Posterior Fossa Extradural Haematomas

Manuscript submitted to Editorial Office of Central European Neurosurgery

Posterior fossa extradural haematomas

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Manuscript ID: Manuscript Type:

Zentralblatt für Neurochirurgie - Central European Neurosurgery Draft

Original Article extradural haematoma, posterior cranial fossa, occipital extension

Keywords (in German):

Extradurales Hämatom, Fossa cranii posterior, Occipitale Extension

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Keywords (in English):

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Background: Posttraumatic epidural haematoma (EDH) of the temporal region is the most common site of the supratentorial extradural bleedings, other locations are considered atypical. We reviewed 24 patients with EDH located in posterior cranial fossa (PFEDH) treated at two neurosurgical centres between January 2000 and November 2006. Material and Methods: In the retrospective study we analysed gender and age distribution, type of injury, clinical presentation, Glasgow coma scale (GCS) on admission, radiological images, time interval from trauma to surgery and outcome. Results: 24 patients with PFEDH represent 11,5% of 209 surgically treated individuals with EDH. The best outcomes were reached by patients with GCS scores 15-14 on admission. Patients in fourth to seventh decade of their life reached less favourable outcomes than younger persons. More than half of patients harboured associated intradural lesions. Only patients with concomitant brain contusion had more favourable recovery. The three worst levels of Glasgow outcome scale (GOS) were observed in patients suffering from subdural or intracerebral haematoma or both accompanying the PFEDHs. The majority of patients with concurrent lesions and supratentorial extension of haemorrhages was observed in the subgroup undergoing craniotomy between 24 and 72 hours after injury. The persons treated in this time interval had also the most unfavourable outcomes. Classical lucid interval was observed only in one of our patients. The mortality rate in the series was 4,2%. Conclusion: The most significant factors influencing outcome in our patients were GCS on admission, age and associated intradural lesions.

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Abstract:

Hintergrund: Das Posttraumatische Epidurale Hämatoma (EDH) der Temporalen Region ist die häufigste der supratentorialen EDH. Andere Regionen sind als atypisch zu betrachten. Wir überprüften 24 Patienten mit EDH in der Fossa cranii posterior (PFEDH) die an zwei Neurochirurgischen Instituten zwischen Januar 2000 und November 2006 behandelt wurden.

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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Material und Methoden: In dieser rückblickenden Studie haben wir Geschlechts- und Altersverteilung, Art der Verletzung, Klinisches Bild, Glasgow- Koma-Skala (GCS) bei Aufnahme, Radiologische Bilder, Zeitintervall von Trauma bis zum Chirurgischen Eingriff und Ergebnis. Resultate: Eine Überprüfung von 24 Patienten mit PFEDH repräsentiert 11.5% von 209 chirurgisch behandelten Individuen mit EDH. Die besten Resultate wurden bei Patienten mit einer GCS von 15-14 bei Aufnahme erreicht. Patienten vom vierten zum siebten Jahrzehnt ihres Lebens erreichten weniger vorteilhafte Resultate als jüngere Personen. Mehr als die Hälfte der Patienten hatten zusammenschließende intradurale Verletzungen. Nur Patienten mit einer zeitgleichen Gehirn Contusion hatten eine vorteilhaftere Genesung. Die drei schlechtesten Level der GlasgowOutcome-Scale (GOS) wurden bei Patienten entdeckt, die an Subduralem oder Intracerebralem Hämatom oder beiden Begleiterscheinungen der PFDEHSs. Die Mehrheit der Patienten mit gleichzeitiger Verletzung und Supratentorialen Extensionen von Blutungen wurde in der Untergruppe durchgeführter Craniotomien zwischen 24 und 72 Stunden beobachtet. Die behandelten Personen in diesem Zeitinterwal hatten auch die schlechtesten Resultate. Klassische klare Zeitspannen wurden in einem von vier Patienten beobachtet. Die Mortalitätsrate betrug in den Serien 4,2%. Abschluss: Die meisten signifikanten Faktoren die das Resultat in unseren Patienten beeinflussten waren die GCS bei Aufnahme, Alter und zusammenhängende Intradurale Verletzungen.

