UpToDate: Spontaneous posterior fossa subdural hematoma

Spontaneous posterior fossa subdural hematoma

Posterior fossa subdural hematomas may be spontaneous, with no previous trauma. These cases are usually secondary to bleeding from an underlying pathology such as arteriovenous malformation (AVM), aneurysm 1),tumor or coagulation disorder2) 3).

see also Spontaneous retroclival subdural hematoma.

Posterior fossa craniectomy may be preferable in terms of diagnosis and safe treatment 4).

Outcome

Prognosis seems to be related to the clinical condition of the patient at the moment of surgery, according to the GCS. Patients with mild symptomatology usually have a good outcome, whereas, in most cases, there is no improvement if a moderate or severe neurologic deficit has already been established 5) 6).

Case reports

Finger G, Martins OG, Basso LS, Ludwig do Nascimento T, Schiavo FL, Cezimbra Dos Santos S, Stefani MA. Acute spontaneous subdural hematoma in posterior fossa: case report with great outcome. World Neurosurg. 2018 Aug 1. pii: S1878-8750(18)31700-5. doi: 10.1016/j.wneu.2018.07.220. [Epub ahead of print] PubMed PMID: 30077031.


A 69-year-old woman was admitted with nausea, headache, and mild consciousness disturbance. Computed tomography and magnetic resonance imaging showed bilateral pCSH. To prevent further neurological deterioration, we performed surgery under general anesthesia by midline suboccipital craniectomy. Unexpected bleeding from a developed circuitous occipital sinus was stopped with hemoclips. After hematoma removal, she recovered and was transferred to a rehabilitation hospital. By the 19(th) postoperative day, she had developed no neurologic deficits.

This experience demonstrates the risk of blind surgical therapy in patients with pCSH. In such patients, posterior fossa craniectomy may be preferable in terms of diagnosis and safe treatment 7).


A 83-year-old woman was admitted with recent sudden headache and dizziness. Magnetic resonance imaging showed a thin collection of blood in the subdural space adjacent to the clivus, along the wall of the posterior fossa, and at the cervical spine level. A right posterior communicating artery aneurysm was diagnosed using computed tomography angiography and digital subtraction angiography. The aneurysm had two lobes, one of which was attached to the right dorsum sellae. The aneurysm was occluded by stent-assisted coil embolization. The patient was discharged 3 weeks after admission with absence of neurological deficit.

A ruptured aneurysm of the posterior communicating artery may cause an acute SDH 8).


A rare case of concomitant cranial and spinal subdural haematoma (SDH) in a 12-year-old boy with severe thrombocytopenia due to aplastic anaemia, and review the available literature. Magnetic resonance (MR) imaging at presentation revealed a cranial SDH confined to the posterior fossa, and spinal SDH extending from the C1 to S3 segments. The child was managed conservatively due to his poor general condition and lack of any neurological deficit. Repeat MR imaging done at six weeks showed complete resolution of the spinal SDH and partial resolution of the cranial SDH. Although rare, a spontaneous spinal SDH can occur simultaneously with a cranial SDH. Urgent surgical decompression is considered the treatment of choice for spinal SDH; however, a conservative approach may succeed in patients with poor general condition, and/or mild/no neurological deficit 9).


Berhouma M, Houissa S, Jemel H, Khaldi M. Spontaneous chronic subdural hematoma of the posterior fossa. J Neuroradiol. 2007 Jul;34(3):213-5. PubMed PMID: 17572494 10).


Usul et al., present a spontaneous posterior fossa subdural hematoma in a term neonate and discuss conservative management 11).


A case of spontaneous acute subdural haematoma in the posterior fossa following anticoagulation 12).


The association of the posterior fossa chronic subdural hematoma with spontaneous parenchymal hemorrhage without anticoagulation therapy was never related in the literature. Costa et al., describe a case of a 64 year-old woman who suffered a spontaneous cerebellar hemorrhage, treated conservatively, and presented 1 month later with a chronic subdural posterior fossa hematoma 13).


Miranda et al., present a case of a posterior fossa acute subdural hematoma occurring in an anticoagulated patient who was preoperatively misdiagnosed as an intracerebellar hemorrhage 14).


A 52-year-old woman treated for acute myeloproliferative disease developed progressive stupor. CT showed obstructive hydrocephalus resulting from unexplained mass effect on the fourth ventricle. MRI revealed bilateral extra-axial collections in the posterior cranial fossa, giving high signal on T1- and T2-weighted images, suggesting subacute subdural haematomas. Subdural haematomas can be suspected on CT when there is unexplained mass effect. MRI may be essential to confirm the diagnosis and plan appropriate treatment 15).


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.

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 differential diagnosis in elderly patients with cerebellar and vestibular symptomatology even without a history of trauma 16).


A case of spontaneous acute subdural hematoma complicated with idiopathic thrombocytopenic purpura was reported. He was hospitalized complaining of sudden onset of headache and nasal bleeding without neurological deficit. CT scan revealed subdural hematoma in the posterior fossa especially below the tentorium cerebelli. Further hematological examination proved very low platelet count (1,000/mm3) and antiplatelet antibody in confirmation of a diagnosis of idiopathic thrombocytopenic purpura. As his neurological status was good, he was treated medically. His symptoms and platelet count improved gradually with corticosteroid therapy. Reviewing the literature, acute subdural hematoma with idiopathic thrombocytopenic purpura was quite rare and only three cases reported 17).


Aicher KP, Heiss E, Gawlowski J. [Spontaneous subdural hematoma in the posterior cranial fossa]. Rofo. 1988 Dec;149(6):669-70. German. PubMed PMID: 2849170 18).


