1

POSTERIOR FOSSA EPIDURAL HEMATOMAS : CASE SERIES

Meviraf Benny Tanio1, Ahmad Faried1, Agung Budi Sulistiono1,

Muhammad Zafrullah Arifin1, Akhmad Imron1
1
Departemen of Neurosurgery, Faculty of Medicine, Padjadjaran University/
Dr. Hasan Sadikin General Hospital, Bandung, Indonesia,

Abstract

Introduction: Posterior fossa epidural hematoma is a very rare case with an incidence of 4 -
12.9% of all epidural bleeding cases. Clinical-based diagnosis is difficult to enforce. The use of
head CT scans in early diagnosis may provide a better prognosis. The study reported all cases of
traumatic posterior epidural fossa bleeding found.
Method: This research uses case series method. All cases of posterior traumatic fossa epidural
hematomas treated at the Department of Neurosurgery RSHS Bandung during the period of
January - December 2017 were reported by age, gender, trauma mechanism, clinical symptoms,
GCS score (Glasgow Coma Scale), CT head scan, patient management , and patient output.
Results: During the period January - December 2017, there were 3 cases of epidural fossa
posterior traumatic injury. Result includes 1.66% of cases of epidural bleeding and 0.23% of
cases of head injury. Of the 3 cases found, there were variations in terms of the trauma
mechanism, GCS score, clinical symptoms, radiological features, and management performed.
Conclusion: Epidural fossa posterior traumatic bleeding is a rare case and has no specific
clinical symptoms. Bleeding is common in patients with fractures in the occipital region. The
diagnostic determinant is a CT Scan head. Surgery provides a good prognosis and output in
patients with a decreased consciousness.

Keywords: epidural bleeding, posterior fossa, occipital fracture

Introduction

Epidural hematoma is one type of intracranial traumatic bleeding with incidence rate
ranging from 1 - 3% of all head injuries. Epidural bleeding is most common in supratentorials.
Epidural hematoma which is located in the posterior fossa is a very rare case with an incidence
of 4-12.9% of all cases of epidural hematoma.

The diagnosis of posterior fossa epidural hematoma which is caused by trauma in clinical
disorders is very difficult to determine. This is due to unusual clinical symptoms and rare cases,
so clinicians sometimes do not consider the diagnosis. The clinical symptoms develop slowly,
but can cause rapid and sudden loss of consciousness which cause fatal outcomes when it is not
treated on time. It is associated with the effect of mass on the brain stem in a narrow space and is
associated with possible hydrocephalus arise. Radiological radiographs of skull x ray at posterior
fossa epidural hematoma usually indicate a linear fracture of the occipital bone or a diastatic
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fracture of the lambdoid suture, or both. However, the examinations modalities are not enough,
since they can not detect any hemorrhage occurring. The use of head CT-Scans in early diagnosis
is the most appropriate modality and is able to determine which management which is taken so
that it can provide a better prognosis.

This study reports all cases of traumatic posterior fossa epidural hematoma at Dr. Hasan
Sadikin Bandung period January - December 2017, which includes patient characteristics,
trauma mechanisms, clinical symptoms, radiological features, managements, and patient
outcomes.

Method

This study uses case series method, where all cases of traumatic posterior fossa epidural
hematoma which are handled in Department of Neurosurgery General Hospital of Dr. Hasan
Sadikin Bandung (RSHS Bandung) during the period of January - December 2017 are reported.
The data which is presented are age, gender, trauma mechanism, clinical symptom, GCS score
(Glasgow Coma Scale), CT head scan, management, and patient outcome.

Result

During January – December 2017 period, there are 3 cases of traumatic posterior fossa
epidural hematomas. From the 3 cases found in RSHS during 2017, there were variations in
terms of the trauma mechanism, GCS score, clinical symptom, CT head scan, and management
performed.

Table 1. Characteristics of Patients with Head Injury in Department of Neurosurgery RSHS

Bandung Period from January to December 2017

Frequency (n) Percentage (%)

The severity of Head Injury
Mild Head Injury (GCS 14-15) 821 64.04
Moderate Head Injury (GCS 9-13) 352 27.46
Severe Head Injury (GCS 3-8) 109 8.50
Total 1282 100.00

Intracranial Hemorrhage
Epidural Hemorrhage 181 38.11
Subdural Hemorrhage 102 21.47
Intracerebral Hemorrhage 85 17.89
Subarachnoid Hemorrhage 90 18.95
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Intraventricular Hemorrhage 17 3.58

Total 475 100.00

Epidural Hemorrhage
Supratentorial 178 98.34
Infratentorial (fossa posterior) 3 1.66
Total 181 100.00

Table 2. Description of Patient with Posterior Fossa Epidural Hematoma Case in Department of
Neurosurgery RSHS Bandung Period from January to December 2017

Case Age Sex Symptoms Mechanism of GCS Neurological CT-Scan Result Therapy Outcome
trauma Deficits

Linear fracture in left

occipital bone, EDH
in the left
parietooccipital and
left cerebellum
Loss of GCS 15,
E3M5 hemisphere;
1 5 years F consciousness, Fall No Operative no
V3= 11 enlargement on the
vomit disability
lateral and ventricular
3; temporal horn>
2mm, FH / ID 35.7%,
Evans ratio 0.3; no
midline shift

Linear fracture in the

right occipital bone;
Loss of EDH in the right GCS 15,
45 E3M5
2 M consciousness, Fall No occipital and right Operative no
years V3= 11
vomit cerebellar disability
hemisphere; no
midline shift.

