Conservative management of significant epidural haematomas in children

Predictive Factors for Delayed Surgical Intervention in Children With Epidural Hematomas

BACKGROUND

Optimal treatment of children with traumatic intracranial epidural hematomas (EDHs) is unknown. We sought to identify clinical and radiographic predictors of delayed surgical intervention among children with EDH admitted for observation.

METHODS

We retrospectively identified patients younger than 15 years with acute traumatic EDHs evaluated at our level 1 pediatric trauma center. We excluded patients with penetrating head injuries, recent surgical evacuation of EDH, or depressed skull fracture requiring surgical repair and assigned the remaining subjects to the immediate surgery group if they underwent immediate surgical evacuation, to the supportive-therapy-only group if they underwent observation only, and to the delayed surgery group if they underwent surgery after observation. We abstracted clinical and laboratory findings, surgical interventions, and neurological outcome and measured EDH dimensions and volumes, adjusting for cranial size. We compared clinical and radiographic characteristics among groups and performed receiver-operator characteristic analyses of predictors of delayed surgery.

RESULTS

Of 172 patients with EDH, 103 patients met the inclusion criteria, with 6 (6%) in the immediate surgery group, 87 (84%) in the supportive-therapy-only group, and 10 (10%) in the delayed surgery group. Headache, prothrombin time of >14 seconds, EDH maximal thickness of ≥1.1 cm, volume of ≥14 mL, EDH thickness/cranial width index of ≥0.08 and EDH volume/cranial volume index of ≥0.18, and mass effect were associated with delayed surgical intervention. There was no difference in length of stay or functional impairment between the immediate and delayed surgery groups. However, patients in delayed surgery group were more likely to have subjective symptoms at discharge than those in immediate surgery group.

CONCLUSIONS

Among patients with EDH admitted for observation, larger EDH, mass effect, headaches, and prothrombin time of >14 seconds were associated with delayed surgical intervention. A larger-scale study is warranted to identify independent predictors of delayed surgery in children under observation for EDH.

Minimally invasive puncture with twist intraosseous drill needle combined with hematoma drainage in the treatment of acute epidural hematoma in pediatric patients: A technical note

OBJECTIVE

The current neurosurgical intervention for treatment of acute epidural hematoma (AEDH) usually involves a craniotomy. Despite its effectiveness, open surgical decompression has several limitations. The twist intraosseous drill needle (TIDN) is considered a feasible alternative in adult patients with AEDH. AEDH treatment with TIDN in pediatric patients has not yet been described. The study aimed to report the efficacy and safety of minimally invasive puncture with a TIDN combined with hematoma drainage for the treatment of AEDH in pediatric patients.

METHODS

We retrospectively collected medical records of children with AEDH who underwent TIDN surgery at our institution from January 2017 to May 2021, and analyzed their clinical and imaging results. A detailed step-by-step surgical guide was provided.

RESULTS

Three pediatric patients with AEDH received TIDN treatment (including two males and one female; average age 7.66 years, range from 5 to 11 years). There were no intraoperative or postoperative complications in any case; 1 day after the operation, the AEDH was cleared in one of the three patients, and a slight hematoma remained in two patients. The remaining hematoma was evacuated after injecting urokinase into the hematoma cavity during indwelling drainage.

CONCLUSION

For pediatric patients with AEDH in a stable condition with a clear consciousness, TIDN puncture combined with hematoma drainage is safe, effective, and less invasive, and may present a viable surgical alternative option.

Prognostic Factors and Outcome of Surgically Treated Supratentorial versus Infratentorial Epidural Hematoma in Pediatrics: A Comparative Study of 350 Patients at a Tertiary Center of a Developing Country

PURPOSE

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients.

METHODS

This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score.

RESULTS

Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups.

CONCLUSIONS

Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.

Risk factors for bad outcome in pediatric epidural hematomas: a systemic review

Background

Pediatric epidural hematomas (EDH) represent a neurosurgical emergency. Both surgical and conservative treatment can lead to a good clinical outcome. The aim of the study was to review our series of pediatric EDH and to determine the clinical and radiologic factors, which can influence the final outcome.

Methods

All children aged from 0 to 16 that have been treated between 2013 and 2017 for cranial EDH have been selected.

