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Major Complications in Supratentorial Epidural Hematoma in Infants

 

 

 A.V.Ciurea, A.Tascu, F.M.Brehar, A. Iliescu, R. Rizea, C.Palade
First Neurosurgical Department
Clinical Hospital “Bagdasar-Arseni”, Bucharest, Romania

 

Correspondence 

F.M.Brehar
First Neurosurgical Department, Clinical Hospital “Bagdasar-Arseni”
Av. Berceni 10-12, Sector 4, Cod 041915, Bucharest
Tel: 0040216836895 / Fax: 0040213347350
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Abstract

Aim: Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants. Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific. The aim of this study was to establish the criteria for the surgical versus conservative management of EDH in infants and to underline the main complications of this traumatic affection.

Materials and methods: Authors present a study on 30 infants with epidural hematoma (EDH) admitted in the Pediatric Department of Neurosurgery of the Clinic Hospital “Bagdasar-Arseni” in the period of 1990-2008 (19 years). The mean age of series was 10 months. The Children Coma Scale (CCS) at admission ranged between 13-15 in 11 cases (36,6%), 9-12 in 13 cases (43,3%) and 4-8 in 6 cases (20,1%). The most common presenting symptom was irritability, which occurred in 16 cases (53.3%), of our patients.

Results: Patient management was either surgical or conservative based on the infant’s clinical condition, Children Coma Scale (CCS) score, TINS score, evidence of midline shift on the initial head CT scan, and size of the EDH. In 26/30 cases (86.6%) the size of the EDH was more than 2 cm with midline shift. These underwent to surgical intervention in emergency. Surgical management consisted of craniotomy under general endotracheal anesthesia and removal of the underlying hematoma. The remained 4/30 cases (13.4%) with low size EDH without mass-effect and CCS of 13-15 were managed conservatively. The mortality rate in our series was 6,6%.

Conclusions: EDH in infants represents a life-threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient’s clinical condition, size of EDH, and presence of midline structure shift on head CT scan.

key words: epidural hematoma, infant, pallor, Children Coma Scale (CGS), Traumatic Infant Neurologic Score (TINS), Outcome.

  

Introduction

Traumatic epidural hematoma (EDH) constitutes a rare clinicopathological entity in children. It has been estimated that EDH represents 2–3% of all head injuries in the pediatric population, and the incidence of EDH is even rarer among infants under the age of 12 months [1–5]. However, the specific characteristics of this group of patients and the subtle presenting symptomatology of EDH make it difficult to diagnose this and often challenging to manage. Furthermore, the criteria for utilizing surgical evacuation vs conservative management have remained ill-defined. Thus, the lack of any guidelines regarding the appropriate management of EDH in pediatric patients and particularly in infants makes the management of this specific group of patients all the more complicated. The reported mortality rates associated with EDH in infants and children vary significantly among various clinical series [6–10], and this wide variation is indicative of the regrettable absence of a widely accepted protocol for managing these patients. In our current communication, we present our data from a series of infants diagnosed with traumatic EDH and managed in our institutions; emphasis had been given to their presenting symptoms and signs, their diagnostic significance, and also to the long-term outcome of these patients.

Materials and methods

Thirty cases (14 girls and 16 boys) with supratentorial EDH aged between 0-1 years were admitted in the hospital in the period of 1990-2008 (19 years). The study was approved by the Institutional Review Board of our institutions, and data analysis was performed in accordance to the Health Insurance Portability and Accountability Act regulations. All patients’ hospital and outpatient clinic charts and radiographic studies were meticulously reviewed. Patients with spontaneous EDH or patients with EDH of unknown etiology, as well as patients with infratentorial EDH, were excluded from our current study.

