Pediatric Retroclival Epidural Hematoma in the Acute Trauma Setting: A Sign of Tectorial Membrane Stripping Injury.

OBJECTIVE. A traumatic retroclival epidural hematoma is a rare imaging finding of severe cervical flexion-extension injury in the pediatric population. The purpose of our study was to identify pediatric patients with a retroclival epidural hematoma, record the hematoma size and extent, and examine the major craniocervical ligaments for injury. MATERIALS AND METHODS. Pediatric patients who suffered a retroclival epidural hematoma were identified retrospectively using the keywords "clivus," "epidural hematoma," and "retroclival" included in head CT reports between 2012 and 2019. The cervical and brain MRI examinations for these patients were reviewed for craniocervical ligament injury by two certified neuroradiologists. Detailed descriptions of patient injuries were recorded along with demographic information, clinical history, patient management, and outcome. RESULTS. Eleven pediatric patients were identified with an acute posttraumatic retroclival epidural hematoma with a mean anteroposterior dimension of 4.4 mm and craniocaudal dimension of 4.3 cm. All patients with a retroclival epidural hematoma who underwent subsequent cervical MRI had a stripping injury of the tectorial membrane (TM). Disruption of additional major craniocervical ligaments on MRI (alar ligament, transverse ligament, longitudinal ligaments, and ligamentum flavum) was relatively rare with the most common associated ligamentous injuries involving the anterior atlantooccipital membrane, apical ligament, and interspinous ligaments. None of the patients suffered a cervical cord or severe intracranial injury. The majority of the patients were managed conservatively with excellent clinical outcomes. CONCLUSION. A posttraumatic retroclival epidural hematoma in the pediatric population is a rare injury often identified initially by head CT and easily overlooked by the radiologist. We propose that a retroclival epidural hematoma in the pediatric population is a direct result of a significant flexion-extension force, with a subsequent stripping injury of the TM from the posterior clivus. Pediatric patients with a posttraumatic retroclival epidural hematoma on initial head CT should undergo a cervical MRI to evaluate the integrity of the TM and other craniocervical ligaments.