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Manuscript submitted to Editorial Office of Central European Neurosurgery

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

Manuscript submitted to Editorial Office of Central European Neurosurgery

Introduction Historically, the main source of EDH has been bleeding from middle meningeal artery and as effect of that, temporal area has been considered as typical localization. [11, 14, 34, 39, 45, 50]. Although rarely, other sites of EDHs location were found as well, e.g. frontal, parietal, occipital, vertex or posterior fossa regions [4, 7, 11, 19, 25, 34, 46]. An overall lower incidence of posterior fossa injuries and rarity of PFEDH explained limited experience with management of this type of haematoma [22, 48, 51, 60]. Seeing that condition of patients harbouring PFEDH may rapidly deteriorate, the clinical entity has quite often confusing

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symptoms and potentially lethal outcome due to brainstem compression, we decided to report on our experience with treatment of 24 patients with this bleeding.

Methods and material

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During the period of time from 1st January 2000 to 30th November 2006 209 patients with

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extradural haematomas were treated at two neurosurgical departments: Kosice, Slovak Republic (62 cases) and Helsinki, Finland (147 cases). These hospitals offer neurosurgical

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services for 1 500 000 and 2 000 000 million inhabitants, respectively. The diagnosis of intracranial lesions and skull fractures was made by computed tomography (CT) scan and X-

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ray. PFEDH, retrospectively analyzed, represented 24 of the whole group of 209 patients with EDHs (Tab. 1). There were 7 (3,5 %) PFEDH and 17 (8,1%) PFEDH with supratentorial extension (Fig. 1). All patients were operated on under general anaesthesia. A suboccipital craniectomy or craniotomy in the midline or unilateral was typical approach for PFEDHs. In the case of supratentorial extension of bleeding a combined supra-infratentorial approach was utilized. The patients were positioned sitting or prone with head placed in a horseshoe headrest or in a three-point pin fixation. Age, gender, type of injury, clinical manifestations, GCS on admission, supratentorial extension of haematoma, skull fractures, associated

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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intradural lesions, time interval between trauma and surgery, postoperative course and outcome were analyzed. Functional outcome was evaluated at discharge by Glasgow Outcome Scale (GOS) score as follows: good recovery, moderate disability, severe disability, vegetative state and death [27]. We considered good recovery (GR) and moderate disability (MD) as “good outcome”, whereas severe disability (SD), vegetative state (VS) and death as “poor outcome”.

Results

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Gender and age distribution

Eighteen patients were males so male-to-female ratio was 3:1. Only two patients of the whole

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group (8,3%) were children, one boy (seven years old) and one girl (three years old). The

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peak incidence of the PFEDHs was in the fifth decade. Four patients were older than 50. Average age of patients was 38,7 years, while the youngest patient was three and the oldest one 69 years old .

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Type of injury, clinical presentation and GCS on admission

The major cause of the EDHs were falls (19/24), followed by car accidents (1/24) and

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seizures (1/24). It was not possible to find out the cause of injury in three patients of the whole group. Headache was the most frequent clinical manifestation in the patients suffering from the EDHs. It was recorded in nine patients during initial neurological examination. Disorientation was the second most common clinical symptom observed in eight cases. Three patients had hemiparesis, however in one of them the hemiparesis was result of previous stroke. Table 2 shows complete list of various clinical symptoms observed in time of the initial neurological examination of our patients. Nine persons (37,5%) had GCS score 14-15,

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

Manuscript submitted to Editorial Office of Central European Neurosurgery

eleven (45,8%) reached 13–8, the rest (four patients, i.e. 16,7% of the whole group), had GCS score less than 8.

Radiological findings The right sided haematoma seen on CT scan was noted in eight cases, left sided in thirteen and bilateral appeared in three persons. Occipital extension of haemorrhage was noticed in seventeen cases, five of them on the right side, nine on the left side and in three cases the bilateral supratentorial extension was observed. One half of evaluated patients had fracture

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and in all of them the occipital bone or occipital part of parietal bone on the side of extradural haematoma was broken. Concomitant intradural lesions were confirmed in fifteen patients

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(62,5%), the lesions being a brain contusion in six, an intracerebral haematoma in six, a

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subdural collection in four and a subarachnoid haemorrhage in one patient. An acute hydrocephalus developed due to a compression of fourth ventricle in one individual. One

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patient had combination of contusion with subarachnoid haemorrhage in addition to EDH and another patient harboured subdural haematoma in combination with intracerebral blood clot and brain contusion.

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Time interval from trauma to surgery

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Patients treated surgically within 24 hours following injury comprised seven cases of the whole studied group. Nine patients were operated during the time interval between 24 and 72 hours after injury and in eight cases between surgery and injury elapsed more than 72 hours.

