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

Clinical Outcomes of Hypertonic Saline vs Mannitol Treatment Among Children With Traumatic Brain Injury

Importance

The use of hypertonic saline (HTS) vs mannitol in the control of elevated intracranial pressure (ICP) secondary to neurotrauma is debated.

Objective

To compare mortality and functional outcomes of treatment with 3% HTS vs 20% mannitol among children with moderate to severe traumatic brain injury (TBI) at risk of elevated ICP.

Design, Setting, and Participants

This prospective, multicenter cohort study was conducted between June 1, 2018, and December 31, 2022, at 28 participating pediatric intensive care units in the Pediatric Acute and Critical Care Medicine in Asia Network (PACCMAN) and the Red Colaborativa Pediátrica de Latinoamérica (LARed) in Asia, Latin America, and Europe. The study included children (aged <18 years) with moderate to severe TBI (Glasgow Coma Scale [GCS] score ≤13).

Exposure

Treatment with 3% HTS compared with 20% mannitol.

Main Outcomes and Measures

Multiple log-binomial regression analysis was performed for mortality, and multiple linear regression analysis was performed for discharge Pediatric Cerebral Performance Category (PCPC) scores and 3-month Glasgow Outcome Scale-Extended Pediatric Version (GOS-E-Peds) scores. Inverse probability of treatment weighting was also performed using the propensity score method to control for baseline imbalance between groups.

Results

This study included 445 children with a median age of 5.0 (IQR, 2.0-11.0) years. More than half of the patients (279 [62.7%]) were boys, and 344 (77.3%) had severe TBI. Overall, 184 children (41.3%) received 3% HTS, 82 (18.4%) received 20% mannitol, 69 (15.5%) received both agents, and 110 (24.7%) received neither agent. The mortality rate was 7.1% (13 of 184 patients) in the HTS group and 11.0% (9 of 82 patients) in the mannitol group (P = .34). After adjusting for age, sex, presence of child abuse, time between injury and hospital arrival, lowest GCS score in the first 24 hours, and presence of extradural hemorrhage, no between-group differences in mortality, hospital discharge PCPC scores, or 3-month GOS-E-Peds scores were observed.

Conclusions and Relevance

In this cohort study of children with moderate to severe TBI, the use of HTS was not associated with increased survival or improved functional outcomes compared with mannitol. Future large multicenter randomized clinical trials are required to validate these findings.

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1 month to 18 years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8 years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

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.

[Prehospital care of pediatric traumatic brain injury]

BACKGROUND

Traumatic brain injury (TBI) in children and adolescents is associated with significant morbidity and, in severe TBI, mortality. The aim of this article is to provide an overview of the spectrum of TBI, its pathophysiology, and current treatment recommendations for prehospital management of children and adolescents with TBI.

MATERIALS AND METHODS

The current literature was reviewed for studies on the management of TBI in children and adolescents.

RESULTS

In recent years, a large number of scientific studies have been published that have resulted in evidence-based guidelines for primary care of children with TBI. The primary aim is to minimize secondary brain damage following TBI, for which immediate assessment of the severity of TBI at the scene based on clinical findings and the accident mechanism and initiation of specific treatment measures to prevent hypoxia, hypotension, and hypothermia are critical. Not only prehospital management, but also the rapid transfer of children with severe TBI to centers with high neurosurgical, pediatric surgical, and pediatric intensive care expertise is of particular importance to improve survival and neurological outcome after severe TBI.

CONCLUSION

Structured prehospital management may help reduce secondary brain injury after TBI and lead to improved clinical outcomes.

Management of Epidural Hematomas in Pediatric and Adult Population: A Hospital-Based Retrospective Study

OBJECTIVE

We retrospectively reviewed and evaluated our treatment protocols in epidural hematoma (EDH) cases to compare surgical versus nonsurgical treatment subsections with their trauma mechanism, injury type, clinical pattern, radiological details, functional outcome, and mortality rates.

METHODS

This study included 350 patients (142 females and 208 males) treated for EDH between 2010 and 2018. Two hundred seven operated and 143 observed patients for EDH were compared for demography, injury type, treatment, and outcome scores retrospectively. Glasgow Coma Scale and Glasgow Outcome Scale were used to standardize the clinical findings. Marshall and Rotterdam classifications classified radiological abnormalities. The Infinity PACS system measured hematoma volume, and volume parameters were evaluated differently in pediatric and adult groups.

