Traumatic extradural hematoma in childhood

Clinico-radiological correlation with outcome in acute epidural haematoma: a tertiary centre experience from Nepal

Background

Epidural haematoma (EDH) accounts for up to 15% of severe traumatic brain injury (TBI) cases and remains the most common cause of mortality and disability. Several clinical and radiological factors affect patient outcomes. This study aims to correlate patients' clinical and radiological profiles with acute EDH outcomes.

Methods

A retrospective, single-centred, consecutive case series was conducted on the patients diagnosed with an acute EDH admitted to Tribhuvan University Teaching Hospital (TUTH) between May 2019 and April 2023. The modified Rankin scale (mRS) was used to assess the outcome. Univariate analysis and Kruskal-Wallis H test with Dunn-Bonferroni post-hoc test was conducted.

Results

There were 107 patients diagnosed with EDH, of which 52.3% were less than 20 years old with male preponderance. Falls were the most common mechanism of injury (64.5%), and most cases were referred to, not brought directly. The majority had a GCS score greater than or equal to 13 (85%) at presentation, and only 5.5% had a GCS score less than or equal to 8. According to the mRS, most patients had favourable outcomes, with 88.7% having no significant disability and 11.3% having a slight disability.

Conclusion

This case series is the largest and most recent report from Nepal and demonstrated that GCS, pupillary response, skull fracture, neurological symptoms, pre-hospital and intra-hospital delay, and management modalities are critical factors in determining the total hospital and ICU stay but did not have an impact on the mRS scores.

Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review

BACKGROUND

Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage.

METHODS

We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon.

RESULTS

Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002).

CONCLUSIONS

The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.

Management of Traumatic Epidural Hematoma in Infants Younger than One Year: 50 Cases - Single Center Experience

AIM AND BACKGROUND

Traumatic epidural hematoma (EDH) is a rare but possibly fatal complication of head trauma in infants. In this study, infants who were younger than 1 year and followed up and treated for TEDH in our clinic were evaluated. Our series is the largest series consisting only infantile cases in the literature.

MATERIAL AND METHODS

There were 50 patients younger than 1 year followed up and treated in our hospital between January 2011 and December 2019. Their age, gender, hospital admission signs and symptoms, trauma type, localization and thickness of the hematoma, and accompanying skull fracture were noted from their hospital files. Decisions for conservative or surgical treatment were made according to neurological status, Children Coma Scale (CCS) score, and EDH thickness, degree of the midline shift on cranial computerized tomography (CT), and presence of additional intracranial pathology.

RESULTS

Patients' age ranged from 0 day to 12 months (7 months as median), and their male/female ratio was 30/20. Falling from a height (<1 m) was the most frequent trauma mechanism, with a 96% rate. The most common finding was irritability and unusual crying (88%). The CCS score was 5-15 (median 13). The hematoma was located most frequently in the parietal region (48%) and least frequently in the posterior fossa (2%). Linear fracture was observed in 62% of the cases. Thirty-nine (78%) patients were treated conservatively (hematoma thickness ≤17 mm). Eleven (22%) cases were surgically treated (hematoma thickness was between 15 and 40 mm (26.3 ± 6.6 mm, mean ± standard deviation [SD]). The midline shift in the operated cases was between 1.8 and 11.8 mm (6.4 ± 3 mm, mean ± SD). One of them with a hematoma thickness of 15 mm was operated for associated open depression fracture above the hematoma. Other 10 patients were operated for primarily hematoma evacuation. None of the patients treated conservatively worsened neurologically or required operation during or after hospitalization. Two patients died (4%) during hospitalization, and both of them were anisocoric on admission. The hospital stay was between 1 and 10 (median 3) days, and the follow-up period of the living patients was between 1 month and 6 years (median 24 months). All of the living patients were neurologically normal on their last controls.

CONCLUSIONS

Because the symptoms and signs in infants are nonspecific, it is difficult to diagnose EDH clinically. Cranial CT should be performed in cases with irritability, swelling of the scalp, pallor, deterioration of consciousness, and anisocoria after head trauma. Traumatic EDHs with normal neurological examination, high CCS score, hematoma thickness below 20 mm, no apparent shift, and without associated brain pathology can be treated conservatively. None of those patients treated conservatively required operation after that.

Role of routine post-operative CT brain following evacuation of extradural haematoma in children: a single-centre experience

PURPOSE

Extradural haematoma (EDH) is a serious neurosurgical emergency in children, which confers significant morbidity and mortality rates. The objective of this study was to retrospectively evaluate the role of post-operative imaging in children with EDH who were managed surgically in a national paediatric neurosurgical unit over a 9-year period (January 2008 to December 2016).

METHODS

A retrospective case review of paediatric patients who underwent surgical evacuation of extradural haematoma between January 2008 and December 2016 was performed. This included demographic and clinical details, indications for post-operative imaging and outcomes.

