A simultaneous acute supra- and infra-tentorial EDH is a rare case which appears both in front of lateral sinus and behind it. The cases are generally associated with lateral sinus injury [4,5]. EDH of the posterior fossa is mainly seen in young-aged patients, which representing 55% of the reported series of Jang et al [6]. The higher incidence in children may be attributed to the rich vascularization of their dura and diploe, as well as the fact that cranial trauma in children often affects or involves the occipital region.

The cause of trauma can vary, ranging from high-energy impacts to less severe events. Unlike EDH in the anterior and middle cranial fossae, supra- and infra-tentorial EDH do not present with distinct clinical symptoms. Clinical manifestations of supra-tentorial EDH may include headache, nausea, vomiting, memory loss, hemiparesis, and loss of consciousness, while infra-tentorial EDH may present with neck pain, cranial nerve palsy, and cerebellar dysfunction [1]. The absence of clinical signs does not rule out the diagnosis.

Hooper classified traumatic posterior fossa EDH into three stages: acute, subacute, and chronic, based on the onset of symptoms. Acute EDH occurs within the first 24 hours after trauma, subacute EDH develops between the 2nd and 7th days, and chronic EDH appears more than 7 days after the trauma [1]. Acute EDH is typically associated with severe trauma, with the primary symptom being impaired consciousness or coma. In subacute EDH, common signs include intracranial hypertension and compression of the cerebellum or brainstem, which is often seen in children, as in our case. The chronic form is rare and typically presents similarly to an infra-tentorial expansive process, usually managed with follow-up rather than surgery. The posterior fossa EDH is usually associated with occipital fracture [1,3,6,7]. The fracture cannot be visible on radiological exam and CT scan but can be seen during operation.

Surgery remains the gold standard for treating supra- and infra-tentorial EDH, involving hematoma evacuation via craniotomy. Perioperative evaluation provides an opportunity to identify the source of the bleeding. According to the study of Upadhyay, et al [4] the origin of bleeding could be arterial from the posterior meningeal artery or venous from the lateral sinus or the torcula.

Many authors [1,6,8] recommended combined supra-tentorial and sub-occipital craniotomy and leave a bone bridge over the transverse sinus for dural suspension. Nasi, et al [8] reported that the source of bleeding of supra- and infra-tentorial EDH is venous bone fracture with diploe bleeding (50%), transverse/sigmoid sinus injury (22%), oozing meningeal venous vessel (8%), detachment of transverse sinus without wall injury (6%), and unknown in the other cases. Some authors suggested providing conservative treatment for small non-compressive hematomas but strict clinical and radiological follow-up is mandatory [6].

The supra- and infra-tentorial EDH prognosis has improved since the advancement of the CT scan. The bad prognosis factors of supra- and infra-tentorial EDH including initial or secondary consciousness disorders associated parenchymal lesions. The reported mortality rates were various. Aji et al [1] in their literature review reported that in general, the overall mortality of supra- and infra-tentorial EDH is 17%, the operative mortality rate is 14%, and the morbidity rate is 6% and a better prognosis can be achieved in patients under 10 years of age. After literature review, Nasi et al [8] reported that overall mortality of supra- and infra-tentorial EDH is 4%; 92% of the supra- and infra-tentorial EDH patients obtained favorable outcomes (Glasgow outcome score (GOS) 4–5) after surgery, while 8% of them obtained an unfavorable outcome (GOS 1–3) [8].

EDH is a true neurosurgical emergency, and cases located in the supra- and infra-tentorial regions are rare. Due to the lack of specific clinical signs for supra- and infra-tentorial EDH, greater attention should be given to diagnosing pediatric trauma patients with occipital impact. Early diagnosis through CT scan and timely hematoma removal are key factors in ensuring a favorable prognosis.