Acta Neurochir (Wien) (2002) 144: 497–500 Acta Neurochirurgica > Springer-Verlag 2002 Printed in Austria Spontaneous Bilateral Chronic Subdural Haematoma of the Posterior Fossa. Case Report and Review of the Literature R. Stendel, T. Schulte, T. A. Pietilä, O. Suess, and M. Brock Department of Neurosurgery, Benjamin Franklin Medical Center, Free University of Berlin, Germany Summary Introduction Chronic subdural haematomas of the posterior fossa in adults without a history of trauma are very rare. To our knowledge, only 15 cases have so far been reported in the literature, including those with anticoagulation therapy. A case of spontaneous bilateral infratentorial chronic subdural haematoma associated with anticoagulation therapy in an alive adult is presented and the relevant literature is reviewed. our knowledge, only 15 cases have so far been reported in the literature, including those with anticoagulation therapy (Table 1). The case of a woman with spontaneous, bilateral chronic subdural haematomas of the posterior fossa associated with anticoagulation therapy is presented and the relevant literature concerning this subject is reviewed. Case Report Case Report A 70 year old female presented with progressive dizziness, vertigo and gait ataxia. She was on anticoagulation therapy for heart disease. Neuro-imaging revealed bilateral infratentorial subdural masses. The subdural masses were suspects for chronic subdural haematomas by neuroradiological criteria. Because of the progressive symptomatology, the haematomas were emptied through burrhole trepanations. Chocolate-colored fluid, not containing clotted components, gushed out under great pressure. The source of bleeding could not be identified. The patient recovered well from surgery, but died 4 months later shortly after admission to another hospital from heart failure. Discussion The chronic subdural haematomas in this patient may have been due to rupture of bridging veins caused by a very mild trauma not noticed by the patient and possibly aggravated by the anticoagulation therapy. Infratentorial chronic subdural haematoma should at least be a part of the di¤erential diagnosis in elderly patients with cerebellar and vestibular symptomatology even without a history of trauma. Keywords: Infratentorial haematoma; subdural bleeding; posterior fossa. Introduction Chronic subdural haematomas of the posterior fossa in adults without a history of trauma are very rare. To This 70-year-old female patient was su¤ering from progressive dizziness, which first occurred about two months ago when she was completely well. The patient was on anticoagulation therapy for a long time because of heart disease. She was admitted to the medical ward of another hospital after having been unable to walk for a couple of days because of pronounced vertigo and gait ataxia. A cardiovascular disease was suspected but medical examinations including echocardiography and long-term electrocardiography yielded no abnormal findings. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated bilateral infratentorial subdural haematomas. Coagulation was normalised and the patient was transferred to our department. On admission, the obese patient was in a good general condition. She could not remember any previous head injury. She was awake, alert, and complained of severe dizziness when moving the head or rising. The neurological examination revealed a gaze nystagmus to the right. No other cranial nerve deficits were noted. The patient was unable to walk because of vertigo and gait ataxia. Blood tests showed that coagulation was within the normal range. The CT and MRI studies demonstrated subdural space-occupying masses at the convexity of the cerebellar hemispheres with compression of the cerebellum and the 4th ventricle (Figs. 1–3). The masses were hypodense on the CT scans and hyperintense on the T1- and T2-weighted MR images, indicating chronic subdural haematomas. Because of the patient’s progressive and severe symptoms, the haematomas were emptied through bilateral burrhole trepanations on the day of admission. Chocolate-coloured fluid, not containing clotted components, gushed out under great pressure. The source of bleeding could not be identified. The subdural space was thoroughly rinsed with saline solution. A subdural Jackson-Pratt drain was placed on the right because of little intra-operative expansion of the cerebellum. 498 R. Stendel et al. Table 1. Synopsis of 16 Cases of Chronic Subdural Haematoma of the Posterior Fossa in Adults Without a History of Trauma Reported in the Literature Author Age Sex Anticoagulation therapy Duration of symptoms Headache, vomiting Cerebellar signs Neisser and Pollack 1904 [15] Neisser and Pollack 1904 [15] Schönbauer 1937 [18] Achslogh 1952 [1] Holub 1953 [9] Gross 1955 [7] Giroux and Leger 1962 [6] Zenteno-Alanis et al. 1968 [20] Capistrant et al. 1971 [4] Murthy 1980 [14] Kanter et al. 1984 [12] Izumihara et al. 1993 [10] Ashkenazi et al. 1994 Lagares et al. 1998 [13] Kachkov 1999 [11] Stendel et al. 2001 ? 