Linear fracture of the

left occipital bone;
Loss of Traffic EDH in the left GCS 15,
18 E3M5
3 M consciousness, No parietooccipital and Operative no
years V4= 12
Hiccup Accident left cerebellum disability
hemisphere; there is
no midline shift.

Case 1

A 5-year-old girl came to Emergency Room (ER) RSHS Bandung with decreased level of
consciousness since 2 days before entering the hospital, while the patient was playing near the
stairs in patient's house in Garut, pastient was slipped and fell with back of head hit the floor.
After the incident, patient experienced decreased level of consciousness and vomited 4-5 times.
There was no bleeding from the nose, mouth, and ears. Patient was then taken to Garut General
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Hospital for treatment. The patient was then referred to the RSHS emergency department for
further treatment.

Figure 1. Photo
of CT-Scan Bone Window and Brain Window

The GCS score upon arrival was E3M5V3 = 11 with isokor round pupil 3 mm in
diameter and positive light reflex for both eyes. No motor abnormalities occured in the patient.
On physical examination of the head, was found soft tissue swelling in the left parietooccipital
region. Laboratory tests were within normal limits. A radiological CT-Scan of the head was then
performed and a linear fracture was found in the left occipital bone; sulcus, gyrus, Sylvian
fissura, and compressed cistern; enlargement of the lateral and ventricular ventricles 3; temporal
horn> 2mm; FH / ID 35.7%, Evans ratio 0.3; there was a hyperdense mass biconvex-shaped in
left parietoccipital and left cerebellar hemisphere; and there was no midline shift.

The patient was diagnosed as a moderate head injury with a closed linear fracture in the
left parieto occipital accompanied by epidural hematoma in the left parietal and left cerebellum
hemisphere resulting acute non communicating hydrocephalus. The patient was then performed
an evacuation craniotomy.

The operation was performed 4 hours after the patient entered the ER with 20-hour
operating interval. Intraoperative findings were closed linear fracture in left parieto occipital;
epidural hematoma in the left cerebellum hemisphere area had 15 cc blood clots and 5 cc lysis
and epidural hematoma in the left occipital region in the form of blood clot as much as 10 cc, the
source of hemorrhage was from a linear fracture; white color duramater, relax, and intact.
Preoperative GCS E3M5V3 = 11. After surgery, GCS improved to 15. Patients were then treated
for 4 days to be subsequently discharged with fully conscious (GCS 15), without neurological
deficits.
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Case 2

45-year-old man came to the Emergency Room of RSHS Bandung with decreased level
of consciousness since 5 hours before admission. When the patient was repairing the roof of the
house in Subang, the roof of the house collapsed and patient fell with the back of the head
against the floor. Patient was immediately fainted, followed by vomiting. The complaint was
accompanied by a history of nasal hemorrhage. There was no ear, and mouth bleeding. The
patient was then taken to Mitra Medika Subang clinic then referred to the ER of Hasan Sadikin
Hospital.

The patient's GCS score upon arrival was E3M5V3 = 11 with isokor round pupil of 3 mm
diameter and positive light reflex for both eyes. No motor abnormalities were found. On physical
examination of the head was found hematoma in the middle occipital region. Then CT-Scan
examination was performed which result was the presence of soft tissue swelling in the right
occipital region; linear fracture in the right occipital bone; sulcus, gyrus, Sylvian fissura, and
compressed cistern; uncompressed ventricles; there was hyperdense mass with biconvex-shaped
on the right occipital and right cerebellum hemisphere. There was no midline shift.

Figure 2. Photo of CT-Scan Bone Window and Brain Window

The diagnosis of this patient was moderate head injury accompanied by fracture at the
base of the anterior fossa's skull and closed linear fracture of the right occipital bone with
epidural hematoma in the right occipital and right cerebellum hemisphere. Patient was planned
for evacuation craniotomy.
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The operation was performed 3 hours later with a 10-hour operating interval.
Intraoperative findings were linear fracture in the right occipital region; epidural hematoma in
the form of blood clot as much as 15 cc and 10 cc lysis; white, relaxed, and intact duramater;
with preoperative GCS E3M5V3 = 11. GCS after surgery increased to 15. Patients was
discharged 3 days later with fully conscious (GCS 15) and no neurological deficits.

Case 3

18-year-old boy came to the RSHS emergency department with a major complaint of
decreased level of consciousness since 12 hours before admission. When the patient was riding a
motorcycle in Cililin in medium speed without using helmet, suddenly patient lost his balance
and fell with his head hit the asphalt. Complaints accompanied by a history of decreased level of
consciousness in the scene of the accident and he regained his consciousness. Complaints
accompanied by hiccups. History of vomiting, ear, nose and mouth hemorrhage were absent. The
patient was taken to Puskesmas Cililin, performed wound care and experienced loss of
consciousness and then referred to RSHS for further treatment.

