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Pediatric retroclival hematomas
Yahya H Khormi1,2, Mohamed M Aly3,4, Hossam K Hamda5
1Department of Surgery, Neurosurgery Division, Jazan University, Al Maarifah Road, PO Box 114, 45142, Jazan, Saudi Arabia. yakhormi@jazanu.edu.sa.
Insights
Traumatic retroclival hematomas (RCHs) in children are often linked to craniocervical junction instability, which can lead to poor outcomes. Early cervical MRI is crucial for diagnosing ligamentous injuries in pediatric RCH cases.
Area of Science:
- Pediatric Neurosurgery
- Neuroradiology
- Trauma Surgery
Background:
- Traumatic retroclival hematomas (RCHs) are rare in children, with limited research guidance.
- Existing literature consists mainly of case reports, hindering effective management strategies.
Purpose of the Study:
- To report four cases of pediatric RCHs, including a rare spontaneous subdural RCH.
- To systematically review and consolidate existing literature on pediatric RCHs.
Main Methods:
- Systematic review adhering to PRISMA and CARE guidelines.
- Multivariate logistic regression to assess clinical variables and outcomes.
- Documentation of four pediatric RCH cases.
Main Results:
- Analysis of 65 traumatic RCHs revealed craniocervical junction instability in 64.6% and ligamentous involvement in 83.3%.
- Children aged 5-9 years were most affected; cranial nerve palsies occurred in 29 patients, typically resolving within 6 months.
- Craniocervical junction injuries were associated with poorer outcomes (OR 4.88, p=0.04); 76.5% of cases were managed conservatively.
Conclusions:
- Pediatric RCHs are predominantly traumatic and extradural, with a peak incidence in children aged 5-9.
- Craniocervical junction injuries, particularly ligamentous, are common and correlate with adverse outcomes.
- Cervical MRI is vital for detecting ligamentous injuries; conservative management is preferred unless severe complications arise.
Background:
Traumatic retroclival hematomas (RCHs) are infrequent occurrences among the pediatric population. The existing body of research pertaining to these hematomas primarily consists of case reports or small case series, which do not provide adequate guidance for managing this condition.
Objective:
This study aims to present a report on four cases of RCHs. Additionally, we aim to conduct a systematic review to consolidate the existing literature on pediatric RCHs.
Methods:
The authors conducted a systematic review in accordance with the PRISMA and CARE guidelines. A multivariate logistic regression model was developed to evaluate the potential impact of various clinical variables on clinical outcomes. The study also documented four of our cases, one of which was a rare occurrence of spontaneous subdural RCH.
Results:
A total of 62 traumatic RCHs have been documented in the literature. We documented three cases of traumatic RCHs and one case of spontaneous RCH. A systematic analysis of 65 traumatic RCHs was performed. Of trauma cases, 64.6% demonstrated craniocervical junction instability with 83.3% ligamentous involvement. Thirty-five patients were males. 50.7% were aged between 5 and 9 years. Cranial nerve palsies occurred in 29 patients (27 had abducent palsy), 26 of which resolved within 6 months of trauma. 23.5% underwent surgery, and 76.5% were conservatively managed. Surgeries targeted hematomas, hydrocephalus, or craniocervical instability. Approaches to hematomas included transclival and far/extreme lateral suboccipital approaches. Clinical outcome was good in 75.4% and intermediate or poor in 24.6%. Logistic regression suggested an association between craniocervical junction injuries and poor or intermediate outcomes (OR 4.88, 95% CI (1.17, 27.19), p = 0.04).
Conclusion:
Pediatric RCHs are mostly traumatic and extradural. Children between 5 and 9 years old are most vulnerable. Craniocervical junction injuries, mainly ligamentous, are common in RCHs and are associated with intermediate or poor outcomes. Cervical MRI could be important in cases of trauma to rule out ligamentous injuries of the craniocervical junction. The small size of RCHs should not exempt the careful assessment of craniocervical junction instability. Cranial nerve palsies are common and usually resolve within 6 months. Conservative treatment is typical unless brainstem compression, hydrocephalus, or craniocervical junction instability exists.
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