The mean age of series was 10 months. The etiology was: fall from other level 18 cases (60.0%), domestic accidents 6 cases (20,0%), car accidents 4 cases (13.3%), and child abuse 2 cases (6.6%). The Children Coma Scale (CCS) at admission ranged between 13-15 in 11 cases (36,6%), 9-12 in 13 cases (43,3%) and 4-8 in 6 cases (20,1%), (table 1)

 

Children Coma Scale (CCS) at admission

Patients number

 

13-15

11 (36.6%)

9-12

13 (43.3%)

4-8

6 (20.1%)

Table1: CCS admitting scores in our series 

The clinical status was characterized by pallor in all cases (100%), irritability 16 cases (53.3%), somnolence 13 cases (43,3%), fullness of fontanel 12 cases (40%), hemiparesis 7 cases (23,4%), seizures 5 cases (16.7%), third nerve paresis 4 cases (13.4%), fever 3 cases (10%), hemorrhagic shock 4 cases (13.4%); The comatose state in 6 cases (20%) was noticed. Each infant’s admitting laboratory workup included measurements of complete blood count, serum electrolytes, blood urea nitrogen, creatinine, serum glucose, and prothrombin and partial thromboplastin times. No associated coagulopathy is detected in this series. Long bone radiographic survey and ophthalmologic examination, includ- ing but not limited to fundoscopic examination, were obtained whenever suspicion of child abuse was raised.

All cases were investigated by CT scan within 3-6 hours by traumatic event. Twenty cases (66,7%) presented associated subgaleal haematoma and 21 cases (70,0%) had cranial fracture. Patient management was either surgical or conservative based on the infant’s clinical condition, Children Coma Scale (CCS) score, TINS score, evidence of midline shift on the initial head CT scan, and size of the EDH.

In 26/30 cases (86.6%) the size of the EDH was more than 2 cm with midline shift. These underwent to surgical intervention in emergency. Surgical management consisted of craniotomy under general endotracheal anesthesia and removal of the underlying hematoma. The remained 4/30 cases (13.4%) with low size EDH without mass-effect and CCS of 1315 were managed conservatively. Conservative management consisted of close observation in either a neonatal or a pediatric intensive care environment, with heart rate, respiratory rate, and oxygen saturation monitoring in addition to frequent neurological clinical examinations and serial head CT scans (initially at admission, and then at 12, 24, 48, and 72 h unless neurological changes dictated otherwise). The follow-up time in our series ranged between 12 and 60 months (mean 36.8 months). The patient’s follow-up included clinical examination with detailed neurological examination, imaging studies (head CT in all patients), electrophysiologic studies (EEG) in 10/30 (33,4%) patients, and neuropsychological evaluation in 6/30 (20,0%) patients. The Glasgow Outcome Scale (GOS) was utilized for evaluating the outcomes in our series.

Results

The ages of patients ranged between 1 day and 12 months, with a mean age of 10 months. There were 14 girls and 16 boys. In regard to the lateralization of the hematoma in our study, 18/30 (60%) were located on the right side, and the remaining 40% were located on the left side, while the temporo-parietal area was the most common anatomical location of the hematoma (table 2). In order to obtain a better assessment of clinical state of infants at admission we have used also the Trauma Infant Neurologic Scores (TINS). It is interesting to note that both of our patients who died had a TINS score of 10 upon their admission (table 3).

Anatomic location of EDH

Number of patients

 

Temporoparietal

14 (46.7%)

Parietal

7 (23.4%)

Temporal

5 (16.6%)

Frontal

3 (10%)

Fronto-temporoparietal

1 (3.3%)

Table 2: Anatomic location of the EDH in our series 

 

Trauma Infant Neurologic admitting Score (TINS)

Number of patients

 

10

2 (6.6%)

9

1 (3.3%)

8

1 (3.3%)

6

3 (10%)

5

5 (16.7%)

1-4

18 (60.1%)