RESULTS

Radiological parameters showed that the observation was more favorable when the EDH volume was <30 ml in the adult and <20 ml in the pediatric group. However, close clinical follow-up with repeated computerized tomography scans suggested that when the hematoma increases in volume in the first 24 hours, it should be treated surgically. Headache, vomiting, and paresis were significant clinical symptoms in this period. Only 11% of conservatively followed cases required delayed surgical intervention. When we analyzed the findings of the 2 groups of the patient, pediatric and adult, we noticed that rebleeding after the first surgery was more common in the adult group than the pediatric group, whereas surgery due to a growing hematoma was less common in the pediatric group.

CONCLUSIONS

Age, trauma severity, initial neurological statuses, and accompanying comorbidities can affect the functional outcome in acute EDH. We found that urgent surgical intervention and conservative treatment may lead to excellent results in most cases. Thus, EDH can be managed both conservatively and surgically in certain conditions. We made a comparison between pediatric and adult age groups according to treatment modalities. Both rebleeding and mortality rates are relatively lower in the pediatric operated group than in the adult operated group. In the adult observation group, rates of delayed surgery because of growing hematoma seem relatively higher than in the pediatric observation group. During radiological follow-up, we found that the progression rate of EDH in the adult observed group according to time is faster than in the pediatric observed group (P < 0.05).

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.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury

OBJECTIVES

Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level.

METHODS

The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis.

RESULTS

The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001).

CONCLUSIONS

In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Predictors of In-Hospital Mortality for Road Traffic Accident-Related Severe Traumatic Brain Injury

(1) Background: Road traffic accidents (RTAs) are the leading cause of pediatric traumatic brain injury (TBI) and are associated with high mortality. Few studies have focused on RTA-related pediatric TBI. We conducted this study to analyze the clinical characteristics of RTA-related TBI in children and to identify early predictors of in-hospital mortality in children with severe TBI. (2) Methods: In this 15-year observational cohort study, a total of 618 children with RTA-related TBI were enrolled. We collected the patients' clinical characteristics at the initial presentations in the emergency department (ED), including gender, age, types of road user, the motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and the intracranial computed tomography (CT) Rotterdam score, as potential mortality predictors. (3) Results: Compared with children exhibiting mild/moderate RTA-related TBI, those with severe RTA-related TBI were older and had a higher mortality rate (p < 0.001). The in-hospital mortality rate for severe RTA-related TBI children was 15.6%. Compared to children who survived, those who died in hospital had a higher incidence of presenting with hypothermia (p = 0.011), a lower mGCS score (p < 0.001), a longer initial prothrombin time (p < 0.013), hyperglycemia (p = 0.017), and a higher Rotterdam CT score (p < 0.001). Multivariate analyses showed that the mGCS score (adjusted odds ratio (OR): 2.00, 95% CI: 1.28-3.14, p = 0.002) and the Rotterdam CT score (adjusted OR: 2.58, 95% CI: 1.31-5.06, p = 0.006) were independent predictors of in-hospital mortality. (4) Conclusions: Children with RTA-related severe TBI had a high mortality rate. Patients who initially presented with hypothermia, a lower mGCS score, a prolonged prothrombin time, hyperglycemia, and a higher Rotterdam CT score in brain CT analyses were associated with in-hospital mortality. The mGCS and the Rotterdam CT scores were predictive of in-hospital mortality independently.

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 child after traumatic epidural hematoma with pulmonary edema and arrhythmia

We present a case of severe neurogenic pulmonary edema and arrhythmia complicating management of a 7-year-old child with acute epidural hematoma and impending cerebral herniation. The underlying mechanisms for this are discussed as well as management of severe neurogenic pulmonary edema. We emphasize the need to recognize this rare complication early and institute prompt aggressive management.