Outcome The good outcome was gained by seventeen our patients (70,8%, GR or MD in GOS), four patients (16,7%) showed severe disability at discharge, two patients (8,3%) remained in

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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permanent vegetative state and one (4,2%) died. The recovery was more favourable in patients with less deteriorated level of consciousness on admission and in young patients (Tab. 3). In addition, the frequency of poor outcome was increased in persons with associated intradural lesions (Tab. 4).

Discussion In the year 1986 Brambilla in his review [10] stated that there were only 157 cases of EDH localized in posterior cranial fossa published since 1901. Scarce occurrence of this clinical

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entity symbols their incidence ranging from 1,2 to 15,0% of all epidural haematomas [3, 5, 6, 10, 15, 17, 22, 31, 33, 36, 38, 40, 42, 44, 48, 51, 56, 57, 60]. However, some reports

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confirmed more frequent appearance of PFEDH (ranging from 41 to 55% of all reviewed

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cases) in children and adolescents [10, 40, 42, 48, 52]. Evently Garza – Mercado [17] reported 6 observations in teenagers younger than 16 in a group of 7. Our experience showed the

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incidence of PFEDHs 11,5%. Actually, incidence in children was lower in comparison with published data, when only two our patients were below eighteen. The frequenter occurrence

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of PFEDHs is explained by higher incidence of occipital fractures, relative thickness of diploe and richer dural blood supply in children [2, 21, 24, 26, 51]. Rivano et al. [48] reported an

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association of occipital fracture with PFEDHs in 8 of 9 teenagers younger than 17, which composed 41% of all his patients with PFEDHs. We detected an occipital fracture only in one girl and supratentorial extension of blood clot was noticed in one boy. The peak incidence of PFEDHs in our patient group was in the fifth decade of their life, while the average age of our patients was 38,7 years and four of them were older than 50. It is in concordance with results published by Rivano et al. [48].

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

Manuscript submitted to Editorial Office of Central European Neurosurgery

Male gender dominated in our group, which is in line with data in the literature [17, 30, 33, 36, 40, 42, 44, 48, 57]. This fact is explained by greater liability to trauma at work, road accidents and alcoholism in men [51]. A leading cause of PFEDHs in our series were falls (in 79,2%). Mraček et al. [40] observed this cause of posterior fossa epidural bleeding in 39% of cases which constituted the most common etiologic factor, and similar observations were reported by some other authors [36, 57]. On the other hand, in some reports traffic accident was observed as leading etiologic factor of the lesion [3, 33].

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The clinical manifestation of PFEDHs is generally non-specific [57]. For pathognomonic should be regarded cerebellar or lower cerebral nerves symptomatology [5, 16]. Among the

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three most frequent clinical symptoms observed in our patients were headache, disorientation

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and coma. In Wang’s study [57] three of thirteen cases (23%) had no episode of unconsciousness whereas five patients (20,8%) of our group were comatose before

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craniotomy and somnolent at the time of admission. A combination of impaired consciousness, drowsiness and soft tissue injury in occipital area should arouse the highest

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degree of suspicion of PFEDHs. The other clinical signs observed in our patients in descending frequency were nausea, vomiting, dysphasia, hemiparesis, dizziness, seizures and

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mydriasis, quadriparesis, central and peripheral paresis of facial nerves and oculomotor paresis. The unilateral mydriasis was observed only in 8,3% of patients (as frequently as in two other series) [30, 57], which was not in concordance with 21 - 71% occurrence reported by other authors [12, 17]. The majority of PFEDHs were unilateral with prevalence on the left side (54,2%). In three patients (12,5%) the PFEDH was bilateral and similar observation was reported by Karasu et al. [30]. However, acute bilateral PFEDHs are rare and till 1997 they have only been reported in nine patients [1, 8, 10, 18, 42, 49, 53, 55, 59].

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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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. In addition, diastasis of the lambdoid suture was also reported [22, 30, 35, 42, 51, 57]. One half of our patients had fracture of occipital bone, or parietal bones in occipital region on the side of extradural haematoma. An occipital extension of blood clot was noticed in 70,8% of cases and in three patients the supratentorial extension of haemorrhage was recognized bilaterally. Similar observations were reported by others [17, 26, 33, 40, 48, 54, 57]. The bilateral supratentorial extension may give rise to cortical blindness [20]. Overlapping of epidural clot into supratentorial area is not only

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possibility of PFEDH propagation. A case of contemporary occurrence of EDH in posterior and middle cranial fossa caused by a bleeding from superior petrosal sinus was reported, too

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[28]. The mortality rate in the group of patients with PFEDHs restricted to the posterior

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cranial fossa was 10,0%, in the case of supratentorial extension the rate increased up to the 22,0% [33]. In our series death was observed just in one patient suffering from PFEDH with supratentorial extension.