RESULTS

Seventy patients underwent surgical management of EDH during this time period, with a male preponderance (69%) and a mean age of 8 years. The commonest location of haematoma in this cohort was in the parietal region (n = 24), with a mean maximum thickness of 25.9 mm and mean volume of 57 ml. Post-operative imaging was performed in 84% of patients. However, only one patient had a change in the course of their post-operative management as a result of post-operative imaging findings.

CONCLUSIONS

Post-operative imaging in asymptomatic paediatric patients after evacuation of EDH could therefore be avoided as a routine investigation.

Surgical management of traumatic extradural hematomas in children: an analysis of 201 patients at a tertiary neurosurgical center

INTRODUCTION

The effects of traumatic extradural hematoma (EDH) are potentially reversible if treated early. Pediatric EDH differs from its adult counterpart because of the differential elastic and adherence properties of skull bone and dura respectively. There is a paucity of literature regarding prognosis and factors predicting the outcome of pediatric EDH. In this study, we aimed to study the factors predicting outcome and prognosis of traumatic EDH in the pediatric age group.

MATERIALS AND METHODS

We did a retrospective chart review of all pediatric EDH operated in our center between 2011 and 2017. Factors affecting prognosis were analyzed through univariate and multivariate analyses.

RESULTS

Two hundred one patients qualified for the study. There were 159 boys and 42 girls with a sex ratio of 3.78:1. The most common modes of injury were road traffic accidents (n = 108, 53.3%) followed by falls from a height. The most common clinical presentation was vomiting (n = 168, 83.3%), followed by headache (n = 72, 35.8%). Pupillary asymmetry was present in 11.4% (n = 23) patients. The mean GCS at presentation was 12.71. The mean volume of EDH was 37.18 cc, with a mean maximum thickness of 23.19 mm. The most common location of the EDH was at temporoparietal region (n = 67, 33.3%). The median time of diagnosis from injury was 14.69 h (SD, 32.9 h). The mean GCS at discharge was 14.43 (SD ± 0.51). Sixteen patients were lost to follow; 185 patients were available for follow-up and were included in the outcome analysis. The mean GOS at follow-up was 4.9 (SD ± 0.368) with a median follow-up of 13.46 months. In our cohort, only one child died. Univariate and multivariate analyses revealed that pupillary asymmetry, pyramidal signs, low GCS at presentation, associated parenchymal injuries, and post-operative complications correlated negatively with outcome, whereas vomiting correlated positively with outcome.

CONCLUSION

Pediatric EDH differs from adults in complications as well as outcome. EDH in this pediatric cohort had a better outcome with very less mortality. Increased transportation facilities and the industrial revolution may have facilitated the shift of mode of injury from fall of height in the past to road traffic accidents in this study. A large study comparing the outcomes with pediatric and adult patients is warranted.

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.

Pediatric Extradural Hematoma: Clinical Assessment Using King's Outcome Scale for Childhood Head Injury

Introduction:

Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane and predominantly consists of venous blood in infants. The study aims to assess the outcome of pediatric EDH using King's Outcome Scale for Childhood Head Injury (KOSCHI).

Materials and Methods:

A total of 72 patients’ files were reviewed retrospectively with a diagnosis of EDH from January 2012 to December 2014. Predesigned proforma was filled using data from patient records. In addition, KOSCHI was calculated using recent telephone interviews.

Results:

Among 72 patients, 65.3% were male and 34.7% were female. Overall, road traffic accident was the most common cause (52.8%) followed by fall, assault, and sports injury. The most common symptom was more than two episodes of vomiting which was present in 51.4% of patients followed by loss of consciousness in 37.5%, ENT bleed in 33.3%, headache in 16.7%, and fits in 11.1% of patients. The median follow-up of our patients was 19 (6–40) months. Most of our patients made good recovery with 76.4% of our patients scoring 5b on KOSCHI.

Conclusion:

EDH is not uncommon among children with head injury. It should be suspected in every child with posttraumatic skull fracture or scalp hematoma. Prompt surgical intervention can give good long-term outcome.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Trephination mini-craniectomy for traumatic posterior fossa epidural hematomas in selected pediatric patients

PURPOSE

Posterior fossa epidural hematomas (PFEDH) are uncommon in children but usually require timely surgical intervention due to the risk of life-threatening brainstem compression. We attempt to make the surgical procedure less invasive by treating selected pediatric patients with trephination mini-craniectomy.

METHODS

We retrospectively reviewed the clinical courses, radiological findings, surgical procedures, and prognoses of the pediatric patients who were treated in our departments for traumatic PFEDH from January 2010 to January 2015.

RESULTS

During this period, a total of 17 patients were surgically treated for PFEDH and 7 were managed with trephination mini-craniectomy for hematoma evacuation. The outcomes were good in all 7 patients as evaluated with Glasgow Outcome Score. There was no mortality in this series. The on average 30-month clinical follow-up showed that patients experienced satisfactory recoveries without complications.

CONCLUSION

Our results suggest that trephination mini-craniectomy is a safe surgical technique for selected PFEDH patients with moderate hematoma volume and stabilized neurological functions. However, standard craniectomy is recommend when there are rapid deteriorations in patients' neurological functions or the hematomas are large and exerted severe mass effects.