Predictors of In-Hospital Mortality for School-Aged Children with Severe Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of mortality in children. There are few studies focused on school-aged children with TBI. We conducted this study to identify the early predictors of in-hospital mortality in school-aged children with severe TBI. In this 10 year observational cohort study, a total of 550 children aged 7-18 years with TBI were enrolled. Compared with mild/moderate TBI, children with severe TBI were older; more commonly had injury mechanisms of traffic accidents; and more neuroimage findings of subarachnoid hemorrhage (SAH), subdural hemorrhage (SDH), parenchymal hemorrhage, cerebral edema, and less epidural hemorrhage (EDH). The in-hospital mortality rate of children with severe TBI in our study was 23%. Multivariate analysis showed that falls, being struck by objects, motor component of Glasgow coma scale (mGCS), early coagulopathy, and SAH were independent predictors of in-hospital mortality. We concluded that school-aged children with severe TBI had a high mortality rate. Clinical characteristics including injury mechanisms of falls and being struck, a lower initial mGCS, early coagulopathy, and SAH are predictive of in-hospital mortality.

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.

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 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.

Prediction of Poor Prognosis After Severe Head Injury in Children Using Logistic Regression

OBJECTIVES

Head trauma is one of the main causes of death in childhood and often leaves severe disability with serious neurological damage. Appropriate treatment must be provided immediately to improve outcomes. This study was performed to identify factors associated with a poor prognosis at an early stage of severe head injury in children.

METHODS

The subjects were registered in the Japan Neurotrauma Data Bank. They were 119 children (mean age, 8 years; male, 67.2%) with severe head injury registered during a period of 4 years (from July 1, 2004 to June 30, 2006 and from July 1, 2009 to June 30, 2011). Univariate and multivariate analyses were performed to examine relationships among factors and outcome 6 months after discharge. Logistic regression analysis was performed to develop models for poor prognosis and death.

RESULTS

Outcome was evaluated based on the Glasgow Outcome Scale: 73 children (61.3%) had good recovery, 11 (9.2%) had moderate disability, 8 (6.7%) had severe disability, 4 (3.3%) were in a vegetative state, and 23 (19.3%) had died. Four factors were identified as predictors of a poor prognosis: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, presence of mydriasis, and presence of traumatic subarachnoid hemorrhage. Three factors were identified as predictors of death: serum glucose level greater than or equal to 200 mg/dL, Glasgow Coma Scale score on admission less than or equal to 5, and presence of mydriasis.

CONCLUSIONS

Using these predictors, subsequent exacerbation may be predicted just after arrival at the hospital and appropriate treatment can be provided immediately.

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.

Relevance of neuroimaging for neurocognitive and behavioral outcome after pediatric traumatic brain injury

This study aims to (1) investigate the neuropathology of mild to severe pediatric TBI and (2) elucidate the predictive value of conventional and innovative neuroimaging for functional outcome. Children aged 8–14 years with trauma control (TC) injury (n = 27) were compared to children with mild TBI and risk factors for complicated TBI (mild^RF+, n = 20) or moderate/severe TBI (n = 17) at 2.8 years post-injury. Neuroimaging measures included: acute computed tomography (CT), volumetric analysis on post-acute conventional T1-weighted magnetic resonance imaging (MRI) and post-acute diffusion tensor imaging (DTI, analyzed using tract-based spatial statistics and voxel-wise regression). Functional outcome was measured using Common Data Elements for neurocognitive and behavioral functioning. The results show that intracranial pathology on acute CT-scans was more prevalent after moderate/severe TBI (65%) than after mild^RF+ TBI (35%; p = .035), while both groups had decreased white matter volume on conventional MRI (ps ≤ .029, ds ≥ −0.74). The moderate/severe TBI group further showed decreased fractional anisotropy (FA) in a widespread cluster affecting all white matter tracts, in which regional associations with neurocognitive functioning were observed (FSIQ, Digit Span and RAVLT Encoding) that consistently involved the corpus callosum. FA had superior predictive value for functional outcome (i.e. intelligence, attention and working memory, encoding in verbal memory and internalizing problems) relative to acute CT-scanning (i.e. internalizing problems) and conventional MRI (no predictive value). We conclude that children with mild^RF+ TBI and moderate/severe TBI are at risk of persistent white matter abnormality. Furthermore, DTI has superior predictive value for neurocognitive out-come relative to conventional neuroimaging.

Clinical Outcome of Epidural Hematoma Treated Surgically in the Era of Modern Resuscitation and Trauma Care

OBJECTIVE

Patients from contemporary populations with traumatic brain injury (TBI) resulting from epidural hematoma (EDH) may differ regarding age, comorbidities, and coagulation status. We therefore analyzed predictors for the clinical outcome of patients with EDH treated surgically regarding modern approaches to resuscitation and trauma care.

