Romanian Neurosurgery (2019) XXXIII (2): pp. 160-165 DOI: 10.33962/roneuro-2019-030 www.journals.lapub.co.uk/index.php/roneurosurgery Traumatic posterior fossa extradural hematoma. A comprehensive analysis of cases from a tertiary care centre in Southwestern Rajasthan Vibhu Shankar Parashar, Vivek Kumar Kankane, Gaurav Jaiswal, Tarun Kumar Gupta * Department of Neurosurgery, Rabindra Nath Tagore Medical College & M.B. Groups of Hospital, Udaipur, Rajasthan, INDIA ABSTRACT Background. Extradural hematoma of posterior fossa (PFEDH) is less common and there are not many articles about PFEDH. These patients can deteriorate very rapidly due to compression over brainstem. Thus, early identification and immediate intervention can save the lives of these patients. Objective. This study aims to conduct a comprehensive analysis of patients with PFEDH and evaluate the postoperative outcome which may be of help to make further preventive strategies. Methods and Materials. The study included 16 patients admitted with traumatic PFEDH from July 2016 to July 2018 at R.N.T. Medical College & M.B. Groups of Hospital Udaipur, southwestern Rajasthan, India. We have retrospectively reviewed the data. Analysed factors were gender, age, Glasgow Coma Scale (GCS), Noncontrast CT scan findings, associated brain injury, type of intervention, Glasgow Outcome Scale (GOS). GOS was assessed at discharge, at 3 months and 6 months follow-up. Results. Out of a total of 16 patients, 11 were male and 5 were female with age ranging from 05-46 years. 12 patients had GCS 13 -15 at admission and only one of them had GCS < 8. 15 patients underwent surgical intervention. At 6 months follow- up, 12 patients had good recovery GOS is 5. Conclusion. Early detection and immediate evacuation of PFEDHs should be done if causing fourth ventricle, basal cistern or brain stem compression. It may be rapidly fatal due to the expansion of hematoma leading to brainstem compression, tonsillar herniation, and/or obstructive hydrocephalus. Early detection and immediate evacuation lead to a better outcome in these patients. INTRODUCTION PFEDH is an uncommon trauma sequel accounting for only 4% to 12.9% of all EDHs [1,2]. In PFEDH clinical progress may be silent and slow, but sudden deterioration may occur without significant warning signs. Because of limited space in posterior fossa, comparatively small volume can cause clinical deterioration. The patient may deteriorate very rapidly due to compression over the brainstem usually without Keywords posterior fossa, extradural hematoma, traumatic, Glasgow outcome Scale Corresponding author: Vivek Kumar Kankane Rabindra Nath Tagore Medical College & M.B. Groups of Hospital, Udaipur, Rajasthan, India drvarunaggarwal86@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2019 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 161 Traumatic posterior fossa extradural hematoma any prior warning sign. Thus, early intervention before progression to herniation is lifesaving. Early diagnosis by cranial computed tomography and emergent evacuation is vital for a good outcome [3]. MATERIAL AND METHODS In our study, we have retrospectively reviewed the data from July 2016 to July 2018 at tertiary care hospital in R.N.T. Medical College & M.B. Groups of Hospital Udaipur, southwestern Rajasthan. We found 16 cases of traumatic Extradural Hematoma (EDH) which were located in the posterior fossa. The Data was analysed for clinical presentation, Glasgow Coma Scale (GCS) at admission, mode of injury, radiological findings, any other associated intracranial traumatic lesion, type of intervention and postoperative outcome. Postoperative scans, within 6-12 hour of surgery were acquired in all cases. Outcomes were assessed on the basis of Glasgow Outcome Score (GOS) divided into good (normal, moderate disability) and poor (severe, vegetative, dead) outcome at 3 months, 6 months of follow-up. We also assessed the prognosis of posterior fossa EDH depending on the compression over the fourth ventricle, basal cistern and brain stem. All patients were divided in two groups. Group A were those who showed isolated PFEDH and in group B were those patients who showed PFEDH associated with brain injury. FIGURE 1. NCCT head revealed Left posterior fossa Extradural Hematoma with supratentorial extension FIGURE 2. NCCT head revealed left posterior fossa Extradural Hematoma with bilateral frontal intracerebral hematoma 162 Vibhu Shankar Parashar, Vivek Kumar Kankane, Gaurav Jaiswal et al. RESULTS A total of 16 cases of PFEDHs were admitted to our tertiary care centre during 24 months from July2016- July 2018.The mean age of patients was 28.6 years (range 5-46years). 