J Neurosurg Pediatrics 9:139–143,

9:000–000, 2012

Posterior fossa epidural hematomas in children: clinical

experience with 40 cases
Clinical article

AltAy Sencer, M.D., yAvuz ArAS, M.D., MehMet OSMAn AkcAkAyA, M.D.,
Burcu GOker, M.D., tAlAt kırıS, M.D., AnD Ali tuncAy cAnBOlAt, M.D.
Department of Neurosurgery, Istanbul School of Medicine, Istanbul University, Istanbul, Turkey

Object. Traumatic posterior fossa epidural hematoma (PFEDH) is rare, but among children it may have a slightly
higher incidence. With the widespread use of CT scanning, the diagnosis of PFEDH can be established more accu­
rately, leading to an increased incidence of the lesion and possibly to a better patient prognosis. This study presents
40 pediatric cases with PFEDH.
Methods. The authors assessed the type of trauma, clinical findings on admission, Glasgow Coma Scale scores,
CT findings (thickness of the hematoma, bone fracture, compression of the fourth ventricle, and ventricle enlarge­
ment), type of treatment, clinical course, and prognosis. Early postoperative CT scans (within the first 6 hours) were
obtained and reviewed in all surgical cases.
Results. Twenty­nine patients underwent surgery and 11 patients received conservative therapy and close fol­
low­up. All patients fared well, and there was no surgical mortality or morbidity.
Conclusions. Based on the data in this large series, the authors conclude that PFEDH in children can be treated
in experienced centers with excellent outcome, and there is no need to avoid surgery when it is indicated.
(http://thejns.org/doi/abs/10.3171/2011.11.PEDS11177)

key WOrDS • epidural hematoma • posterior fossa • children • surgery •

trauma

T
raumaTic PFEDHs represent a rare clinical entity.
Their rate among all epidural hematomas ranges
between 1.2% and 15% for all age groups accord­
ing to various reports.2,3,6–8,15,17 Among children, PFEDHs
may have a slightly higher incidence.7,18,20
With widespread use of CT scanning, the diagnosis
of PFEDHs can be established more accurately. Improved
diagnostic capability has led to an increased incidence of
the lesion and possibly to a better prognosis.5,7,10,14,15,25 In
the present study we provide data obtained in 40 pedi­
atric patients with PFEDH treated surgically or conser­
vatively with no mortality or morbidity. We believe this
report may be an important contribution to the literature
because the literature contains a cumulative number of
approximately 100 cases and we provide 40 additional
cases.1,3,7–9,11,19,27
Methods
Of 824 patients with epidural hematomas treated
surgically or conservatively at the Department of Neuro­
Abbreviations used in this paper: GCS = Glasgow Coma Scale;
PFEDH = posterior fossa epidural hematoma; SAH = subarachnoid
hemorrhage.
surgery Trauma Care Unit, Istanbul School of Medicine,
between January 1995 and April 2011, 473 patients were
younger than 17 years. Files of those with PFEDHs were
retrospectively reviewed. The study group consisted of 40
children with PFEDHs of traumatic origin. There were
22 boys and 18 girls with a male/female ratio of 1:2. Ages
ranged from 1 to 17 years (mean 6.7 years). We recorded
and evaluated the type of trauma, clinical findings on ad­
mission, GCS score, CT findings (thickness of the hemato­
ma, bone fracture, compression of the fourth ventricle, and
ventricle enlargement), type of treatment, clinical course,
and prognosis. Early postoperative CT scans (within the
first 6 hours) were acquired in all surgical cases.
Results
The predominant cause of PFEDH was a fall from
a height resulting in a blow to the back of the head in 34
patients (85%). Motor vehicle accidents were the second
most frequent cause (4 patients [10%]), and there was an
“other” type of injury in 2 patients (5%).
Thirty­one patients (77.5%) were admitted within
24 hours of injury, 8 (20%) within 48 hours, and 1 was
brought to the hospital within 72 hours.