METHODS

A retrospective observational analysis was carried out. All patients included underwent surgery. The indication for surgery followed international guidelines. Retrospective data evaluation considered data reflecting the effectiveness of trauma care, baseline characteristics, and radiologic findings. In this analysis, we divided patients into 2 groups (isolated EDH vs. EDH plus other intracranial traumatic injuries). The neurologic outcome was assessed at discharge using the Glasgow Outcome Scale.

RESULTS

Two hundred and sixty-eight patients with epidural hematoma, of whom 131 underwent surgery, were treated between January 1997 and December 2012 in our level-1 trauma center. The overall mortality was 6.8% (mortality for patients with Glasgow Outcome Scale score <9, 15%). As expected, factors with a highly significant (P < 0.01) impact on outcome were concomitant with other intracranial injuries, brain midline shift, and higher Injury Severity Score. Alcohol intoxication was a significant (P < 0.05) predictor of an unfavorable outcome. Anticoagulants and Glasgow Coma Scale score at admission had no significant impact on the outcome.

CONCLUSIONS

The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. Therefore, EDH is a treatable disease with a high probability of a favorable outcome.

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.

Pre-Adult MRI of Brain Cancer and Neurological Injury: Multivariate Analyses

Brain cancer and neurological injuries, such as stroke, are life-threatening conditions for which further research is needed to overcome the many challenges associated with providing optimal patient care. Multivariate analysis (MVA) is a class of pattern recognition technique involving the processing of data that contains multiple measurements per sample. MVA can be used to address a wide variety of neuroimaging challenges, including identifying variables associated with patient outcomes; understanding an injury's etiology, development, and progression; creating diagnostic tests; assisting in treatment monitoring; and more. Compared to adults, imaging of the developing brain has attracted less attention from MVA researchers, however, remarkable MVA growth has occurred in recent years. This paper presents the results of a systematic review of the literature focusing on MVA technologies applied to brain injury and cancer in neurological fetal, neonatal, and pediatric magnetic resonance imaging (MRI). With a wide variety of MRI modalities providing physiologically meaningful biomarkers and new biomarker measurements constantly under development, MVA techniques hold enormous potential toward combining available measurements toward improving basic research and the creation of technologies that contribute to improving patient care.

Day of injury CT and late MRI findings: Cognitive outcome in a paediatric sample with complicated mild traumatic brain injury

OBJECTIVES

Complicated mild traumatic brain injury (mTBI) or cmTBI is based on the presence of visibly identifiable brain pathology on the day-of-injury computed tomography (CT) scan. In a paediatric sample the relation of DOI CT to late MRI findings and neuropsychological outcome was examined.

METHODS

MRI (>12 months) was obtained in paediatric cmTBI patients and a sample of orthopaedically injured (OI) children. Those children with positive imaging findings (MRI+) were quantitatively compared to those without (MRI-) or with the OI sample. Groups were also compared in neurocognitive outcome from WASI sub-tests and the WISC-IV Processing Speed Index (PSI), along with the Test of Everyday Attention for Children (TEA-Ch) and a parent-rated behavioural functioning measure (ABAS-II).

RESULTS

Despite the MRI+ group having significantly more DOI CT findings than the MRI- group, no quantitative differences were found. WASI Vocabulary and Matrix Reasoning scores were significantly lower, but not PSI, TEA-Ch or ABAS-II scores. MRI+ and MRI- groups did not differ on these measures.

CONCLUSIONS

Heterogeneity in the occurrence of MRI-identified focal pathology was not associated with uniform changes in quantitative analyses of brain structure in cmTBI. Increased number of DOI CT abnormalities was associated with lowered neuropsychological performance.

Conservative management of significant supratentorial epidural hematomas in pediatric patients

BACKGROUND

Radiologically significant epidural hematomas are generally treated with craniotomy and evacuation. However, pediatric patients with such hematomas may have normal neurological examinations. We aim to report the presenting features, management, and outcomes of pediatric patients who underwent conservative management of such hematomas at our center and also show that serial neurological examinations are a safe and effective way of managing these patients.

METHODS

A retrospective review of pediatric patients with extradural hematoma (EDH) thickness of at least 1 cm and who were conservatively managed was performed. All patients were followed up in neurosurgery outpatient clinics after discharge at 1-month, 3-month, 6-month, and 1-year intervals. Detailed neurological examination was performed at each visit, and a standardized questionnaire was also used to document the parent's subjective opinion of the patient's quality of life.

