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Título

Traumatic Retroclival Traumatic Subdural Hematoma due to Gunshot Wound to the Skull: a Case Report and Literature Review

RESUMO

Case Presentation: A 48-year-old male patient was admitted to the emergency room with a gunshot wound to the skull. At baseline, he had 14 points on the Glasgow Coma Scale (GCS), left foot paresis, and two open gunshot wounds to the frontal bone. Computed tomography (CT) revealed projectile fragments entering the right frontal region, traveling in the left parietal and frontotemporal regions and lodged in the left frontoparietal region. A subdural hematoma was observed posterior to the clival ramp, with greater volume on the right, with a thickness of up to 0.6 cm. He underwent frontal craniotomy with debridement and duraplasty. Subdural HRC was treated conservatively. Postoperatively, he had a 15-point GCS and persistence of grade 1 paresis in the left foot.
Discussion: Retroclival hematomas (RCH) are rare, representing 0.3% of acute extra-axial hematomas, and form a subgroup of extra-axial posterior fossa hemorrhage. They can be classified as subdural, blood up to the lower border of C3 and absence of blood anterior to the transverse ligament, or extradural, presence of blood loss at the attachment of the tectal membrane to the body of C2. The classification relates to neurological deficits, subsequent complications, and management of the patient's conditions. The most common clinical presentation is unilateral or bilateral abducens nerve palsy, as well as severe headache simulating subarachnoid hemorrhage and nerve involvement by direct compression or contusion. Most reports are epidural hematomas associated with traumatic brain injury in pediatric patients. We found only 31 reported cases of subdural RCH in adults, none of which were caused by a firearm.
Final Comments: Traumatic posterior fossa hematomas are particularly rare conditions. The conservative approach with immobilization is sufficient in most cases.