Results

Thirty children have been included in the study. Seventeen cases have been treated with surgical evacuation and 13 conservatively. Six months after the trauma, the outcome was excellent (mRS 0) in 25/30 (83.3%) cases, mild deficits (mRS 1–2) were present in 4/30 (13.3%), and severe deficits (mRS 3–5) in 1/30 (3.3%) cases. Only a GCS (Glasgow Coma Scale) below 8 at admission was significantly related to the presence of a neurologic deficit at 6 months (p = 0.048).

Conclusions

EDH can be managed with excellent outcomes. Even in the presence of bad initial clinical and radiologic conditions, a correct treatment strategy can lead to a good recovery. In our series, only a GCS below 8 at admission was significantly related to the presence of neurological sequelae.

Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls

BACKGROUND/PURPOSE

The purpose of this study was to review the initial clinical presentation of EDH, identify potential clinical markers and highlight diagnostic pitfalls.

METHODS

Retrospective review of all pediatric patients admitted to a Level I Trauma Center diagnosed with blunt traumatic EDH from 2008 to 2018.

RESULTS

A total of 699 pediatric patients were identified with blunt traumatic brain injury (TBI); 106 with EDH made up the study population. A skull fracture was present in 84%. Overall, the most common clinical finding was a scalp hematoma (86%), followed by loss of consciousness (66%), emesis (34%), headache (27%), amnesia (18%), and seizures (12%). Importantly, 40% of patients with EDH presented with GCS 15. Four children (4%) had GCS 15 and were completely asymptomatic on admission. In three children (3%) the only symptom was a scalp hematoma. 50% of all EDH required craniotomy, and this was not significantly different if GCS was 15 on presentation (45%, p = 0.192). Mortality was 2%. Fourteen patients (13%) were discharged with cognitive/motor deficits.

CONCLUSIONS

Pediatric EDH frequently present with subtle clinical signs, including a normal GCS half the time. Irrespective of asymptomatic presentation, threshold for CT scan or an observation period should be low after head injuries in children.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II/III.

The outcome of observation of acute traumatic extradural hemorrhage in pediatric age group

PURPOSE

The non-operative management of extradural hemorrhage in the pediatric age group has been increasingly considered in the last decade with good clinical outcomes and comparable results to surgical intervention in carefully selected patients. The purpose of this study is to evaluate the outcome of observation in the management of pediatric patients with extra dural hematoma.

PATIENTS AND METHODS

All consecutive pediatric patients with traumatic EDH after TBI who were presented to a single neurosurgical institution between January, 2008 and November, 2018 were retrospectively reviewed. Mechanism of injury, Glasgow coma scale (GCS) on admission, presenting neurological examination, treatment modality, the first and last imaging findings, and outcome were analyzed. The outcome was measured using the Glasgow outcome scale (GOS) on discharge from the hospital.

RESULTS

A total of 83 patients were identified. The median age was 7.1 years (0.8-14 years) and 67% of the patients were male (n = 56). The median thickness of acute EDH was 1.1 cm (0.2-2.6 cm). 44 patients were managed conservatively with a close observation at a specialized neurotrauma unit for any clinical deterioration, and the remaining 39 patients were managed surgically. There was no significant difference in the patients age, hematoma thickness, presence of skull fractures, systemic injuries, and other types of cerebral injuries between the two groups. The presenting GCS was significantly lower in the surgical group which reflects the severity of the injury. Hospital stay was significantly longer among the surgical group, and the GOS was significantly better in the non-surgical group. The majority of the surgical group showed complete resolution of the hematoma on discharge, while only 50% of the non-surgical patients (n = 22) had a complete resolution of the hematoma one month after the TBI.

CONCLUSION

The conservative management is applicable in carefully selected pediatric patients with acute traumatic extradural hematoma provided that the observation is accomplished in a well-established and equipped neurosurgical unit. These results are congruent with similar earlier studies.

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas

INTRODUCTION

Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making.

METHODS

A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon.

RESULTS

Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline.

CONCLUSION

Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.

Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center

BACKGROUND

Extradural hematoma (EDH) is one of the most common causes of mortality and morbidity after traumatic brain injury in pediatric patients. Early surgical intervention in these patients produces excellent results.