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Whereas some authors reported the occurrence of coexisting lesions in 23 - 50% of cases [33,

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42, 47, 48, 51, 57], we observed them in fifteen patients, i. e. in 62,5%. The most common associated intradural lesion was brain contusion and intracerebral haematoma followed by a

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subdural collection, subarachnoid haemorrhage and acute hydrocephalus. Reported incidence of acute hydrocephalus with PFEDH ranges from 7.7 to 61% [22, 41, 42, 43, 30, 36]. Karasawa et al. [29] published significant relationship between hydrocephalus and supratentorial extension of posterior fossa epidural haematoma. As a possible mechanism for development of acute hydrocephalus he considered compression of aqueduct. Because hydrocephalus improves immediately after evacuation of the haematoma, ventricular drainage is considered an unnecessary part of PFEDH treatment. One of our patients, who underwent external ventricular drainage due to hydrocephalus, had good outcome (MD in GOS) at

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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discharge. In other series development of this complication mostly increased mortality rate of PFEDH [22, 36, 42]. More than one concomitant associated intradural lesion was noted in two patients seen by Neubauer et al. [42] One of them had contusion with subarachnoid haemorrhage, the second one subdural haematoma in combination with intracerebral bleeding and contusion. Both of them had poor outcome. Probability of good recovery in our patients without associated lesions was almost three times higher than in those with coexisting intradural lesions. Similar results have been observed by Neubauer et al. [42] and Rivano et al. [48]. Our findings also demonstrate that only patients with contusion obtained good

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recovery and on the other side the three the worst levels of GOS were reached mostly by patient harbouring subdural or intracerebral haematoma or both accompanying the PFEDH.

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Higher mortality of these patients is usually caused by associated pathology more than by PFEDH itself [10, 47].

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Classical lucid interval was observed only in one our patient which means the diagnosis of

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PFEDH must be established by help of history of blow to the occipital region, cerebellar symptomatology and CT examination [10, 25, 37, 40].

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The majority of patients with concurrent lesions and supratentorial extension of haemorrhages was observed in the group of patients undergoing craniotomy between 24 and 72 hours after

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injury. The persons treated in this time interval had also the most unfavourable outcomes. Some other authors obtained different results, however they had grouped patients as subacute and chronic cases using different criteria. The mortality rate in Rivano’s series [48] of patients with acute course (when similar conditions for definition of the course have been used for as in our group) was 22%, while outcome was good in 64% which is in concordance with our results. This observations support the conclusion that early surgical intervention leads to better outcome [42, 44]. It is necessary to mention that patients who underwent surgery later than 72 hours after injury had similar results as persons operated on during first 24 hours after

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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injury. An explanation of this observation can be a fact that EDHs in this group did not cause such degree of brainstem compression and increase of intracranial pressure with its devastating consequences for patient as in the group with a time interval 24 - 72 hours, where also delayed medical examination could affiliate. 77,8% of patients with GCS of 15 to 14 on admission recovered completely and the rest were moderately disabled at the time of discharge. Our results are in concordance with published data [57]. Age below 16 years is considered to be a favourable prognostic factor in PFEDHs [33, 36, 57] which was also noticed in our series.

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The mortality rate decreased from 50% to 11,1% also in consequence of improved diagnostics by CT [3, 23, 60]. The mortality rate in our series was 4,2% which was at about the same

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level as was observed by others [11, 30]. The usefulness of repeated CT scanning in persons

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after head injuries is emphasized, especially within the first 24 hours. As our findings also indicate, almost 40% of patients had GCS score 15-14 on admission, hence clinical picture

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can be obscured. The haematoma can be isodense with cerebellum, few millilitres of blood in epidural space can be overlooked or the posterior fossa epidural haematoma can develop later

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on after evacuation of a supratentorial haemorrhage [9, 13, 32, 42, 47, 57, 58]. Such an experiences stress that the presence of trauma to the occipital region should alert attending

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clinician to the possibility of development of this potentially fatal condition.

Conclusion The most significant factors influencing outcome in our study were GCS on admission, age of patient and associated intradural lesions.

