Retroclival Hematoma

Abstract

A 2-year-old boy was brought to our emergency department for pain along the cervical spinal cord area, preventing normal movements of the trunk and causing difficulty walking. The pain started without any apparent precipitating factors. There was no history of trauma, although his parents reported a habit of somersaults. He was in distress, had truncal rigidity, and refused to walk. On exam, passive movements of the lower limbs were free, deep tendon reflexes were present, and neurologic findings were normal. Magnetic resonance imaging of the brain and spine showed an epidural hemorrhage along the clivus and ventral cervical spine (Figure), without active bleeding, excluding the need for surgery. During follow-up, we observed complete resolution of his symptoms in 3 days. Three weeks later, a follow-up magnetic resonance imaging showed complete resolution of the hematoma. Epidural hematomas of the posterior cranial fossa are relatively rare, and the majority of these cases present in childhood.1Agrawal D. Cochrane D.D. Traumatic retroclival epidural hematoma—a pediatric entity?.Childs Nerv Syst. 2006; 22: 670-673Crossref PubMed Scopus (23) Google Scholar The most frequent cause is a trauma with hyperflexion or hyperextension of the neck. These dynamics can cause detachment of the tectorial membrane from the clivus and venous bleeding. Some anatomical differences make children more predisposed to this injury. Children have larger size of the head in proportion to the body, weaker neck muscles, less stable cranio-cervical junction, smaller occipital condyles, and looser ligamentous apparatus. Symptoms include headache, nausea, and paralysis of the cranial nerves. Most cases are treated conservatively with complete resolution. However, if there is an injury to ligaments, surgical stabilization is required. In cases of paralysis or respiratory abnormalities, evacuation of the hematoma should be considered.2Guillaume D. Menezes A.H. Retroclival hematoma in the pediatric population. Report of two cases and review of the literature.J Neurosurg. 2006; 105: 321-325PubMed Google Scholar, 3Kwon T.H. Joy H. Park Y.K. Chung H.S. Traumatic retroclival epidural hematoma in a child: case report.Neurol Med Chir (Tokyo). 2008; 48: 347-350Crossref PubMed Scopus (26) Google Scholar