RESULTS

A total of 17 patients satisfied the study criteria and were included. Conservative management was successful in 15 patients, while a craniotomy with evacuation of hematoma had to be performed in two patients. All patients had a GOS score of 5 on 1-year follow-up, had normal schooling, and reported complete satisfaction with the management protocol.

CONCLUSION

Conservative treatment is an optimal treatment option, and patients can be followed safely using a protocol of serial neurological examinations. A center must have resources to perform a craniotomy with evacuation of EDH in case of neurological worsening and be able to provide trained staff to carry out serial neurological examinations before treating these patients conservatively.

The cost-effectiveness of diagnostic management strategies for children with minor head injury

AIM

To estimate the cost-effectiveness of diagnostic management strategies for children with minor head injury and identify an optimal strategy.

METHODS

A probabilistic decision analysis model was developed to estimate the costs and quality-adjusted life years (QALYs) accrued by each of six potential management strategies for minor head injury, including a theoretical 'zero option' strategy of discharging all patients home without investigation. The model took a lifetime horizon and the perspective of the National Health Service.

RESULTS

The optimal strategy was based on the Children's Head injury Algorithm for the prediction of Important Clinical Events (CHALICE) rule, although the costs and outcomes associated with each strategy were broadly similar.

CONCLUSIONS

Liberal use of CT scanning based on a high sensitivity decision rule is not only effective but also cost saving, with the CHALICE rule being the optimal strategy, although there is some uncertainty in the results. Incremental changes in the costs and QALYs are very small when all selective CT strategies are compared. The estimated cost of caring for patients with brain injury worsened by delayed treatment is very high compared with the cost of CT scanning. This analysis suggests that all hospitals receiving children with minor head injury should have unrestricted access to CT scanning for use in conjunction with evidence-based guidelines.

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.

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.

Outcome after severe brain trauma associated with epidural hematoma

OBJECTIVE

The aim of this study was to identify factors contributing to outcomes after severe traumatic brain injury (TBI) associated with epidural hematoma (EDH).

METHODS

Between 02/2002 and 4/2010 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Data sets from patients who had severe TBI (=Glasgow Coma Scale score <9) and EDH were selected. Six-month outcomes were classified as "favorable" if Glasgow Outcome Scale (GOS) scores were 5 or 4, and were classified as "unfavorable" if GOS scores were 3 or less. The Rotterdam score was used to classify computed tomography (CT) findings; the scores published by Hukkelhoven et al. (J Neurotrauma 22:1025-1039, 2005) were used to estimate predicted rates of death and of unfavorable outcomes. Univariate (Fisher's exact test, t test, Chi(2)-test) and multivariate (logistic regression) statistics were used to identify factors associated with hospital mortality and favorable outcome.

RESULTS

Of the 738 patients with severe TBI 159 (21.5 %) had EDH. Of these, 49 (30.8 %) died in the hospital, 21 (13.2 %) survived with unfavorable outcome, 82 (51.6 %) with favorable outcome; long-term outcome was unknown in 7 survivors (4.4 %). Mortality rates predicted by the Rotterdam score showed good correlation with observed mortality rates. According to the Hukkelhoven scores, observed/predicted ratios for mortality and unfavorable outcome were 0.94 and 0.97, respectively. Age, severity of TBI, and neurological status were the main factors influencing outcomes after severe TBI associated with EDH. We were unable to demonstrate significant effects of treatment factors.

Traumatic extradural hematoma in enugu, Nigeria

Aim:

Acute traumatic extradural hematoma (EDH) is life threatening and requires prompt intervention. This is a study of incidence and outcome of consecutive patients with EDH managed in Enugu, Nigeria against a background of delayed referral.

Materials and Methods:

We retrospectively examined all consecutive trauma cases managed between 2003 and 2009 and analyzed patients with acute traumatic extradural hematoma in isolation or in combination with other intra cranial lesions. Age, sex, cause of injury, time of presentation, Glasgow Coma Score (GCS), pupil reactivity, treatment and clinical outcomes were determined.