J Neurosurg: Pediatrics / Volume 9 / February 2012 139

 A. Sencer et al.

During admission, the GCS scores were used to as­ TABLE 1: Summary of clinical fetaures of patients with PFEDH*
sess the level of consciousness of the patients. Thirty­one
patients (77.5%) had a GCS score of 15, 4 had a score of No. of Patients (%)
14 (10%), 1 had a score of 13, and 4 patients had GCS Clinical Features Total Op/No Op
scores of 11, 10, 9, and 8.
Symptoms and clinical findings on admission were interval btwn trauma & admission
nausea and vomiting in 23 patients (57.5%), occipital <24 hrs 31 (77.5) 24/7
swelling in 17 (42.5%), headache in 15 (37.5%), cerebellar 24–48 hrs 8 (20) 5/3
signs in 11 (27.5%), temporary loss of consciousness in 6 48–72 hrs 1 (2.5) 0/1
(15%), and drowsiness in 2 (5%). admission GCS score
Unenhanced head CT scans including bone window <7 0 0
settings were obtained in all patients. An epidural hema­
toma was present in the posterior cranial fossa in all cases. 8–12 4 (10) 4/0
The thickness of the clot varied between 0.2 and 2.5 cm. A 13–14 5 (12.5) 5/0
fracture of the occipital bone could be detected in 35 pa­ 15 31 (77.5) 20/11
tients (87.5%), and multiple intracranial injuries were pres­ symptoms & signs
ent in 9 patients (22.5%). Compression or effacement of the nausea & vomiting 23 (57.5) 15/8
fourth ventricle was encountered in 15 cases (37.5%), and occipital swelling 17 (42.5) 12/5
ventricular dilation was observed in 6 cases (15%).
One child with a diagnosis of hemophilia A was ad­ headache 15 (37.5) 6/9
mitted to the intensive care unit of our pediatrics depart­ cerebellar signs 11 (27.5) 9/2
ment, and another patient had a history of osteogenesis temporary LOC 6 (15) 6/0
imperfecta diagnosed earlier at another hospital. Both of asymptomatic 3 (7.5) 0/3
these patients were followed up conservatively without drowsiness 2 (5) 2/0
need of a surgical intervention. otorrhagia 1 (2.5) 1/0
Clinical and radiological features are summarized in
Tables 1 and 2. epistaxis 1 (2.5) 0/1
In 28 patients (72.5%), we performed immediate trauma type
surgery—a suboccipital craniectomy, usually restricted to fall from a height 34 (85) 25/9
the side of the hematoma and as wide as necessary to con­ MVA 4 (10) 3/1
trol the active bleeding if present. Figures 1 and 2 show bicycle accident 1 (2.5) 1/0
pre­ and postoperative CT scans obtained in one of the hit by a football 1 (2.5) 0/1
surgical cases, demonstrating removal of the hematoma
and resolution of the fourth ventricle compression. One * LOC = loss of consciousness; MVA = motor vehicle accident.
of the patients underwent surgery 24 hours after admis­
sion because the hematoma enlarged and the clinical sta­ counts for 9%–20% of all traumatic extradural hema­
tus worsened. Early postoperative scans acquired in the tomas in children, whereas in adults the range is much
surgical cases showed no significant residual hematoma lower, around 2%–11%. Because this is a rare entity, the
and resolution of ventricular dilation if present before sur­ pediatric cases of traumatic PFEDH published in the lit­
gery. Eleven patients (27.5%) were fully alert at admission erature are limited to case reports and small series. After
and harbored an epidural hematoma. They had no CT­ the introduction of CT scanning, clinical reports on child­
documented mass effect, no compression or displacement hood PFEDH have increased, but still they include only
of the fourth ventricle, obliteration of perimesencephalic small populations.2–5,7–9,11,14–19,21,22 In our institution, which
cisterns, or sign of ventricular dilation. These 11 patients has a busy emergency and traumatology unit, with ap­
were followed conservatively, undergoing clinical neu­ proximately 1500 cases of head trauma annually, trau­
rological examinations and serial CT scanning (at 6, 12, matic PFEDHs in children account for 4.9% of all pa­
24, 48, and 72 hours after admission). Figure 3 provides tients and 8.5% of pediatric­age patients with epidural
an example of a conservatively managed case in which hematomas.
the admission and 48-hour CT scans reveal no significant The cause of PFEDHs in children is most common­
change in hematoma thickness and mass effect. ly a fall, similar to many other forms of craniocerebral
All patients, treated surgically or conservatively, fared trauma in this age group.2,3,7,11,19 In 85% of our patients
well and were discharged with normal neurological status the hematoma was acquired by falling and hitting the oc­
after a mean hospital stay of 6.5 days. The patients were cipital region of the skull. Motor vehicle accidents, which
then followed up in the outpatient clinic 1 and 4 weeks af­ are unfortunately a major cause of death and disability in
ter surgery. An additional control CT scan was obtained 4
weeks after discharge. There were no radiological or clini­
this country, accounted for PFEDHs in 10% of our pa­
cal pathological entities found at the 4-week postdischarge
tients. Posterior fossa epidural hematomas are most often
noted in males in the first 3 decades of life. Most studies
examination. report higher incidences in the second half of the 1st de­
Discussion cade.7,20,22 In our large study group the male/female ratio
was 1:2 and the median age was 6.7 years in accordance
Posterior fossa epidural hematoma is rare. It ac­ with data in previous reports.

