Neurol Med Chir (Tokyo) 48, 347¿350, 2008 Traumatic Retroclival Epidural Hematoma in a Child —Case Report— Taek-Hyun KWON, Hoon JOY, Youn-Kwan PARK, and Hung-Seob CHUNG Department of Neurosurgery, College of Medicine, Korea University, Seoul, R.O.K. Abstract An 11-year-old girl presented with a very rare traumatic retroclival epidural hematoma manifesting as bilateral abducens nerve palsy, deviation of the uvula to the left, and weakened movement of tongue, which developed after a motor vehicle accident. The patient was treated conservatively and showed good outcome. Retroclival hematoma is a mainly pediatric entity usually associated with ligamentous injury at the craniocervical junction, and can be treated conservatively with good outcome. Key words: clivus, epidural hematoma, hyperextension injury Introduction Retroclival epidural hematomas (EDHs) are very rare and only numbered cases have been reported.1,2,4–18,20,22,23) Most reported cases have been noted in pediatric patients after motor vehicle accidents involving the cervical spine. Here we report another case of traumatic retroclival EDH in a child. Case Report Fig. 1 An 11-year-old girl was involved in a motor vehicle accident which caused cervical hyperextension after she was thrown from a passenger seat and collided with the front windshield. On admission, her Glasgow Coma Scale (GCS) score was 15. She complained of headache and neck pain. In addition, swallowing was extremely difficult and she had dysarthria. Physical examination revealed bilateral abducens nerve palsy, deviation of the uvula to the left, and weakened movement of tongue. Brain computed tomography (CT) revealed a hyperdense lesion ventral to the medulla (Fig. 1A). Radiography of the cervical spine showed straightening of the cervical spine lordosis with a large prevertebral swelling in front of the clivus and upper cervical spine (Fig. 1B). Cervical spine CT showed a retroclival hyperdense mass lesion compatible with acute retroclival EDH, extending from the posterior aspect of dens to the upper clival region, indicating that the dura and tectorial memReceived 2008 November 7, 2007; Accepted A: Initial brain computed tomography scan showing a hyperdense lesion ventral to the medulla. B: Lateral radiograph of the cervical spine revealing straightening of the cervical spine lordosis with a large prevertebral swelling in front of the clivus and upper cervical spine. C: Sagittal T2-weighted magnetic resonance image of the cervical spine revealing the better delineation of the hematoma and resultant brainstem compression. brane had been stripped off the clivus by the hematoma (Fig. 2A). Magnetic resonance imaging provided better delineation of the hematoma and resultant brainstem compression (Fig. 1C). There was no visible fracture or dislocation in the skull base or craniocervical region. However, her cervical spine was immobilized with a Philadelphia brace, given the long segmental stripping of the tectorial membrane. Clinical status including swallowing and speech improved with conservative treatment consisting of March 26, 347 T.-H. Kwon et al. 348 simple immobilization. Cervical spine CT obtained 10 days after the accident revealed decreases in the hematoma size and prevertebral soft tissue swelling (Fig. 2B). Follow-up CT 6 weeks after the accident showed spontaneous resorption of the hematoma (Fig. 2C). Her neurological symptoms had also resolved. Fig. 2 Table 1 Serial high resolution computed tomography scans of the cervical spine taken initially (A), and 10 days (B) and 6 weeks after the accident (C) showing gradual decrease of the retroclival hematoma and prevertebral soft tissue swelling. Discussion Posterior fossa EDHs are relatively uncommon, often located between the occipital bone and the dura mater, and, moreover, retroclival EDHs are exceedingly rare. Spontaneous or non-traumatic retroclival are also known in adults.3,6,8,19,21) However, excluding such non-traumatic cases, only 20 cases of traumatic retroclival hematoma, including our case, have been reported (Table 1),1,2,4,5,7,9–18,20,22,23) and some striking clinical similarities can be found. Firstly, most cases occurred in the pediatric population, characteristically after a motor vehicle accident resulting in cervical hyperflexion or hyperextension injuries. The cranio-cervical junction is less stable in children than in adults because the occipital condyles are relatively smaller and the articulation between the cranium and the atlas is more horizontal. In addition, the cranio-cervical junction has increased ligamentous elasticity in children, which predisposes to