OBJECTIVE

We reviewed surgical experience at our center, examining and presenting symptomatology and outcome analysis.

MATERIALS AND METHODS

A retrospective study of 228 pediatric patients of EDH from July 2007 to August 2017 was performed. Patients were evaluated in terms of demographic profile, clinical features, pupillary size and reaction, computed tomography findings, operative measures, and several other parameters. Neurological status was assessed using motor component (M) of Glasgow Coma Scale score. Best motor response was considered as a criterion to classify severity of traumatic brain injury and for the assessment of outcome.

RESULTS

Most of the patients were in the age group of 13-18 years (n = 122, 53.5%). Majority of them were male (n = 182, 79.8%). The commonest mode of injury was fall from height (n = 116, 50.9%) followed by road traffic accident (n = 92, 40.4%). Most common site of hematoma was frontal region (n = 66, 28.9%) followed by parietal region (n = 54, 23.7%). The volume of hematoma was between 30 and 50 mL in majority of the patients (n = 186, 81.6%), and most of the patients had a motor responses of M5 (n = 88, 38.6%) and M6 (n = 108, 47.4%). The association between hematoma site and volume was not significant (χ2 = 5.910, p = 0.749), whereas statistically significant association was noted between volume of hematoma and motor response (χ2 = 93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and volume to time between trauma and surgery (χ2 = 8.469, p ≤ 0.05). Maximum mortality was in patients of low motor (M1-M3) response and who were operated 24 h after injury.

CONCLUSION

Mortality in patients of EDH can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH.

Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma

BACKGROUND AND OBJECTIVES

Guidelines regarding the role of repeated head computed tomography (CT) imaging in the nonoperative management of traumatic epidural hematomas (EDHs) do not exist. Consequently, some children may be exposed to unnecessary additional ionizing radiation. We describe the frequency, timing, and utility of reimaging of EDHs to identify patients who might avoid reimaging.

METHODS

A retrospective cohort study of subjects aged 0 to 18 years with a traumatic EDH treated at a level I pediatric trauma center from 2003 to 2014. Radiographic and clinical findings, the frequency and timing of reimaging, and changes in neurologic status were compared between subjects whose management changed because of a meaningful CT scan and those whose did not.

RESULTS

Of the 184 subjects who were analyzed, 19 (10%) had a meaningful CT. There was no difference in the frequency of CT scans between the meaningful CT scan and no meaningful CT groups (median 1 [interquartile range 1-2] in no meaningful CT and median 1 [interquartile range 1-2] in meaningful CT scans; P = .7). Only 7% of repeated CTs changed management. Neurologic status immediately before the repeat scan (odds ratio 45; 95% confidence interval 10-200) and mass effect on the initial CT (odds ratio 4; 95% confidence interval 1.5-13) were associated with a meaningful CT. Reimaging only subjects with concerning pre-CT neurologic findings or mass effect on initial CT would have decreased imaging by 54%.

CONCLUSIONS

Reimaging is common, but rarely changes management. Limiting reimaging to patients with concerning neurologic findings or mass effect on initial evaluation could reduce imaging by >50%.

Endovascular management of acute epidural hematomas: clinical experience with 80 cases

OBJECTIVE

Small acute epidural hematomas (EDHs) treated conservatively carry a nonmeasurable risk of late enlargement due to middle meningeal artery (MMA) lesions. Patients with EDHs need to stay hospitalized for several days, with neurological supervision and repeated CT scans. In this study, the authors analyzed the safety and efficacy of the embolization of the involved MMA and associated lesions.

METHODS

The study group consisted of 80 consecutive patients harboring small- to medium-sized EDHs treated by MMA embolization between January 2010 and December 2014. A literature review cohort was used as a control group.

RESULTS

The causes of head injury were falls, traffic-related accidents (including car, motorcycle, and pedestrian vs vehicle accidents), and assaults. The EDH topography was mainly temporal (lateral or pole). Active contrast leaking from the MMA was seen in 57.5%; arteriovenous fistulas between the MMA and diploic veins were seen in 10%; and MMA pseudoaneurysms were found in 13.6% of the cases. Embolizations were performed under local anesthesia in 80% of the cases, with N-butyl-2-cyanoacrylate, polyvinyl alcohol particles, or gelatin sponge (or a combination of these), obtaining MMA occlusion and complete resolution of the vascular lesions. All patients underwent follow-up CT scans between 1 and 7 days after the embolization. In the 80 cases in this series, no increase in size of the EDH was observed and the clinical evolution was uneventful, without Glasgow Coma Scale score modification after embolization and with no need for surgical evacuation. In contrast, the control cohort from the literature consisted of 471 patients, 82 (17.4%) of whom shifted from conservative treatment to surgical evacuation.