3 (18.75%) of them were below 18 years. 5(31.25%) of them were Females (TABLE 1). Outcome was better in paediatric patients. Most common mode of injury was road traffic accident (n= 11, 68.75%), rest were either fall from height (n = 04, 25%) or assault (n =1, 6.25%) (TABLE - 2). Most common associated radiological finding is occipital bone fracture followed by supratentorial extension of EDH and frontal contusions (TABLE 3). 15 patients underwent surgical evacuation. At 6 months follow-up, 12 (75%) patients had good recovery and one patient died (6.25%) (TABLE 4). Patients with PFEDH with associated brain injury had lesser GCS Score on admission with increased volume of EDH, increased hospital stay. Outcome was poor in PFEDH patients with associated intracranial injury as compared to those with isolated PFEDH. (TABLE 5) TABLE 1. Correlation of Gender and Age and outcome analysis Total cases Number. of patients (N=16) AGE<18 Yrs AGE>18 yrs Percentage (%) Good outcome (GOS 3-5) Poor outcome (GOS1-2) Gender Male 11 03 08 68.75% 10 01 Female 05 00 05 31.25% 03 02 Age Pediatric patients (<18) 03 18.75 % 03 00 Adults 13 81.25% 10 03 Total 16 100% 13 03 TABLE 2. Correlation of mode of injury, GCS at admission and outcome analysis No. of patients Percentage Good outcome (GOS 3-5) Poor outcome (GOS 1-2) Mode of injury Road traffic accident 11 68.75% 09 02 Fall from height 04 25% 03 01 Assault 01 6.25% 01 00 GCS at admission 13-15 12 75% 12 00 9-12 03 18.75% 01 02 3-8 01 6.25% 00 01 Total 16 100% 13 03 163 Traumatic posterior fossa extradural hematoma TABLE 3. Analysis of clinical presentation and radiological findings Number of patients Percentage Clinical presentation Headache 10 62.5% Altered sensorium 06 37.5% Vomiting 08 50% Radiological findings Occipital bone fracture 12 75% Frontal contusions 01 6.25% Supratentorial extension of EDH 02 12.5% Hydrocephalus 01 6.25% Intraventricular hemorrhage 01 6.25% TABLE 4. Outcome based on GOS (Glasgow outcome score) Outcome based on GOS Discharge At 3 months At 6 months GOS 5 11 12 (75%) 12 (81.25%) GOS 4 03 01 (6.25%) No follow up GOS 3 00 01 (6.25%) 01 (6.25%) GOS 2 01 01 (6.25%) 01 (6.25%) GOS 1 01 - - TABLE 5. Analysis of patients with isolated PFEDH and those with associated brain injuries Parameters Isolated PFEDH (Group A) PFEDH and associated brain injury (Group B) Total patients 13(81.25%) 03(18.75%) Radiological findings Occipital bone fracture 10(76.9%) 02(66.7%) Frontal contusions - 01(33.3%) Supratentorial extension of EDH - 02(66.7%) Hydrocephalus - 01(33.3%) Intraventricular hemorrhage - 01(33.3%) GCS (admission) 15-13 11 01 12-9 02 01 8-3 00 01 Management Surgical evacuation 11 03 Conservative 02 00 Failed conservative and operated 01 00 GCS (discharge) 164 Vibhu Shankar Parashar, Vivek Kumar Kankane, Gaurav Jaiswal et al. 15-13 13 01 12-9 00 01 8-3 00 01 Good outcome (GOS 3,4,5) 12 01 Poor outcome (GOS1,2) 01 02 DISCUSSION Traumatic brain injury is emerging as the most common cause of morbidity and mortality in both developed and developing countries. PFEDHs are reported to constitute 0.1–0.3% of all cranial traumatic conditions. Loss of consciousness and vomiting are the most frequent presenting features of PFEDH which comprises around 10% of EDH. A history of occipital bone fracture combined with these symptoms should raise suspicion of PFEDH. Lucid interval is classically seen in EDH; however, it is uncommon in PFEDH and in children. A rapid deterioration is a feature of these lesions. Thus, all patients need to undergo imaging promptly in order to diagnose the lesions. Unlike supratentorial EDHs where the source of bleeding is usually the middle meningeal artery in temporo-parietal EDHs and the anterior ethmoidal artery in frontal EDHs.