Acute epidural hematoma of the posterior fossa—cases of acute clinical deterioration

Purpose Posterior fossa epidural hematoma (PFEDH) is an uncommon complication of head injury, which is sometimes associated with acute clinical deterioration (ACD) without significant warning symptoms and may results in death. We investigated clinical characteristics of PFEDH with ACD to identify the process of ACD. Methods A retrospective case-control review of all patients admitted with a diagnosis of PFEDH between September 1989 and February 1999 was performed. Results Twenty-one patients (14 men and 7 women) were admitted for PFEDH to Sendai City Hospital. Four patients suffered ACD. All patients had struck their occipital region and had occipital fracture. Patients were treated conservatively on admission because computed tomography (CT) showed no significant findings in 2 patients and PFEDH with minimal symptoms in the others. All patients suffered acute deterioration of consciousness after vomiting. Follow-up CT showed large PFEDH with severe mass effect. Emergency surgery was performed and identified the bleeding point as the venous sinus. The presence of nausea/vomiting was significant risk factor of ACD (Fisher exact test: P = .021). Of the 4 patients, 2 achieved excellent recovery without deficit, 1 was moderately disabled, and 1 died. The outcome of patients with ACD was worse compared to those without ACD (Fisher exact test: P = .046). Conclusions We should note that vomiting itself could be a significant risk factor of ACD for occipital head trauma. The patients with occipital fracture and vomiting must be observed closely and followed up by CT, even if the initial CT is negative. CT performed shortly after the trauma may reveal no evidence of PFEDH but cannot exclude the development of delayed hematoma