CONCLUSIONS

This study suggests that MMA embolization is a highly effective and safe method to achieve size stabilization in nonsurgically treated acute EDHs.

Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment

BACKGROUND

Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable.

OBJECTIVES

Create a prediction rule to identify patients with EDH unlikely to fail hospital observation.

METHODS

Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation.

RESULTS

Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20).

CONCLUSION

Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation.

LEVEL OF EVIDENCE

Retrospective cohort level I.

Spontaneous evacuation of hyperacute extradural hematoma: two illustrative case reports

Spontaneous drainage of extradural hematoma (EDH) through a skull fracture is rare, with only 14 cases reported to date. Five of these belong to pediatric age group. The authors report two cases of spontaneous evacuation of acute EDH, in children, with two differing types of skull fractures, one being an elevated fracture. The context, in which the terminologies of "spontaneous evacuation" and "spontaneous resolution" to be used, is clarified.

Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center

BACKGROUND

Traumatic brain injury (TBI) is a frequent cause of mortality and acquired neurological impairment in children.

HYPOTHESIS

We hypothese that due to adequate treatment of EDH in children and adolescence excellent clinical and functional outcome can be reached.

PURPOSE

To evaluate retrospectively our treatment process of EDH and to elucidate the relationship between trauma mechanism, injury pattern, radiological presentation, subsequent therapy and functional outcome.

PATIENTS AND METHODS

Hundred and twenty infants and children with traumatic brain injuries (TBI) were treated between 1992 and 2009 at a single level-one trauma center. Data regarding accident, treatment and outcomes were collected retrospectively. To classify the outcomes the Glasgow Outcome Scale (GOS) scores at hospital discharge and at follow-up visits were used. EDH was classified according to the Rotterdam score.

RESULTS

Finally, 41 cases were diagnosed with an EDH and therefore included in our study. Twenty-one cases were treated surgically; however of these in 11 patients delayed surgery was necessary. Twenty patients were treated conservatively. Two patients (5%) died within 24hours, 39 patients (95%) survived. One of the operatively treated patients (2%) presented in a vegetative state, another one had severe disability, and however, 32 patients (78%) showed good recovery at latest follow-up.

DISCUSSION

Age, severity of TBI, and neurological status were the main factors influencing outcome after TBI due to acute EDH. We found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases - however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached.

Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature

Patient: Male, 30

Final Diagnosis: Acute epidural hematoma

Symptoms: —

Medication: —

Clinical Procedure: Observation

Specialty: Neurosurgery

Management of children with mild traumatic brain injury and intracranial hemorrhage

BACKGROUND

Traumatic brain injury (TBI) is a significant public health problem affecting tens of thousands of children each year, and an important subset of these patients sustains intracranial hemorrhage (ICH). The purpose of this study was to test the hypothesis that we could identify a subset of children with traumatic ICH who could be monitored on a general neurosurgery ward with a low risk of clinical deterioration.

METHODS

We performed a retrospective review of pediatric patients 18 years or younger with mild TBI (Glasgow Coma Scale [GCS] score 14-15) and traumatic ICH admitted to Saint Louis Children's Hospital between 2006 and 2011. We excluded patients with injuries unrelated to the TBI that would require intensive care unit (ICU) admission and those with penetrating intracranial injuries.