44 38 51 51 51 60 49 50 32 59 70 65 65 41 70 m ? f m m f m m m m f m f f f f no no no no no no no yes yes no yes no yes yes no yes 4 weeks 10 days 4 weeks 1 year 9 days 7 weeks ? 2 months 1 day 8 months acute 2 months 18 months acute ? 8 weeks yes yes yes yes yes yes no yes yes yes yes no no no yes no yes yes no yes yes yes yes yes no yes yes yes yes no yes yes Fig. 1. Preoperative cranial CT scans showing bilateral infratentorial subdural haematomas, more pronounced on the right, with marked compression of the 4th ventricle Fig. 2. T1-weighted MRI following contrast medium administration depicts the subdural haematomas which are much more pronounced on the right side with compression of the cerebellar hemisphere and of the 4th ventricle A clear improvement of the patient’s clinical condition was seen immediately after the intervention. Dizziness and ataxia resolved completely within a few days. Postoperative CT showed a normal postoperative appearance. The mass e¤ects in the posterior fossa had nearly completely disappeared and the 4th ventricle had re-expanded (Fig. 4). About 30 ml of old blood were discharged from the right subdural drain within the first 24 hours, followed by only a few millilitres of blood on the 3rd postoperative day. The drain was removed on the 3rd postoperative day. The postoperative course was uneventful and the patient was discharged after 10 days. Four months later, the patient suddenly developed acute gastrointestinal bleeding and hemiparesis without any preceeding symptoms. She was admitted to another hospital and died 3 weeks later from heart failure. Discussion The incidence of intracranial chronic subdural haematoma is 1–2 cases per 100,000 inhabitants per year, and they predominantly occur in elderly individuals [3]. However, subdural haematomas rarely occur in the posterior fossa. In a study by Ciembroniewicz, only 3 of 535 intracranial subdural haematomas were located in the posterior fossa [5]. In children and above all in new-borns, on the other hand, infratentorial subdural haematomas appear to be more frequent [16]. They are primarily attributed to birth injury with rup- Spontaneous Bilateral Chronic Subdural Haematoma of the Posterior Fossa Fig. 3. T2-weighted MR image in sagittal view showing the hyperintense subdural haematoma on the right side and its mass e¤ect Fig. 4. Postoperative cranial CT scan demonstrating the fully reexpanded 4th ventricle. Only slight residual margins persist subdurally ture of the tentorium or of the venous sinus, but also to moulding of the skull [8]. Chronic subdural haematomas probably represent one of the rarest forms of posterior fossa bleeding. Only 15 cases of spontaneous chronic subdural haematomas of the posterior fossa in adults have so far been reported in the literature, including those associated with anticoagulation therapy (Table 1). Chronic subdural haematomas of the posterior fossa often present with nonspecific symptoms making diagnosis di‰cult. In nearly all cases published before the advent of computed tomography [CT], the diagnosis was established only during surgery or at autopsy [1]. Infratentorial subdural haematomas can result from direct traumatic damage to the posterior fossa with 499 injury of the venous sinus or of bridging veins [2]. About 50% of the patients developing subdural haematomas report a traumatic event, though a very mild one in most cases [3]. Another cause is bleeding associated with cerebellar contusion [2]. The rather low incidence of chronic subdural haematomas in the posterior fossa may be explained by the rare occurrence of venous sinus injuries and the low number of bridging veins present in the posterior fossa [17]. One may also speculate that many chronic subdural haematomas of the posterior fossa remain undetected as a result of the poor visualisation of the posterior fossa by CT and that smaller ones resolve spontaneously. Furthermore, a chronic subdural haematoma can be the result of a transformation of an acute one. The latter are likewise very rare in the posterior fossa and often lead to death. Achslogh attributes chronic subdural haematomas without reliable evidence of a traumatic event to rupture of an aneurysm or an arteriovenous malformation in the posterior fossa [1]. Anticoagulation treatment is a known risk factor for the development of subdural haematomas, especially in patients with head injury [3]. It has been reported that subdural haematomas constitute the most frequent complication of anticoagulation therapy with an incidence of 12–38% [19]. However, to our knowledge only 5 cases of chronic infratentorial subdural haematoma associated with anticoagulation therapy have been described so far in the literature [3, 4, 12, 13, 20]. Acute subdural haematomas of the posterior fossa typically become manifest by the sudden onset of symptoms which progress rapidly and include a reduced vigilance with respiratory insu‰ciency and cardiovascular disorders [5]. The predominant manifestations of the chronic type are headaches, vomiting, cerebellar symptoms, and cranial nerve dysfunction. The few cases of adult chronic infratentorial subdural haematomas reported in the literature include only three more