Purpose or Case Report: Retroclival hematomas most often occur in pediatric patients following high speed motor vehicle accidents. Hematomas may involve the epidural, subdural, or subarachnoid spaces. Of these hematoma patterns, retroclival epidural hematomas are often associated with ligamentous injury to the tectorial membrane, transverse ligament, or alar ligament resulting in instability. Children’s relatively large head size in proportion to their bodies, less muscular support and more superior fulcrum point of cranial vertebrae (C2-C3 in young children) relative to adults predispose pediatric patients to ligamentous injury. Retroclival subdural hematomas are the most often to be associated with non-accidental brain injuries. Therefore, when young non-ambulatory children present without significant trauma, it is not only imperative to recognize the radiographic findings of retroclival subdural hematomas, but to be cognizant of its association with child abuse.
Radiological evaluation should include reconstructed sagittal CT images in soft tissue window as well as bone window. Special attention should be paid to the soft tissue window since hematomas often show low or intermediate attenuation on CT and can be easily missed on bone window. If only CT of the head is performed, extension to the craniocervical junction should be included. MRI, especially T2 weighted thin cut images are best suited for evaluation of ligamentous injury. STIR sequence can also provide ligamentous details as well as bone marrow edema.
Methods & Materials: 1. Review craniovertebral junction anatomy as it pertains to retroclival hematomas.
2. Illustrate the retroclival hematoma injury patterns including epidural, subdural and subarachnoid bleeds.
3. Demonstrate the CT and MRI findings of retroclival hematoma and the significance of scrutiny of the soft tissue windows of the craniovertebral junction.
Results: Demonstration of multiple cases involving retroclival hematomas with review of pertinent anatomical landmarks to help establish the diagnosis.
Conclusions: It is important for pediatric radiologists to be familiar with this disease entity as findings can be subtle and therefore easily overlooked. Each of the hematoma patterns described is associated with certain traumatic injury to the spine or brain that requires different management. Retroclival hematomas among non-ambulatory children without significant trauma history should be considered as abusive injury until proven otherwise.