RESULTS

We identified 118 patients meeting inclusion criteria. Repeat neuroimaging was obtained in 69 (58%) of 118 patients. Radiologic progression was noted in 6 (8.7%) of 69 patients, with a trend toward more frequent progression in patients with epidural hematoma (EDH) versus other ICH (3 [20%] of 15 vs. 3 [5.6%] of 54; p = 0.11). Of 118 patients, 8 (6.8%) experienced clinically important neurologic decline (CIND) and 6 (5.1%) required neurosurgical intervention. Both CIND and the need for neurosurgical intervention were significantly higher in patients with EDH (21% each) compared with those with other types of ICH (4% and 2%, respectively) (p = 0.02, p < 0.01). Based on these results, we developed a preliminary management framework to assist in determining which patients can be safely observed on a neurosurgery ward without an ICU admission. Specifically, those patients without EDH, intraventricular hemorrhage, coagulopathy, or concern for a high-risk neurosurgical lesion (e.g., arteriovenous malformation) may be safely observed on the ward.

CONCLUSIONS

These results demonstrate that few children with mild TBI and ICH experience CIND and the preliminary framework we developed assists in identifying which patients can safely avoid ICU admission. This framework should be validated prospectively and externally.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Asymptomatic Chronic Epidural Hematoma in a Child As a Result of Extracranial Decompression

BACKGROUND

Epidural hematoma (EDH) in children is a diagnostic challenge due to its nonspecific clinical presentation. Asymptomatic chronic epidural hematoma is a very rare entity. Reports of spontaneous decompression into the subgaleal spaces are limited with acute epidural hematomas in the literature.

OBJECTIVE

We report a child presenting with chronic epidural hematoma at 15 days after a head trauma. She remained asymptomatic, owing to spontaneous decompression via a skull fracture. We intend to remind emergency physicians to be alert about epidural hematomas in asymptomatic children in the presence of a history of, even minor and distant, trauma.

CASE PRESENTATION

An 8-year-old girl presented to the Emergency Department with a swelling in the right parietal region. She had fallen at the playground and struck her head on the ground 15 days prior. Computed tomography showed a mixed-density subacute-chronic parietal epidural hematoma with a linear fracture overlying it. There was no evidence of midline shift or ipsilateral ventricular compression.

CONCLUSION

An initially minimal but expanding EDH in a child can remain asymptomatic even in the later phases, owing to the spontaneous decompression through a skull fracture.

Surgical management of traumatic extra dural hematoma in children: Experiences and analysis from 24 consecutively treated patients in a developing country

Background:

Children with epidural hematoma (EDH) present differently than adults. The outcome of treatment is also different. We aim to report our experiences with EDH in pediatric age group in terms of mode of injury, presenting features, management, and outcomes. We also aim to identify different prognostic indicators in pediatric patients with EDH.

Methods:

We prospectively collected data from 24 consecutively surgically treated pediatric patients. The data collected included presenting features, radiological imaging, details of management, and outcomes. Descriptive analysis was performed and different variables were tested for any statistical significance with Glasgow Outcome Score (GOS).

Results:

There were 19 male and 5 female patients. The mean Glasgow Coma Scale (GCS) score at presentation was 9.3 ± 4.4. Falls were the most common cause of EDH. Outcome assessment was done at 3 month follow up. A total of 15 patients had a GOS score of 5, 4 patients had a GOS score of 4, 2 patients had a GOS score of 3, while 3 patients had a GOS score of 1. On univariate analysis, admitting GCS score, patient's age, the time from injury to admission and injury to surgery, anisocoric pupils at presentation and effacement of basal cisterns were significantly associated with the outcome of GOS score.

Conclusion:

Falls are the most common mode of injury leading to EDH in children. Lower GCS at presentation, younger age at trauma, increased time since trauma to surgery and admission, anisocoria and effacement of basal cisterns are statistically significant variables in surgically treated pediatric patients of EDH that confer a poorer prognosis. A timely surgical intervention can result in excellent outcomes.

Postoperative epidural hematoma covering the galeal flap in pediatric patients with moyamoya disease: clinical manifestation, risk factors, and outcomes

OBJECT

Postoperative epidural hematoma (EDH), a blood collection between the inserted galeal flap and the overlying skull flap (epigaleal flap hematoma), is a frustrating complication of the surgical treatment of moyamoya disease (MMD) in pediatric patients. The symptoms of postoperative EDH are often similar to those of postoperative cerebral ischemia, and may cause confusion during clinical decision making. The authors designed this study to evaluate the incidence, clinical presentation, risk factors, and treatment outcomes of postoperative EDH in pediatric patients with MMD.

