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LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 5  |  Page : 778-779

Rare case of closed depressed fracture of the posterior fossa in an adult causing brainstem dysfunction: Management dilemmas


Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India

Date of Submission20-Jun-2011
Date of Decision25-Jul-2011
Date of Acceptance27-Jul-2011
Date of Web Publication22-Oct-2011

Correspondence Address:
A Arivazhagan
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.86570

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How to cite this article:
Bharath R, Arivazhagan A, Pruthi N, Bhat DI. Rare case of closed depressed fracture of the posterior fossa in an adult causing brainstem dysfunction: Management dilemmas. Neurol India 2011;59:778-9

How to cite this URL:
Bharath R, Arivazhagan A, Pruthi N, Bhat DI. Rare case of closed depressed fracture of the posterior fossa in an adult causing brainstem dysfunction: Management dilemmas. Neurol India [serial online] 2011 [cited 2019 Nov 18];59:778-9. Available from: http://www.neurologyindia.com/text.asp?2011/59/5/778/86570


Sir,

Depressed fractures in adults are rare in the posterior fossa because of multiple layers of muscle and soft tissue covering the suboccipital region. [1] We report one such case who succumbed to brainstem dysfunction.

A 35-year-old man, a pedestrian, was allegedly hit by a tractor from front, fell back on his head and lost consciousness. Examination revealed a Glasgow coma scale (GCS) score of E2 M5 V2, normal reacting pupils, intact brainstem reflexes and no focal deficits. Computer tomography (CT) scan of the head done 11 h post-trauma showed a closed suboccipital region depressed fracture with a speck of left cerebellar contusion and no associated hydrocephalus [Figure 1]a-e. He was managed conservatively with anti-edema measures. Repeat CT scan at 23 h revealed no increase in cerebellar contusion or ventricular size. At 40 h following trauma, he deteriorated in sensorium (E1 M4 V1) and developed left hemiparesis. A repeat CT scan showed significant brainstem compression and mild ventriculomegaly due to depressed fracture and edema [Figure 1]f. He underwent an emergency posterior fossa exploration, removal of depressed fracture fragment and decompressive craniectomy. Intraoperatively, there was a comminuted fracture of the occipital bone and invagination of the foramen magnum rim just superior to the posterior arch of C1, causing compression [Figure 1]g. On removal of the bone fragments, foramen magnum rim and posterior arch of C1, a lax dura with two small dural tears was noted, which were primarily repaired. However, post-operatively, the patient's sensorium deteriorated further (E1 M2 VT), brainstem reflexes were absent and pupils were fixed and dilated. He was managed with anti-edema measures, ventilatory support and external ventricular drain for the persistent ventriculomegaly. However, he worsened progressively and succumbed on post-operative day 6.
Figure 1: Computer tomography (CT) head showed suboccipital depressed fracture with a speck of cerebellar contusion with edema (a-e). The temporal horns are not dilated in the initial CT (c). CT head 40 h after trauma revealed development of hydrocephalus (f). Intraoperative photograph showing depressed fracture of the occipital bone (g)

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Depressed skull fractures result from high-energy direct blows to a small surface area of the skull by a blunt object. It is very rare in the suboccipital region in adults. [1] In children, due to the thin skull and relatively less soft tissue in the suboccipital region, they have been reported more commonly. [2] In a series of 1802 patients with head injury involving all age groups, Karasawa et al. reported 32 patients with occipital bone fractures. None of these patients had depressed fracture that merited surgical intervention. [3] A literature search revealed only one case report of closed depressed fracture of the posterior fossa with brainstem dysfunction. [1]

Neurological deficit (s) due to compression or cosmetic deformity is the indication for surgical intervention in closed depressed fractures of the supratentorial region. Because the posterior fossa closed depressed fractures are rare, the surgical indications are unclear. The posterior fossa is a relatively small and crowded space and hence any lesion further reducing the volume of the cavity can elevate the intracavitary pressure. Hydrocephalus due to fourth ventricle compression, secondary to elevated pressure in the posterior fossa following trauma, has been reported to occur in 13.3-61.1% of the patients. [3],[4],[5] The development of hydrocephalus due to cerebellar edema or hematoma may be delayed by about 90 min to 46 h following trauma, and evacuation of the cerebellar hematoma alone does not relieve hydrocephalus. [3] In this patient, hydrocephalus developed 40 h after the injury. The reported mortality and morbidity in patients with intracerebellar hematoma and associated hydrocephalus treated surgically was very high. [3]

We propose that surgical intervention for closed fracture in the posterior fossa with significant depression should be considered with low threshold, considering patient's GCS only. In patients who are in altered sensorium, as in this patient, it may be appropriate to operate early. An early surgical intervention in this patient might have altered the outcome.

 
  References Top

1.Motozaki T, Yamamoto T. Unusual case of depressed fracture in the posterior cranial fossa associated with the syndrome of acute central cervical spinal cord injury. Neurosurg Rev 1989;12 Suppl 1:595-9.  Back to cited text no. 1
[PUBMED]    
2.Colak A, Berker M, Ozcan OE. Occipital depression fractures in childhood. A report of 14 cases. Childs Nerv Syst 1991;7:103-5.  Back to cited text no. 2
[PUBMED]    
3.Karasawa H, Furuya H, Naito H, Sugiyama K, Ueno J, Kin H. Acute hydrocephalus in posterior fossa injury. J Neurosurg 1997;86:629-32.  Back to cited text no. 3
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4.Holzschuh M, Schuknecht B. Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961. Br J Neurosurg 1989;3:171-80.  Back to cited text no. 4
[PUBMED]    
5.Neubauer UJ. Extradural haematoma of the posterior fossa. Twelve years experiences with CT-scan. Acta Neurochir (Wien) 1987;87:105-11.  Back to cited text no. 5
[PUBMED]    


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