References

Georg Thieme Verlag KG, P.O. Box 30 11 20, 70451 Stuttgart, Germany

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operation. Neurol Med Chir (Tokyo) 1990; 30: 24-28

45. Paterniti S, Fiore P, Macrì E, Marra G, Cambria M, Falcone F, Cambria S. Extradural haematoma. Report of 37 consecutive cases with survival. Acta Neurochir (Wien) 1994; 131: 207–210 46. Pereira CU, Leão JDBC, Ribas A, Santos EAS, Monteiro JTS, Duarte GC. Frontal Epidural Haematoma. Analysis of 30 Cases. J Bras Neurocirurg 2004; 15: 18-21

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47. Pozatti E, Tognetti F, Cavallo M, Acciarri N. Extradural hematomas of the posterior cranial fossa. Observations on a series of 32 consecutive cases treated after the introduction of computed tomography scanning. Surg Neurol 1989; 32: 300–303 48. Rivano C, Altomonte M, Capuzzo T, Borzone M. Traumatic Posterior Fossa Extradural Hematomas. A Report of 22 New Cases Surgically Treated and a Review of the Literature. Zentralbl Neurochir 1991; 52: 77-82 49. Rivano C, Borzone M, Altomonte M, Capuzzo T. Traumatic posterior fossa extradural hematomas. Neurochirurgia 1992; 35: 43-47

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58. Wong CW. The CT criteria for conservative treatment-but under close clinical observation-of posterior fossa epidural haematomas. Acta Neurochir (Wien) 1994; 126: 124-127 59. Wright RL. Traumatic hematomas of the posterior cranial fossa. J Neurosurg 1966; 25: 402-409 60. Zuccarello M, Pardatscher K, Andrioli GC, Fiore DL, Iavicoli R, Cervellini P. Epidural hematomas of the posterior cranial fossa. Neurosurgery 1981; 8: 434–437

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Figure 1. Left sided posterior fossa epidural haematoma (A) with supratentorial extension (B) on preoperative CT scan in a young male. GCS 15-14 on admission. Good recovery.

Table 1. Classification of the haematomas.

Table 2. Clinical presentation.

Table 3. Impact of GCS and age decades on GOS.

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Table 4. Influence of associated intradural lesion on GOS.

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Table 1. Classification of the haematomas Adults Children Localization n n Temporal 64 7 Temporal + extension 61 12 Frontal 10 7 Parietooccipital 21 3 Posterior fossa 6 1 Posterior fossa + extension 16 1 Total 178 31

Total n 71 73 17 24 7 17 209

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Table 2. Clinical presentation Patient n % Aphasia/Dysphasia 4 16,7 Central n. VII. 1 4,2 paresis Coma 5 20,8 Disorientation 8 33,3 Dizziness 2 8,3 Headache 9 37,5 Hemiparesis 3 12,5 Mydriasis 2 8,3 Nausea without 2 8,3 vomiting Oculomotor 1 4,2 paresis Peripheral n. VII. 1 4,2 paresis Quadriparesis 1 4,2 Seizures 2 8,3 Somnolence 5 20,8 Sopor 0 0,0 Vomiting 4 16,7

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Table 3. Impact of GCS and age decades on GOS GCS on admission Age decade 15 to 14 13 to 8 7 to 3 I. II. III. IV. V. VI. VII. GOS n n n n n n n n n n GR 7 4 0 2 0 3 3 2 1 0 MD 2 2 2 0 0 2 1 2 0 1 SD 0 4 0 0 0 0 2 1 0 1 PVS 0 1 1 0 0 0 0 2 0 0 Death 0 0 1 0 0 0 0 0 0 1 Total 9 11 4 2 0 5 6 7 1 3 number GCS - Glasgow coma cale; GOS - Glasgow outcome scale; GR - good recovery; MD - moderate disability; SD - severe disability; PVS - persistent vegetative state

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Table 4. Influence of associated intradural lesion on GOS without with CNT HCP ICH SAH SDH AL AL GOS n n n n n n n GR 7 4 4 0 0 0 0 MD 2 4 1 1 2 1 0 SD 0 4 1 0 4 0 1 PVS 0 2 0 0 0 0 2 Death 0 1 0 0 0 0 1 Total 9 15 6 1 6 1 4 number GOS - Glasgow outcome scale; GR - good recovery; MD moderate disability; SD - severe disability; PVS - persistent vegetative state; AL - associated intradural lesion; CNT - brain contusion; HCP - hydrocephalus; ICH - intracerebral haematoma; SAH - subarachnoid haemorrhage; SDH - subdural haematoma

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