METHODS

A retrospective review of 148 pediatric patients with 250 craniotomies who underwent indirect bypass revascularization surgery between January 2002 and December 2006 was performed. This group consisted of 60 male and 88 female patients, and the mean age at surgery was 7.5 years (range 1-18 years).

RESULTS

Of the 250 craniotomies, postoperative EDH was detected in 32 cases. In 12 cases of EDH, surgical treatment was necessary (4.8% of 250 craniotomies). During the same period, 743 non-MMD craniotomy operations were performed. In 6 of these 743 operations, patients developed postoperative EDH that required surgical treatment, significantly less than the percentage of EDH requiring postoperative treatment in patients with MMD (0.8%, p < 0.001). The average interval between craniotomy surgery and the detection of EDH was 1.8 days (range 0-5 days) in patients with MMD and 0.5 days (range 0-2 days; p = 0.018) in the non-MMD craniotomy group. Postoperative EDH was observed in significantly fewer cases (17 of 191) when a subcutaneous drain (SCD) was inserted over the bone flap than in cases in which an SCD was not inserted (14 of 55; p = 0.001). The mean international normalized ratio of prothrombin time in the immediate postoperative blood test was 1.27 ± 0.17 in the EDH group and 1.20 ± 0.11 in the non-EDH group (values are expressed as the mean ± SD; p = 0.008). Central galeal flap tenting suture and immediate postoperative platelet count were not related to the incidence of postoperative EDH following pediatric MMD surgery.

CONCLUSIONS

Postoperative EDH is more likely to be found following craniotomy in patients with MMD than in those without MMD, and may occur in a delayed fashion. Insertion of an SCD and immediate correction of an abnormal value for international normalized ratio of prothrombin time can decrease the incidence of postoperative EDH following surgery for pediatric MMD.

Traumatic extradural hematoma in childhood

OBJECTIVE

This study was undertaken to assess the clinical and radiological characteristics of children with traumatic extradural hematoma (TEDH), and factors affecting the initial neurological status and outcome.

METHODS

Medical records of 269 consecutive children with TEDH from 2005 to 2012 were retrospectively reviewed, factors affecting the initial neurological status and outcomes were explored using univariate and multivariate analysis.

RESULTS

There were 166 boys and 103 girls (average age: 7.0 years). Fall from a height (59 %) was the most common mechanism of head injury. With increasing age, an increase of motor-vehicle accident and assault was noted. Among the children 85.5 % experienced a Glasgow Coma Scale (GCS) of 13-15, 9.7 % with GCS 9-12, and 4.8 % with GCS 3-8. The main clinical manifestations were headache, vomiting and nausea, and conscious disturbance. The main locations were the temporal, temporoparietal, and frontal regions. The 97.4 % saw a favorable outcome, whereas 2.6 % had a poor outcome (overall mortality: 1.1 %).

CONCLUSION

Many factors influenced the prognosis; the most important factors affecting prognosis were the initial neurological condition and secondary brain edema, while the initial neurological status were associated with pupillary abnormality, clinical progression, the number and volume of TEDH, and midline shift. Although the outcome was excellent in most cases, early diagnosis and surgical evacuation before irreversible brain damage was important to lower mortality for those massive TEDHs.

[Bradycardia as a unique sign of an increase in the extradural haematoma volume]

The commonest presentation of an extradural haematoma implies a head trauma with transient loss of consciousness followed by a lucid interval then rapid neurological degradation. Some of these haematomas including small ones with no midline shift and few neurological symptoms can be managed without surgical evacuation. Whilst clear recommendations have been issued regarding surgical indications, guidelines for medical supervision are still needed. We report a case of an eight-year-old girl who presented to our hospital emergency department with headache, vomiting but no neurological deficit, 3 hours after a head trauma without loss of consciousness. The CT-scan proved an extradural haematoma of 6mm width. The patient was monitored in paediatric reanimation and was scoped. Seventeen hours after the fall, the patient presented with severe isolated bradycardia. The CT-scan showed an enlargement of the haematoma with brain herniation, which was evacuated. Therefore, electrocardiogram abnormalities can reveal infraclinic raised intracranial pressure. Systematic continuous ECG monitoring during the first 24 to 48 hours would optimize the surgical management of this disease and then limit its morbi-mortality.