Results:

Of 817 head injuries, 69 (8.4%) had EDH, a mean of 9.9 patients per year. Males were 57 (83%) and females 12 (17%). Peak age incidences were the second and third decades of life, with a mean age of 30.2 years. Causes were road traffic accidents (57%), assault (22%) and falls (9%). Twenty-six (38%) patients presented within 24 h of injury and only one patient presented within 4 h. The average time lag before presentation was 94.2 h. At presentation 39% had GCS of 13-15, 27% had 9-12 and 34% had 3-8. The most common location of hematoma was temporal (27.5%). Forty (59%) patients had surgery while 14 (20%) were managed conservatively. Ten patients (14.5%) died and of these 70% had GCS <8 and 60% had a seizure.

Conclusion:

We conclude that early appropriate treatment of EDH results in good high quality survival (Glasgow Outcome Score 4 or 5). Low GCS should not be an absolute contraindication for surgery. Seizure prophylaxis should be considered in patients with GCS <8.

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.

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.

Pediatric head trauma

Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.

Management of supratentorial epidural hematoma in children: report on 49 patients

Traumatic head injury is a common cause of mortality and acquired neurological impairment in children. However, pediatric epidural hematomas (EDHs) are not common and few series have studied the evolution of these patients. In this study, we present the results from a sample of patients with EDH with long-term follow-up. METHOD: Between January 2006 and December 2008, 49 patients with traumatic EDH were treated at our unit. Clinical course, radiological findings and outcomes were evaluated. Neurological status was assessed using the Glasgow Coma Scale (GCS). The patients' ages ranged from one day to 16 years. The mean follow-up was six months. RESULTS: On admission, most of the patients presented mild trauma and 57% had a GCS of 13-15. The most common symptom was irritability. The most frequent mechanisms of injury were: falling from a height in 29 cases and motor vehicle accidents in 16 cases. Three of these patients presented GCS 3, but only one died. We found a late neurological deficit in nine patients. CONCLUSION: These lesions may occur following mild head trauma and in alert children with nonfocal neurological examinations. However, in children presenting irritability with subgaleal hematomas and a history of loss of consciousness, skull computed tomography must be performed.

Management strategies for severe closed head injuries in children

Brain injuries represent the most common cause of mortality and long-term morbidity from trauma in children. The management of closed head injuries focuses on prevention of secondary injury by optimizing the delivery of oxygen and nutrients to the injured brain while minimizing neuronal metabolic demand. Despite the known differences between the immature and mature brain, treatments used in head-injured children are mainly extrapolated from those employed in adults due to the paucity of class one and two studies focused on the pediatric age group. Therapies intended to minimize secondary brain injury, such as cerebrospinal fluid drainage, hypertonic saline infusion, barbiturate coma induction, brain cooling, and decompressive craniectomy, vary widely in their clinical application among practitioners and trauma centers and have unclear indications, benefits, and long-term consequences. Prospective studies on brain injury management in children are needed to develop treatment strategies that optimize outcomes.

Good mortality prediction by Glasgow Coma Scale for neurosurgical patients

BACKGROUND

How to effectively use the finite resources of an intensive care unit (ICU) for neurosurgical patients is a critical decision-making process. Mortality prediction models are effective tools for allocating facilities. This study intended to distinguish the prediction power of the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Simplified Acute Physiology Score II (SAPS II), and the Glasgow Coma Scale (GCS) for neurosurgical patients.

METHODS

According to the definitions of the APACHE II, this study recorded both APACHE II and SAPS II scores of 154 neurosurgical patients in the ICU of a 600-bed general hospital. Linear regression models of GCS (GCS-mr) were constructed. The t test, receiver operating characteristic (ROC) curve and Wilcoxon signed rank test were used as the statistical evaluation methods.

RESULTS

There were 50 (32.5%) females and 104 (67.5%) males in this study. Among them, 108 patients survived and 46 patients died. The areas under the ROC curves (AUC) of SAPS II and APACHE II were 0.872 and 0.846, respectively. The AUC of GCS-mr was 0.866, and the R(2) was 0.389. The evaluation powers of SAPS II, GCS-mr and APACHE II were the same (p > 0.05). Patients with GCS <or= 5 or motor component of GCS (GCS-M) <or= 3 had a higher probability of mortality than patients with GCS > 5 or GCS-M > 3 (p < 0.01).

CONCLUSION

The predictive powers of SAPS II, APACHE II and GCS-mr were the same. The GCS-mr is more convenient for predicting mortality in neurosurgical patients. Both GCS <or= 5 and GCS-M <or= 3 are good indicators of mortality in these patients.