140 J Neurosurg: Pediatrics / Volume 9 / February 2012

Posterior fossa epidural hematomas in children
TABLE 2: Summary of radiological fetaures in patients with
PFEDH

No. of Patients (%)

Radiological Features Total Op/No Op
thickness of PFEDH
<5 mm 11 (27.5) 0/11
5–15 mm 11 (27.5) 11/0
>15 mm 18 (45) 18/0
accompanying lesions
Fig. 2. Postoperative CT scans obtained in the same patient in Fig. 1.
occipital bone fracture 35 (87.5) 29/6
contusion 5 (12.5) 4/1
scanning at 6, 12, 24, 48, and 72 hours after admission—
pneumocephalus 3 (7.5) 2/1
may not be considered to be a cost­effective practice, but
traumatic SAH 3 (7.5) 2/1 taking into account the potential for rapid and fatal dete­
subdural hematoma 1 (2.5) 1/0 rioration, we find it a useful tool.
mass effect There are no defined criteria for deciding between
4th ventricle compression 15 (37.5) 15/0 conservative and surgical treatment.1,5,15 Neurological
obliteration of perimesencephalic 11 (27.5) 11/0 findings, GCS score on admission, the thickness of the
blood clot, accompanying compression of the fourth ven­
tricle, and ventricular dilation on the first CT scan are im­
cisterns
ventriculomegaly 6 (15) 6/0
portant. Different authors have tried to define indications
for surgery such as hematoma volume of no more than 10
The clinical picture in PFEDH can be grouped as cm3, hematoma thickness of no more than 15 mm, mid­
acute, subacute, and chronic according to the presenta­ line shift of no more 5 mm, and obliteration of perimes­
tion and duration of clinical symptoms. In the acute form encephalic cisterns.5 We used thickness instead of vol­
the clinical symptoms present within the first 3 days of ume as a surgical criterion because, on the one hand, an
injury; the acute variety is usually encountered in the extraaxial hematoma can have much greater volume if it
young children with diffuse injury.7,20 Our patients most is thin but smeared to the inner layer of the bone, whereas
often presented with the acute form of disease and under­ its thickness is much smaller and causes no mass effect.
went surgery on an emergency basis (when surgery was On the other hand, extraaxial hematomas with smaller
indicated); however, the age range was relatively wide, volumes but significant thickness may cause mass effect
with the average age around the middle of the 1st decade. or midline shift especially in a narrow space like the pos­
Clinically, the subacute (symptom onset between Days 3 terior fossa. In our 28 patients (70%) who had signs of
and 14) and chronic (symptom onset after Day 14) forms neurological deterioration or fourth ventricle compres­
were not encountered in our patients. sion, cases of ventricular dilation or epidural hematoma
As was also shown in our study, PFEDH may result with mass effect were immediately treated with surgery.
from mild to moderate head injury and symptoms may Twelve patients who had normal neurological status and
be minor, like headache and vomiting, but the clinical an admission CT scan showing a hematoma without mass
picture can progress rapidly.3,7,8,11,13,15,17,19 Therefore, wide­ effect, with no compression or displacement of the fourth
spread use of CT scanning has facilitated accurate diag­ ventricle, perimesencephalic cisterns, and no signs of
nosis and also improved outcome, and we recommend ventricular dilation, were followed up conservatively with
that CT scans be obtained even with the mildest of suspi­ close clinical neurological examinations.
cions. Moreover, the radiological follow­up criteria used
in our conservatively treated cases—namely control CT