patients in whom vertigo and nystagmus were the main clinical symptoms as in our patient [3, 6, 10]. Vertigo and nystagmus are rather common symptoms indicative of a vestibular disorder. Such symptoms may be caused by a central disorder of the vestibular connections of the CNS (vestibular nuclei and tract, cerebellum, descending tracts of cerebellum) [3]. The bleeding in the present case may have been due to rupture of bridging veins caused by very mild trauma not noticed by the patient and possibly aggravated by the anticoagulation therapy. However, development from an acute subdural haematoma appears to be 500 R. Stendel et al.: Spontaneous Bilateral Chronic Subdural Haematoma of the Posterior Fossa highly unlikely because the patient could not recall any traumatic event. In conclusion, in patients presenting with cerebellar and vestibular symptoms, one should at least think of the possibility of an infratentorial subdural haematoma. The basic therapeutic approach in the chronic variety does not di¤er from the management of supratentorial chronic subdural haematomas. References 1. Achslogh L (1952) Hématome sous-dural chronique de la fosse cérébralé postérieure. Acta Neurol Psychia Belg 52: 790–794 2. Arseni C, Maretsis M (1972) Traumatic cerebellar haematoma associated with posterior cerebral fossa subdural haematoma. Psychiatry Neurol Neurochir 75: 113–115 3. Ashkenazi E, Pomeranz S (1994) Nystagmus as the presentation of tentorial incisure subdural haematoma. J Neurol Neurosurg Psychiatry 57: 830–831 4. Capistrant T, Goldberg R, Shibasaki H, Castle D (1971) Posterior fossa subdural haematoma associated with anticoagulant therapy. J Neurol Neurosurg Psychiatry 34: 82–85 5. Ciembroniewicz JE (1965) Subdural hematoma of the posterior fossa. Review of the literature with addition of three cases. J Neurosurg 22: 465–473 6. Giroux JC, Leger JL (1962) Hematomas of the posterior cranial fossa: a report of three cases. Can Med Ass J 87: 59–61 7. Gross SW (1955) Posterior fossa hematomas. J Mt Sinai Hosp 22: 286–289 8. Hernansanz J, Munoz F, Rodriguez D, Soler C, Principe C (1984) Subdural hematomas of the posterior fossa in normalweight newborns. Report of two cases. J Neurosurg 61: 972– 974 9. Holub K (1953) Ein Fall von subduralem Hämatom im Bereiche der hinteren Schädelgrube. Zbl Neurochir 13: 48–50 10. Izumihara A, Orita T, Kajiwara K, Tsurutani T (1993) Simultaneous supra- and infratentorial chronic subdural hematoma. Eur J Radiol 16: 183–185 11. Kachkov IA, Rusinov AI, Stashuk GA (1999) [Chronic subdural hematoma of the posterior cranial fossa]. Zh Vopr Neirokhir Im N N Burdenko 30–31 12. Kanter R, Kanter M, Kirsch W, Rosenberg G (1984) Spontaneous posterior fossa subdural hematoma as a complication of anticoagulation. Neurosurgery 15: 241–242 13. Lagares A, Dominguez J, Lobato RD, Gonzalez P (1998) Bi- lateral posterior fossa subdural haematomas secondary to anticoagulant therapy. Acta Neurochir 140: 1097–1098 14. Murthy VS, Deshpande DH, Narayana Reddy GN (1980) Chronic subdural hematoma in the cerebellopontine angle. Surg Neurol 14: 227–229 15. Neisser E, Pollack K (1904) Die Hirnpunktion. Probepunktion und Punktion des Gehirnes und seiner Häute durch den intakten Schädel. Mitt Grenzgeb Med Chir 13: 807–896 16. Perrin RG, Rutka JT, Drake JM, Meltzer H, Hellman J, Jay V, Ho¤man HJ, Humphreys RP (1997) Management and outcomes of posterior fossa subdural hematomas in neonates. Neurosurgery 40: 1190–1199, discussion 9-200 17. Rothballer AB (1962) Traumatic cerebellar hematoma in the newborn. Case report of operative removal with survival. J Neurosurg 19: 913–915 18. Schönbauer L (1937) Zur Frage der Behandlung der chronischen, subduralen und interzerebralen Blutungen. Mitt Grenzgeb Med Chir 44: 604–611 19. Silverstein A (1979) Neurological complications of anticoagulation therapy: a neurologist’s review. Arch Intern Med 139: 217–220 20. Zenteno-Alanis GH, Corvera J, Mateos JH (1968) Subdural hematoma of the posterior fossa as a complication of anticoagulant therapy. Presentation of a case. Neurology 18: 1133– 1136 Comments This paper is well written and emphasizes an important point for diagnosing these rarely occurring lesions – the quality of imaging or better lack of quality. MRI is superior to CT scanning in this region. Some of these lesions my easily be overlooked in posttraumatic situations by CT scanning with standard projections, however these haematomas may also disappear gradually and thus spontaneously. J. Haase The authors describe a very rare entity of a spontaneous infratentorial subdural haematoma in a 70 years old female without any recorded preceding injury or blood clotting abnormality. There is a very comprehensive review of an existing limited literature on the subject. This paper indicates, that cerebellar and vestibular symptoms could in some very rare cases result from an subdural haematoma and that surgical evacuation o¤ers a rapid improvement. T. Trojanowski Correspondence: Ruediger Stendel, M.D., Department of Neurosurgery, Benjamin Franklin Medical Center, Free University of Berlin, Hindenburgdamm 30, 12203 Berlin, Germany.