[4] PFEDHs have a venous origin in 85% of the cases and develop as a result of injury to the transverse or sigmoid sinuses secondary to occipital bone fracture.[5] However, an extradural hematoma can develop without fracture. Since most of the PFEDHs are of venous origin and expand slowly, it takes longer for the clinical picture to develop in PFEDH and it is of vital importance to use imaging methods for early diagnosis. Currently, NCCT scan is the imaging of choice in brain trauma. In the literature it has been reported that PFEDHs are most commonly encountered in the first decade. [6,7] In our study, 03 (18.75%) cases were paediatric patients. Male gender dominated in our group, which is in line with data in the literature. This fact is explained by greater liability to trauma at work, road accidents and alcoholism in men. A leading cause of PFEDHs in our series were road traffic accidents, although in paediatric patients the most common mode of injury was falls. In all the female patients, the reason for traumatic PFEDH was attributed to sitting on vehicles as pillion riders and indicating the lack of support in the vehicles. The majority of PFEDHs were unilateral with prevalence on the left side (93.75%). In one patient (6.25 %) the PFEDH was bilateral and similar observation was reported by Karasu et al. Fracture of occipital bone is a common feature (in 58-95% of PFEDH) even though not all of them are visible on plain X-rays of the skull .75% of our patients had fracture of occipital bone, or parietal bones in occipital region on the side of extradural hematoma. Whereas some authors reported the occurrence of coexisting lesions in 23 - 50% of cases. We also observed them in three of our patients. The most common associated intradural lesion was supratentorial extension of EDH, brain contusion followed by a subdural collectionand acute hydrocephalus. Bozbuga et al. reported 73 cases in 1999, the largest series on PFEDH till now. Out of 73, they operated 53 cases [6]. 89% of operated patients had a good recovery, and 5.4% died. Malik et al. published another series of 61 patients in 2007[8]. Of these 48 were managed surgically, 36 (59%) had a good recovery and 15% died. Roka et al [9]. reported 43 patients in 2008, of these 33 were operated and were followed up for 79 months with 81.8% good recovery in the operated patients and 3% overall mortality [9]. In our study 15 patients underwent surgical evacuation. During 6 months follow­ up, 12(75%) patients had good recovery and one patient died (6.25%). This was similar to study by Jang et al [10] and Balik et al. [11]. Jang et al., in 2011, published the review of 34 patients with 96 months follow-up [10]. Nineteen patients underwent surgical evacuation with 73.7% having a good recovery and 5.3% mortality. Three series comprised paediatric cases only., Gupta et al.in 2002[12], Sencer et al., in 2012[13] Prasad et al. in 2015[14], and published paediatric series with 18,40 and 18 cases, respectively. Sencer reported good recovery in all cases. Prasad's series had 94.4% patients with good recovery. Both these series showed better outcomes in paediatric age group. Outcome was better in paediatric patients in our study. Admission GCS is the single most important 165 Traumatic posterior fossa extradural hematoma factor that determined the immediate and long-term outcomes. Patients with additional intracranial findings had relatively poor GCS at admission and categorically much poor outcomes. Patients with mass effect over brainstem had lesser GCS Score on admission with increased volume of EDH, increased hospital stay and increased mortality [15]. Nonsurgical management is a viable option in select patients with low EDH volumes, but option should be kept for surgical evacuation in such patients for better outcome. CONCLUSION PFEDH is a rare entity and posterior fossa is an unfavorable location. They are usually associated with occipital bone fractures. Early diagnosis and emergent evacuation lead to good outcome. 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