Fig. 1. Preoperative CT scans revealing a large PFEDH in a 14-year- Fig. 3. Admission (left) and 48-hour postadmission (right) CT scans
old boy, displacing the fourth ventricle and causing ventriculomegaly. acquired in an 8-year-old boy with conservatively managed PFEDH.

J Neurosurg: Pediatrics / Volume 9 / February 2012 141


Retrospective analysis of our data revealed that all pa­
tients with a hematoma thickness of less than 5 mm were
followed up conservatively. All 29 patients with a hema­
toma thickness of greater than 5 mm underwent surgery.
In 18 patients the hematoma thickness was greater than
15 mm, which has been accepted as a surgical indication.
The other 11 patients, in whom the hematoma thickness
varied between 5 and 15 mm, had accompanying injuries/
conditions (for instance, a contusion, pneumocephalus, or
SAH) causing additional mass effect or a GCS score less
than 15, so surgical intervention was chosen in their man­
agement. Morbidity and mortality rates were found to be
higher in former publications. In our study, which to our
knowledge represents the largest pediatric PFEDH series
to date, we believe the absence of mortality and morbidity
might be associated with our surgical criteria. Based on
our data and the successful outcomes in our series, we be­
lieve a 5-mm-thick hematoma might be a better surgical
indication in pediatric cases. Considering the difficulty of
assessing of neurological status or administering the GCS
in small children, neurosurgeons must be aware of each
PFEDH, even those of a relatively “small” size.
An occipital fracture accompanying PFEDH has
been widely reported in the literature. We have identified
occipital fractures in almost 87.5% of our patients and
multiple intracranial injuries in 22.5%. The frequent use
of CT is again of utmost importance in cases with multiple
injuries. It helps to detect the types of injury and predict
the prognosis and outcome in these cases. The literature
suggests that the relative incidence of hydrocephalus or
ventricular dilation is low in cases of PFEDH.3,4,7,16,17,21,22
In our series, we observed ventricular dilation in 15% of
our patients. In all cases, ventricular dilation was resolved
immediately after surgery. Displacement of the fourth
ventricle was more common (37.5%) with no associated
hydrocephalus or ventricular dilation probably because
emergency evacuation of the hematoma was performed
in these cases. There was no need for external ventricu­
lar drainage insertion, considering that there were no
hematomas with mass effect in the conservatively man­
aged group, whereas other hematomas with a mass effect,
clinical signs, and symptoms were evacuated immediate­
ly. In the postoperative period, ventricular dilation was
dissolved and there was no need for external ventricular
drainage during the hospital stay or further shunt surgery
after discharge in our patient group.
Our clinical protocol for conservatively managed pe­
diatric PFEDHs is based on serial control scans obtained
within the first 72 hours of trauma (at 6, 12, 24, 48, and
72 hours postinjury). Enlargement of the hematoma and
compression of the fourth ventricle with or without ven­
tricular dilation were evaluated as evidence of mass effect
and brainstem compression. One patient (2.5%) underwent
surgery 24 hours after admission due to the enlargement
of the hematoma and worsening of neurological status.
Regarding this data, one may question our serial imaging
protocol and the necessity of the extensive investigative
protocol, considering that enlargement of the hematoma
resulted in delayed surgery in only 1 patient. However, our
institution is a tertiary trauma center, which is the oldest
and most experienced university clinic in a metropolitan
142
A. Sencer et al.
area with an approximate population of 15 million inhabit­
ants. Compared with the data in the literature, our series
contains significantly more patients with a delayed admis­
sion. Nine (22.5%) of our patients were admitted after the
first 24 hours. Most of these patients were referred to our
clinic because of hematoma enlargement or clinical dete­
rioration, as the patients were conservatively followed up
in small state hospitals or private clinics. The initial CT
scan obtained at our institution was actually like a control