Kanter et al., report a patient in whom a spontaneous subdural hematoma developed in the posterior fossa during anticoagulation therapy for mitral valve disease. This rare complication of anticoagulation has been reported in only three other patients 19).


A case of spontaneous posterior fossa subdural hematoma secondary to anticoagulation therapy with definitive diagnosis made by vertebral angiography is reported. Vertebral angiographic findings are illustrated and demonstrate primarily mass effect from posterior compartment of posterior fossa and avascular area. Carotid angiography did not show hydrocephalus. A review of the literature was made and this appears to be the first reported case in which a posterior fossa subdural hematoma has been diagnosed by vertebral angiography 20).


A report of spontaneous posterior fossa subdural haematoma associated with anticoagulation therapy. The possibility of posterior fossa lesions related to spontaneous haemorrhage is suggested by the combination of severe headache and increasing disturbance of consciousness associated with signs of brain-stem decompensation. A thorough neurological evaluation including appropriate contrast studies will help rule out a supratentorial lesion. This is a neurological emergency which can be successfully treated by early detection and prompt surgical decompression. This is the second reported case of spontaneous subdural haematoma of the posterior fossa occurring during anticoagulant therapy 21).

References

1) , 8)

Kim MS, Jung JR, Yoon SW, Lee CH. Subdural hematoma of the posterior fossa due to posterior communicating artery aneurysm rupture. Surg Neurol Int. 2012;3:39. doi: 10.4103/2152-7806.94287. Epub 2012 Mar 24. PubMed PMID: 22530173; PubMed Central PMCID: PMC3327002.
2) , 16)

Stendel R, Schulte T, Pietilä TA, Suess O, Brock M. Spontaneous bilateral chronic subdural haematoma of the posterior fossa. Case report and review of the literature. Acta Neurochir (Wien). 2002 May;144(5):497-500. Review. PubMed PMID: 12111507.
3) , 10)

Berhouma M, Houissa S, Jemel H, Khaldi M. Spontaneous chronic subdural hematoma of the posterior fossa. J Neuroradiol. 2007 Jul;34(3):213-5. PubMed PMID: 17572494.
4) , 7)

Takemoto Y, Matsumoto J, Ohta K, Hasegawa S, Miura M, Kuratsu J. Bilateral posterior fossa chronic subdural hematoma treated with craniectomy: Case report and review of the literature. Surg Neurol Int. 2016 May 6;7(Suppl 10):S255-8. doi: 10.4103/2152-7806.181979. eCollection 2016. PubMed PMID: 27213111; PubMed Central PMCID: PMC4866054.
5) , 14)

Miranda P, Alday R, Lagares A, Pérez A, Lobato RD. Posterior fossa subdural hematoma mimicking intracerebellar hemorrhage. Neurocirugia (Astur). 2003 Dec;14(6):526-8. PubMed PMID: 14710308.
6) , 15)

Pollo C, Meuli R, Porchet F. Spontaneous bilateral subdural haematomas in the posterior cranial fossa revealed by MRI. Neuroradiology. 2003 Aug;45(8):550-2. Epub 2003 May 22. PubMed PMID: 12761603.
9)

Jain V, Singh J, Sharma R. Spontaneous concomitant cranial and spinal subdural haematomas with spontaneous resolution. Singapore Med J. 2008 Feb;49(2):e53-8. Review. PubMed PMID: 18301828.
11)

Usul H, Karaarslan G, Cakir E, Kuzeyl K, Mungan L, Baykal S. Conservative management of spontaneous posterior fossa subdural hematoma in a neonate. J Clin Neurosci. 2005 Feb;12(2):196-8. PubMed PMID: 15749432.
12)

Pal D, Gnanalingham K, Peterson D. A case of spontaneous acute subdural haematoma in the posterior fossa following anticoagulation. Br J Neurosurg. 2004 Feb;18(1):68-9. PubMed PMID: 15040720.
13)

Costa LB Jr, de Andrade A, Valadão GF. Chronic subdural hematoma of the posterior fossa associated with cerebellar hemorrhage: report of rare disease with MRI findings. Arq Neuropsiquiatr. 2004 Mar;62(1):170-2. Epub 2004 Apr 28. PubMed PMID: 15122456.
17)

Saito K, Sakurai Y, Uenohara H, Seki K, Imaizumi S, Katakura R, Niizuma H. [A case of acute subdural hematoma in the posterior fossa with idiopathic thrombocytopenic purpura]. No To Shinkei. 1992 Apr;44(4):377-81. Review. Japanese. PubMed PMID: 1633035.
18)

Aicher KP, Heiss E, Gawlowski J. [Spontaneous subdural hematoma in the posterior cranial fossa]. Rofo. 1988 Dec;149(6):669-70. German. PubMed PMID: 2849170.
19)

Kanter R, Kanter M, Kirsch W, Rosenberg G. Spontaneous posterior fossa subdural hematoma as a complication of anticoagulation. Neurosurgery. 1984 Aug;15(2):241-2. PubMed PMID: 6483141.
20)

McClelland RR, Ramirez-Lassepas M. Posterior fossa subdural hematoma demonstrated by vertebral angiography. Neuroradiology. 1976;10(1):181-5. PubMed PMID: 1256644.
21)

Capistrant T, Goldberg R, Shibasaki H, Castle D. Posterior fossa subdural haematoma associated with anticoagulant therapy. J Neurol Neurosurg Psychiatry. 1971 Feb;34(1):82-5. PubMed PMID: 5313648; PubMed Central PMCID: PMC493691.

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