ligamentous injury at the cranio-cervical junction.1,7,16) The mechanism of retroclival EDH is controversial. In addition to ordinary retroclival hematoma formation after clivus fracture, cervical hyperflexion or hyperextension in- Clinical summary of all published cases of traumatic retroclival hematoma Author (Year) Age (yrs) Orrison et al. (1986)15) 8 Kurosu et al. (1990)11) 11 Papadopoulos et al. (1991)16) Castillo et al. (1994)4) Marks et al. (1997)12) Mizushima et al. (1998)13) Muller et al. (1998)14) Fuentes et al. (2000)5) Khan and Zumstein (2000)10) Suliman et al. (2001)20) 10 10 8 8 7 47 19 16 Yang (2003)23) Paterakis et al. (2005)17) Agrawal and Cochrane (2006)1) Calisaneller et al. (2006)2) Guillaume and Menezes (2006)7) 5 10 8 11 5 8 12 26 5 11 Itshayek et al. (2006)9) Ratilal et al. (2006)18) Vera et al. (2007)22) Present case Cause of hematoma MVA, hyperflexion, lt atlanto-occipital dislocation MVA, hyperextension, diastasis of spheno-occipital synchondrosis MVA, atlanto-occipital dislocation MVA, hyperextension MVA, hyperextension, C1-2 dislocation MVA, hyperextension, C1-2 dislocation MVA, hyperflexion MVA, bil occipital condyle fracture MVA, transverse clivus fracture MVA, hyperextension, avulsion fracture of lt occipital condyle MVA MVA, longitudinal clivus fracture MVA MVA MVA ATV accident running fall, hyperextension MVA, hyperextension MVA, atlanto-occipital dislocation MVA, hyperextension GCS score GOS score 3 death 7 GR 4 coma 6 6 6 NA 15 10 GR GR GR GR GR GR GR GR 7 12 7 15 7 15 15 13 3 15 GR GR GR GR GR GR GR GR death GR ATV: all terrain vehicle, GCS: Glasgow Coma Scale, GOS: Glasgow Outcome Scale, GR: good recovery, MVA: motorvehicle accident, NA: not available. Neurol Med Chir (Tokyo) 48, August, 2008 Retroclival EDH jury may cause disruption of the insertion of the tectorial membrane from the clivus, resulting in venous bleeding. The dura is more easily separated from the skull in children, so children are more susceptible to this type of stripping injury.18,23) Motor vehicle accidents are more prevalent in adults than in children, but these anatomical characteristics of children contribute to the relatively high occurrence of traumatic retroclival EDH in the pediatric age group. Secondly, the clinical course of retroclival hematoma seems to be very benign. GCS score is an effective predictor of the course and prognosis in a patient with traumatic brain injury. However, no positive correlation could be established between GCS on admission and outcome in patients with retroclival EDH. Among the 20 cases, all but two patients who died showed good recovery irrespective of GCS score on admission, and even one patient comatose on admission achieved full recovery.4) The present patient had multiple cranial nerve pareses manifesting as bilateral abducens nerve palsy, swallowing difficulty, and tongue weakness. Many previous patients had various cranial nerve pareses: the abducens nerve was the most commonly injured (37%), followed by the hypoglossal nerve (21%) and the glossopharyngeal nerve (16%). The 6th cranial nerve seems to be the most susceptible, possibly because of the longest intracranial course. Direct contusion or stretching of the nerve by the hematoma may be the cause of the cranial nerve paresis,2) so most pareses showed good recovery. Most patients with retroclival hematoma were treated conservatively and had good outcomes, as in our case. Four patients were treated surgically, one with transoral evacuation12) and the other three with posterior decompression.5,14,16) Regardless of the management option, all patients showed good recovery, except the patients who died due to comorbidities. In our patient, all the symptoms and signs of swallowing and speech difficulties due to multiple cranial nerve pareses resolved gradually within weeks after cervical immobilization. Conservative treatment, in the absence of progressive neurological deterioration, seems to be the treatment of choice. However, evacuation of the hematoma and stabilization procedure should be considered in patients with critical compression of the brainstem or instability of the cranio-cervical junction. 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) References 1) Agrawal D, Cochrane DD: Traumatic retroclival epidural hematoma — a pediatric entity? 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Pediatr Neurosurg 39: 339–340, 2003 Address reprint requests to: Youn-Kwan Park, M.D., Department of Neurosurgery, Korea University Guro Hospital, 80, Guro–dong, Guro–ku, Seoul, 152–703, R.O.K. e-mail: ykapa76@yahoo.co.kr Neurol Med Chir (Tokyo) 48, August, 2008