Subdural H e m a t o m a of the Posterior Fossa
R e v i e w of the Literature with Addition of T h r e e C a s e s
JULIUS E. CIEMBRONIEWICZ,M.D.
Department of Neurological Surgery, Boston City Hospital, Boston, Massachusetts
N COa~PARrSON to the large n u m b e r of
I head injuries t h a t are seen in the hospi-
tal and at a u t o p s y , t r a u m a t i c lesions of
surgical consequence to the posterior fossa
are relatively rare and, of those, subdural
h e m a t o m a over cerebellar hemispheres prob-
ably represents one of the rarest forms of
hemorrhagic space-occupying lesion. T h e
rarity of this lesion coupled with its confus-
ing clinical p r e s e n t a t i o n justifies a review of
the subject and the reporting of 3 new cases.
I n the neurosurgical unit of the Boston
C i t y Hospital o v e r a 15-year period (1948-
196~) 1589 p a t i e n t s were hospitalized be-
cause of extensive h e a d injuries. Subdural
h e m a t o m a s over the cerebral hemispheres
were verified in 53~ of these patients. Sub-
dural collection of blood in the posterior
fossa was found in 3 cases only (0.57 per
cent). I n 1960, M c K i s s o c k et al. 19 reported on
389 cases of subdural h e m a t o m a , of which
were in the posterior fossa. Ciarla, Greviewing
the results of ~ 1 5 autopsies, found p a c h y -
meningitis h e m o r r h a g i c a interna a b o v e the
t e n t o r i u m in 163 cases and only twice in the
posterior fossa. Vance, 33 on the basis of 507
autopsies on p a t i e n t s in w h o m d e a t h was
a t t r i b u t e d to head t r a u m a , stated t h a t "sub-
dural hemorrhages below the t e n t o r i m n were
caused b y cerebellar lacerations a n d were
rather rare. M o s t of t h e m were insignifi-
c a n t . " I n the statistics of Fisher et at., 11 of
135,000 hospitalized patients only 300 were
a d m i t t e d because of t r a u m a to the occipital
region a n d in 4 of t h e m subdural h e m a t o m a
of the posterior fossa was present. W e b s t e r
et at., ~4 in an analysis of 300 cases of pene-
t r a t i n g cranial wounds during World W a r
I I , f o u n d cerebellar wounds in only 10.
Received for publication May 12, 1964.
465
B a r n e t t and Meirowsky 2 in their s t u d y of
K o r e a n W a r casualties found wounds of the
cerebellum in 3.8 per cent of patients. P r o b -
ably the first successful o p e r a t i v e case of
subdural h e m a t o m a in the posterior fossa
was described b y Neisser a n d Pollack ~2 in
1904. T h e patient, with a history of head-
ache, vomiting and unsteadiness for a few
weeks, was a d m i t t e d to hospital in coma. I n
addition to the signs indicating i n v o l v e m e n t
of the posterior fossa, left facial weakness of
the u p p e r - m o t o r neuron t y p e was present.
After negative exploration o v e r the right
m o t o r area, the posterior fossa was trephined
twice and 180 gm. of clotted and semiliquid
blood were removed. T h e operation was
followed by a complete recovery. T h e same
authors mentioned ~ other patients manifest-
ing cerebellar signs and a chronic course; in
t h e m trephination of the posterior fossa
revealed blood in the subdural space, the
a m o u n t and character of which were not
clarified. In 1913 Ciarla 6 presented a single
case of t r a u m a t i c pachymeningitis hemor-
rhagica in the posterior fossa, and in the
following years other authors 1,5,7,1~ .14.19.21-32
added more cases, bringing the t o t a l n u m b e r
reported to 31.
R e p o r t of C a s e s
Case 1. E.D., a 47-year-old white male, was ad-
mitted on June ~9, 1954 and died on June 30,
1954. Shortly before admission the patient was
struck on the forehead with a baseball bat, and on
falling to the ground he struck his occiput on a
curbstone. He did not lose consciousness and
there was no headache or vomiting.
Examination. On admission he was fully con-
scious, alert and talking, but slightly confused. A
small laceration of the occipital scalp was recog-
nized. The neurological findings at this time were
negative except for a slightly larger left pupil.
Pulse rate was 1~0, blood pressure 1~0/90, and
respiratory rate ~0. Roentgenograms showed no
466 Julius E. Ciembroniewicz
evidence of fracture of the skull. The laceration of
his scalp was sutured and the patient was ad-
mitted to one of tile general surgical wards in
good condition. Half an hour later he suddenly
became comatose and unresponsive. Neurological
examination at that time revealed flaccid ex-
tremities and absence of muscular reflexes. Plan-
tar responses were absent. Pupils reacted to light,
the left much more than the right. Pulse rate was
80, blood pressure 150/90 and respiratory rate
6-8/min. Lumbar puncture revealed pink fluid
under a pressure of 350 mm. of water.
