for their review of this manuscript.

References

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Acute subdural hematoma of the posterior fossa

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