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Neurology India, Vol. 59, No. 5, September-October, 2011, pp. 778-779 Letter to Editor Rare case of closed depressed fracture of the posterior fossa in an adult causing brainstem dysfunction: Management dilemmas R Bharath, A Arivazhagan, Nupur Pruthi, Dhananjaya I Bhat Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India PMID: 22019678 DOI: 10.4103/0028-3886.86570 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. 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
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