Retroclival Hematoma

Retroclival hematoma is a cause of thunderclap headache. It must either be very rare (there are only 2 cases reported in the thunderclap headache literature), or is often missed as usually it will not be seen unless MRI Brain scans are performed.

I have one patient with this diagnosis suspected, but still awaiting further investigations and follow-up before I can confirm that the syndrome my patient experienced is going to give no future problems.

The retroclival space is difficult to visualise on CT Brain scanning, and it usually requires an MRI to exclude a retroclival abnormality (retro = behind, clival = of the clivus).

Usually, a retroclival haemorrhage is due to trauma, such as a road traffic accident, and is a cause of persistent headache after head injury.

In the most widely quoted case, Schievink (a famous Californian Neurosurgeon, still in active practice and reknowned for his work on spontaneous intracranial hypotension) reported a middle aged woman with severe acute, maximal at onset headache i.e. thunderclap headache.

This unfortunate woman experienced the worst headache of her life while bending forward to clean. No other cause was found other than bleeding at the base of the brain, behind the part of the skull base called the clivus.

Fortunately, despite an extremely worrying set of presenting symptoms, this patient made a full recovery. Her neurosurgeons never found the source of bleeding. Her severe headache took 4 weeks to resolve.

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