GCS score upon arrival to RSHS E3M5V4 12, round isokor pupils with 3 mm in
diameter, and a positive light reflex for both eyes. No motor abnormalities were found in
patients.

On the physical examination of the head was found a torn wound on the left parietal area
which was already sewn. Laboratory blood tests were within normal limits.

From radiological examination was found soft tissue swelling in the left parietooccipital
region; linear fracture of left occipital bone; sulcus and gyrus were compressed; Sylvian fissura
and cistern were compressed; ventricle was compressed; there was a hyperdens mass of
biconvex-shaped on the left occipital and left cerebellum hemisphere with an estimated volume
was 20 cc; and there is no midline shift.

The diagnosis of this patient was moderate head injury with closed linear fracture on the
left parieto occipital bone, epidural hematoma in the left cerebellum hemisphere and left parieto
occipital. Patient was planned for evacuation craniotomy.
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Figure 3. Photo of CT-Scan Bone Window and Brain Window

The operation was performed 4 hours later with a 16-hour operating interval.
Intraoperative findings were diastatic fracture in Lamboidea suture; epidural hematoma in
parieto occipital in the form of blood clot as much as 20 cc and 10 cc lysis; white, relax, and
intact duramater; with preoperative GCS E2M4V2 = 8. GCS after surgery increased to 15.
Patients were discharged 5 days later with fully conscious (GCS 15) and no neurological deficits.

Discussion

Traumatic posterior fossa epidural hematoma presents an unspecific clinical picture.

Patients who were conscious after the incident may experience a sudden decreased level of
consciousness due to cerebellar tonsil herniation to the foramen magnum or due to the
occurrence acute hydrocephalus which is caused from secondary obstruction of the cerebrospinal
fluid flow. Hemorrhage could be occured from venous damage, so it set a slow clinical course, or
from arterial branch damage, which can cause rapid symptoms of deterioration and high
mortality. The prognosis depends on the patient's clinical course, the level of consciousness, and
the timing of the operative action.

Epidural hematoma in this case included 1.66% of all cases of epidural hematoma and
0.23% of all head injury cases. The entire patient were <14 years old and male. Direct impact on
the occipital region is the main cause of hemorrhage, 2 of which are caused by a fall and another
was caused by a traffic accident. Collisions can cause linear fractures in the occipital region, as
occurs in 2 cases, and lambdoid sutura fracture diastasis, occurring in 1 case. In another study,
the occipital fracture rate of occipital bone or lambdoid sutura diastatic fracture in patients with
posterior fossa epidural hematoma was reported as much as 40-86% of cases. Unlike epidural
hemorrhage cases in the anterior fossa and media, hemorrhage in the posterior fossa does not
provide typical clinical symptoms. This corresponds to three reported cases.

The soft-tissue swelling that is occured almost entirely in the parieto occipital area at the
same point as the location of bumps and hemorrhage. Symptoms of vomiting occur in all cases.
The mechanisms of vomiting are not known yet, but may be due to stimulation of vomiting
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centers in reticular formation by impact or mass effect. The decreased level of consciousness
depends on the size and speed of hematoma formation. The lucid interval may occur in 42.1% of
cases of epidural hemorrhage in the posterior fossa. In this case series, lucid interval occurs in
one case (33.3%). The narrow space in the posterior fossa and the presence of vital structure of
the nervous system inside it (including the brainstem) which is compressed by the cerebellar
tonsil can cause sudden loss of consciousness. In some cases, the condition can not be assisted so
that operative action is not required. The mortality rate of posterior fossa epidural hematoma
ranges from 12% -20%. In this study there were no casualties. All patients were returned from
the hospital with fully conscious and no neurological deficits.

Early determination of diagnosis provides good outcomes. The use of head CT-Scans is
recommended in patients with x ray image shows linear fracture or lambdoid sutura diastatic.
Based on other studies, the volume of epidural hematoma in the posterior fossa on head CT-Scan
image ranges from 5-30 cc, on larger amount usually it will extend to supratentorial area. In the
89 series of posterior epidural fossa hematoma cases which is conducted by Lui et al, there are
30 cases of pure posterior fossa epidural hematoma that extends over the transverse sinus to the
occipital area. Head CT-Scan may also indicate a mass effect that causes the whole or partial loss
of perimesenphalic cistern and compression or ventricular 4 dislocations. This condition causes
non-communicative hydrocephalus as occurs in one case in this study.

Decision management in both operative and conservative patients depend on clinical and
radiological symptoms. In this study, operative action was performed on all three cases in which
all three cases experienced decreased level of consciousness. All the cases in this study showed a
good outcome, both in the operative patient.

Conclusion

Traumatic posterior fossa epidural hematoma is a rare case and has no specific clinical
symptoms. Bleeding is common in patients with fractures in the occipital region. The diagnosis
determinant is head CT-Scan. The surgery provides a good prognosis and outcomes in patients
with the decreased level of consciousness.

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