CT scan for these patients, and in most of the patients sur­
gery was undertaken based on this investigation. This find­
ing indicates that conservative management of pediatric
PFEDH is a very dynamic process. Computed tomography
scans play a crucial role in the decision-making process
because it is known that radiological findings occur before
the change in the clinical picture.4,5 We believe that repeat
CT scans are important in the follow­up of conservatively
treated cases, and although recent reports suggest restric­
tion of CT use in children due to the threat of radiation,
early repeat CT scans may be lifesaving in the follow­up of
PFEDH in children. Repeat CT scans should not be aban­
doned until there is more solid evidence of any harmful ef­
fects of the radiation dose delivered by CT scanning. Newer
protocols for control cranial CT scans with readjustment of
doses for children should be considered in the meantime.
Our radiology department complies with ALARA prin­
ciples12,23,24 (recently defined adjustment of imaging proto­
cols to reduce the radiation dose for pediatric patients, also
known as “as low as reasonably achievable”) for children
but other measures for control cranial CT scans in children
can be considered, such as fewer scans of the supratento­
rial area, just to rule out the development of hydrocephalus.
As with any surgical report, the focus of this paper
should at least partly be on the success and outcome of
surgery. In this study, 72.5% of the patients received sur­
gical treatment and 27.5% were followed up conserva­
tively. The neurological status in all patients was favor­
able during admission, and there were no cases of severe
head injury. All patients fared well after surgery, which
may imply, contrary to the opinion of some authors,
that surgery may not add further morbidity or mortal­
ity to the existing neurological state. Additionally, other
reports with favorable results (also with no mortality or
morbidity) have been published, as have other reports of
low mortality and morbidity rates, but they all included
much smaller patient populations.3,7,8,11,19,26 We believe
that emergency surgery must be undertaken whenever
it is deemed necessary, especially considering the rapid
and fatal progression of the lesion, although surgery may
require other expertise due to anatomical considerations.
Conclusions
This is a relatively large and recent review of data
from a university hospital with a busy emergency unit.
The favorable outcome may be attributed to the exclusive
use of CT scanning in the diagnosis and follow­up of all
cases, the improvement of neuroanesthesia and intensive
care, and cumulative data from very recent experience,
in addition to the mostly favorable admission statuses of
the patients.
J Neurosurg: Pediatrics / Volume 9 / February 2012
Posterior fossa epidural hematomas in children
Finally, we believe that with the use of modern tools
in neuroimaging, surgery, and intensive care, PFEDH
in children can be treated safely at experienced centers.
There is no need to avoid surgery when it is indicated.
Disclosure
The authors report no conflict of interest concerning the mate­
rials or methods used in this study or the findings specified in this
paper.
Author contributions to the study and manuscript prepara­
tion include the following. Conception and design: Sencer, Aras.
Acquisition of data: Akcakaya, Sencer, Aras, Goker. Analysis and
interpretation of data: Akcakaya, Sencer, Aras, Goker. Drafting
the article: Akcakaya, Sencer, Aras. Critically revising the article:
all authors. Reviewed submitted version of manuscript: all authors.
Approved the final version of the manuscript on behalf of all authors:
Akcakaya. Study supervision: Sencer.
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Manuscript submitted May 6, 2011.
Accepted November 1, 2011.
Please include this information when citing this paper: DOI:
10.3171/2011.11.PEDS11177.
Address correspondence to: Mehmet Osman Akcakaya, M.D.,
Department of Neurosurgery, Istanbul Universitesi Istanbul Tıp
Fakultesi Norosirurji Anabilim Dalı, Norolojik Bilimler Binası 6.kat
Çapa/Fatih/İstanbul 34093, Turkey. email: moakcakaya@gmail.
com.
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