Utility of clinical and radiographic findings in the management of traumatic epidural hematoma

BACKGROUND

There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups.

METHODS

We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center.

RESULTS

Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation.

CONCLUSIONS

Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

Our experience with surgically treated epidural hematomas in children

OBJECTIVE

Traumatic epidural hematomas (EDHs) in children are a relatively unusual occurrence. The cause and outcome vary depending on period and region of study. The aims of this analysis were to review the cause and outcome of pediatric EDHs nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children.

METHODS

This is a retrospective review of 29 patients with surgically treated EDHs between Jan 2000 and February 2010. Patients' medical records, computed tomographic (CT) scans, and, if performed, magnetic resonance imaging (MRI) were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score), parenchymal brain injury, and diffuse axonal injury.

RESULTS

The mean (SD) age of the patients was 109 months (0-185 months). Most of the injuries with EDHs occurred in traffic accident (14 cases, 48.2%) and followed by slip down in 6 cases and falls in 6 cases. There were one birth injury and one unknown cause. EDHs in traffic accidents occurred in pedestrians hit by a motor vehicle, 9 cases; motorbike and car accidents, 5 cases and bicycle accidents, 1 case. The locations of hematoma were almost same in both sides (left side in 15 cases). Temporal lobe is the most common site of hematomas (13 cases, 44%). The mean size of the EDHs was 18 mm (range, 5-40 mm). Heterogeneous hematomas in CT scans were 20 cases (67%). Two patients were referred with unilateral or bilateral dilated pupil(s). There was enlargement of EDH in 5 patients (17%). All of them were heterogeneous hematomas in CT scans. Except for 4 patients, all EDHs were associated with skull fracture(s) (87%). There was no case of patient with major organ injury. CT or MRI revealed brain contusion in 5 patients, and diffuse axonal injury in one patient. The mortality was zero, and the outcomes were excellent in 26 and good in 2 patients. None of the tested variables were found to have a prognostic relevance.

CONCLUSION

Regardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH were excellent.

Spontaneous slow drainage of epidural hematoma into the subgaleal space through a skull fracture in an infant--case report

A 4-month-old girl fell off a table onto the floor. Computed tomography performed 4 hours after the trauma showed a left parietal epidural hematoma (EDH) with an omega-shaped fracture line in the left parietal region. The EDH was enlarged after another 4 hours. However, the EDH showed drainage into the subgaleal space through the skull fracture 2 days after the trauma and was almost completely discharged into the subgaleal space by 5 days after trauma. Both the EDH and the subgaleal hematoma had resolved completely by 12 days after the trauma. No symptoms or signs were observed during the course. This case suggests that EDH can drain slowly and spontaneously into the subgaleal space through a skull fracture in an infant.

Epidemiology of traumatic epidural hematoma in young age

BACKGROUND

Epidural hematoma (EDH) is a major traumatic brain injury and a potentially life-threatening condition, with the mortality rate in the young age group varying across studies. The aim of this analysis was to investigate the magnitude of traumatic EDH in young patients aged 0 year to 24 years in Queensland, Australia.

METHODS

Study patients presented to the emergency department of 14 public hospitals participating in the Queensland Trauma Registry during 2005 to 2007 and were diagnosed and admitted for treatment of EDH. Age group comparisons were performed for demographic, injury, treatment, operation details, and outcome-related variables.

RESULTS

We identified 224 young patients with traumatic EDH. The most frequent cause of injury was a fall in the 0 year to 9 years age groups and road traffic crash in those aged 10 years to 24 years. Almost 81% of the EDH cases were due to accidental injury, 17% due to assault, with the remainder due to self-harm and undetermined intent. Skull fracture was present in 75% of the study patients. Neurosurgical operations were performed on 40%. The overall Injury Severity Score adjusted in-hospital mortality rate was 4.8%. The odds of in-hospital mortality was 2.5 (95% confidence interval, 0.8-8.2) compared with older patients (25-64 years).

CONCLUSIONS

The results indicate that the Injury Severity Score adjusted in-hospital mortality rates for young patients with EDH were 4.8%. Given the limited information on morbidity resulting from EDH, further analysis to examine modifiable factors for better management and to evaluate survivor's long-term health outcomes via a longitudinal follow-up study is warranted.