The clinical impression was that of acute epi-
dural or subdural hematoma over the left cerebral
hemisphere. He was transferred to the neuro-
surgical unit.
Operation. Burr holes were made in the parietal,
temporal and frontal areas. The only abnormality
found was marked brain edema. The posterior
fossa was then explored, revealing a discolored
dura mater under great pressure. When the dura
mater was incised a copious amount of solid blood
clot extruded itself, and immediately the patient's
labored and irregular respirations became less
stertorous and soon assumed a regular rhythm.
The clot was estimated at over 30 cc. and when
almost completely removed the presumed source
of bleeding, a small artery over the upper part of
the right cerebellar hemisphere, was uncovered.
The bleeding was controlled with coagulation.
Course. The following day the patient was
deeply comatose. The left pupil was slightly larger
than the right. Both pupils, however, reacted to
light. Pulse rate was 110, blood pressure 150/60,
and respiratory rate 18. About e0 hours after
operation the patient suddenly stopped breathing
and despite intubation and artificial respiration,
he expired. Postmortem examination disclosed a
swollen brain, weighing 1580 gin., with recurrent
blood clot in the posterior fossa, herniation of
tonsils, and a flattened hemorrhagic pons. A linear
fracture of the skull on the right side extended
from the occiput into the foramen magnum.
Comment. T h e p a t i e n t s u s t a i n e d a severe
i n j u r y t o t h e occipital area, w h i c h h o w e v e r
d i d n o t p r o d u c e unconsciousness. O n a d m i s -
sion, n e u r o l o g i c a l findings were e n t i r e l y
n e g a t i v e a p a r t from slight anisocoria. F i h n s
of t h e s k u l l failed to reveal t h e f r a c t u r e which
w a s l a t e r f o u n d o n a u t o p s y . A f t e r a short
lucid interval, the patient suddenly became
d r o w s y a n d lapsed i n t o deep c o m a r a p i d l y .
A t t h i s stage t h e r e were no l a t e r a l i z i n g signs,
a p a r t f r o m m a r k e d anisocoria. Signs of cere-
b e l l a r d y s f u n c t i o n were n o t n o t i c e d , p r e s u m -
a b l y e s c a p i n g d e t e c t i o n because of t h e u n -
consciousness. T h e decision to open t h e
p o s t e r i o r fossa w a s m a d e after several explo-
r a t i o n s t h r o u g h s u p r a t e n t o r i a l b u r r holes
failed to reveal a lesion.
Case 2. D.E., an 84-year-old white male, was
admitted on Feb. 3, 1960 and died on Feb. 5,
1960. Shortly before admission he was struck on
the head with a club which rendered him un-
conscious for half an hour.
Examination. On admission the patient was
lucid and alert, complaining only of some head-
ache. He did not vomit. A few small lacerations
of the scalp were over the forehead and a larger
one in the occipital area. Neurological findings at
that time were negative except for an extensor
plantar response on the right side. Roentgeno-
gram of the skull disclosed a linear fracture in the
right parietal area, and the patient was admitted
to the general surgical service with a diagnosis of
cerebral contusion.
Course. About 6 hours later, while sitting up in
bed, he started to vomit and suddenly became
unresponsive and apneic. He was intubated and
respirations were maintained by positive pressure.
Neurological examination revealed a deeply co-
matose patient not responding to painful stimuli,
flaccid in all extremities and totally areflexic.
Pupils were equal, very small and did not react
to light.
The patient was transferred to the neurosur-
gical unit with the diagnosis of brain edema,
brain-stem compression and possible expanding
lesion of the posterior fossa.
Operation. After negative exploration through
burr holes over the line of fracture of the skull,
both lateral ventricles were tapped through the
burr holes in the parietal area with the recovery
of grossly bloody fluid under pressure of 300 mm.
of water. Approximately 80 cc. of fluid were
drained from each of the ventricles. The posterior
fossa was explored. The dura mater over both
cerebellar hemispheres was bluish and strongly
bulging. After incision of the dura mater about
40 cc. of fresh subdural clot extruded itself. A
small area of laceration with a cortical hematoma
was found over the right cerebellar hemisphere.
Cerebellar tonsils were found herniated through
the foramen m a g n u m and were necessarily re-
moved. The cerebellum started to pulsate again.
The subdural clot was found to extend down to
the level of Ce and to compress the spinal cord
severely. I t was removed by suction. The wound
was closed in the usual manner.
Course. During the operation the patient's con-
dition deteriorated. Blood pressure had to be
maintained with large amounts of Levophed and
no spontaneous respirations were recorded. Four
hours after operation the patient expired.