Post-Traumatic Frontal and Parieto-Occipital Extradural Haematomas: a Retrospective Analysis of 41 Patients and Review of the Literature

The purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors.

In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a “good” or “favourable outcome”, whereas severe disability, a vegetative state or death was a “poor outcome”.

In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had “good outcomes” than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.

Traumatic epidural hematomas in children and adolescents: outcome analysis in 39 consecutive unselected cases

OBJECTIVE

Despite early diagnosis of traumatic epidural hematomas (EDHs) in children, mortality remained quite high in recent series. The aims of this analysis were to review the cause and outcome of pediatric EDH nowadays and to discuss outcome-related variables in a large consecutive series of surgically treated EDH in children.

METHODS

This is a retrospective case series of 39 patients (27 males, 69%) with surgically treated EDH between June 1997 and February 2007. Patients' medical records, computed tomographic scans, and, if performed, magnetic resonance imagings were reviewed to define variables associated with outcome. Variables included in the analysis were age, associated severe extracranial injury, abnormal pupillary response, hematoma thickness, severity of head injury (Glasgow Coma Scale score < or = 8), parenchymal brain injury, and diffuse axonal injury. Long-term follow-up (mean [SD], 51.3 [27] months) was available in 38 patients, and outcomes were classified as excellent (modified Rankin Scale score [mRS], 0; Glasgow Outcome Scale score, 5) and good (mRS scores, 1 and 2; Glasgow Outcome Scale score, 4).

RESULTS

The mean (SD) age of the patients was 83.1 (59.9) months (range, 1-191 months). The mortality was zero, and the outcomes were excellent in 34 and good in 4 patients (one was lost to follow-up). Most of the injuries with EDH occurred in familial settings (23 cases), with falls being the most common mechanism of injury in 20 patients. Trauma was caused by traffic accidents in 14 cases (pedestrians hit by a motor vehicle, 7 cases; bicycle accidents, 5 cases; and motorbike and car accidents, 1 case each). One EDH occurred during delivery. The mean size of the EDH was 18.5 (12) mm (range, 5-40 mm). Three patients were referred with unilateral or bilateral dilated pupil(s). Except in 4 patients, all EDHs were associated with skull fracture(s) (90%). Computed tomography or magnetic resonance imaging revealed brain contusion in 13 patients, and 1 had diffuse axonal injury. None of the tested variables were found to have a prognostic relevance as tested by multivariate analysis (backward exclusion, Wald method).

CONCLUSIONS

Regardless of the EDH size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the patients with EDH are excellent.

Biochemical effects of experimental epidural hematoma on brain parenchyma of rats

INTRODUCTION

The management of epidural hematoma is classified into surgical or conservative treatment according to clinical and radiologic parameters. In the recent years, the number of paper suggesting conservative management has been increasing. The experimental works that have been performed are based on especially the effects of epidural hematomas. Basic pathophysiologic factors on ischemia result of brain trauma are based on biochemical mediators. Nitric oxide (NO) and malondialdehyde (MDA) are the substances that play important roles in brain damage after trauma.

MATERIAL AND METHOD

In this study, 36 rats are divided into three groups (n = 12/group). Epidural hematoma was achieved by 0.1 ml autolog blood in rat epidural space with balloon model. Early and late phase biochemical effects on parenchyma of epidural hematoma operated in a volume which neither alters intracranial pressure (ICP) nor creates shift effect were observed. Biochemical changes of NO and MDA levels were examined in each of three experimental groups.

RESULTS

NO values increased significantly in the early group (6 hours) compared with those in the control group. Difference of NO values between the control and late groups was not significant. An increase has been found in MDA values in the control group compared with those in the early group. MDA values of the late group (30 days) were closer to that of the control group.

CONCLUSION

In this study, considering biochemical results, we have found that conservative volumes which neither increase ICP nor cause brain shift do not lead to permanent changes on brain.

Spontaneous extracranial decompression of epidural hematoma

Epidural hematoma (EDH) is a common sequela of head trauma in children. An increasing number are managed nonsurgically, with close clinical and imaging observation. We report the case of a traumatic EDH that spontaneously decompressed into the subgaleal space, demonstrated on serial CT scans that showed resolution of the EDH and concurrent enlargement of the subgaleal hematoma.