Table 3: Our data regarding TINS admitting scores 

The CT scan performed at admittance showed that the size of the EDH was more than 2 cm in 26/30 (86.7%) patients, between 1 and 2 cm in 2/30 (6,6%), while in 2/30 (6,6%), EDH was less than 1 cm in its largest diameter. Emergent surgical evacuation ( fig. 1a, b) under general endotracheal anesthesia was performed in 26/30 cases (86,7%) of our patients, while the remaining 4/28 (13,4%) were conservatively treated. The length of hospitalization in our series ranged between 3 and 12 days (mean 4.2 days, median 5 days). In 27/30 cases (90%) the evolution was good (GR); the neurological status was improved both after surgical treatment and medical treatment only. Two cases (6,6%) died postoperative by acute anemia. The median period of follow-up was 3 years. No outcome changes were observed at 24 months after treatment. No long-term posttraumatic sequels were encountered except in three cases (two were surgically treated and one conservatively) where the patients suffered rare episodes of seizures. One of these patients (3,3%) has remained with longterm morbidity on anticonvulsant medications, and the other two are seizure-free with no medications. Neuropsychological evaluation data were available in six of our patients. Analysis of these data demonstrated normal psychomotor development in all these children.

16 JPSS 8 1 2010-16 

Fig 1 a, b: Preoperative head CT scans in a 3-month-old infant with EDH 

Discussion

It is well known that acute epidural hematomas in children, and especially in infants, represent a quite rare and potentially life-threatening complication resulting from head injuries [11– 13]. Furthermore, epidural hematomas in infants constitute a different clinical entity than the ones in adults due to their nonspecific clinical presentation and the inability of infants to communicate. The most common mechanism of injury in infants, in our series, was domestic fall from height in 48.4% of our cases. Our finding is in agreement with previous reports stating that this is the predominant cause of such injuries [11–15]. BeniAdani et al. [14], in their infantile series, reported that in 63.6% of their cases, fall from height was responsible for the development of an acute epidural hematoma. Similarly, Pasaoglu et al. [12] found that fall was the most common underlying mechanism in 63% of their pediatric cases, and Ersahin et al. [13] identified fall as the most common mechanism of injury in 62% of their pediatric cases. Contrariwise, Rocchi et al. found that traffic-related accidents were the most common cause of EDH in their series; this finding might be explained by the fact that they reported on children and not solely on infants [11]. It has been demonstrated since before that falls represent the most common cause of EDH in infants and children up to 5 years old [15]. It has also been emphasized that even minor head injuries can lead to the development of an acute EDH in infants [14, 16]; this is despite of the fact that falls from more than 1 m height carry worse prognoses [14]. The appearance of moderate pallor in all of our patients upon admission was a characteristic sign of major diagnostic significance. Similarly, Pasaoglu et al. [12] reported that pallor and anemia occurred in 90% of their infantile cases. Anemia, associated with pallor, has been identified since before as an important laboratory finding in infants with acute EDH [2, 7, 13, 17, 18]. Cephalhematoma was another common clinical sign, which occurred in 71.4% of our cases. Likewise, Beni- Adani et al. reported the existence of cephalhematoma in the vast majority of their patients [14]. It is interesting to note that we did not observe lucid intervals in any of our patients. Pasaoglu et al. [12], however, reported that 32% of their pediatric patients presented with a typical lucid interval. Ersahin et al. [13] reported that 24% of their patients who presented with a lucid interval died, while their mortality rate among patients presenting without a lucid interval was significantly lower.

Past studies demonstrate that the presence of a lucid interval can easily mislead or delay the accurate diagnosis and the prompt management of an underlying EDH [14, 19]. Various clinical examination grading systems have been proposed for the evaluation of infants [11–14, 20]. Ersahin et al. [13] and Pasaoglu et al. [12] concluded in their studies that the Glasgow Coma Scale (GCS) scoring system accurately assessed neurological condition even in infants and was associated with outcome in a statistically significant fashion. Similarly, Rocchi et al. [11] found that preoperative neurological status examined either by GCS or CCS had a significant impact on outcome. In their study, BeniAdani et al. stated that the widely used CCS system included parameters which were difficult to interpret and score, and they therefore suggested a new scoring system (TINS) that included more objective parameters [14]. We utilized their system in our study because we share their concerns regarding the applicability of the GCS and the CCS grading system for evaluating infants. We found high TINS scores (10) in both of our patients who eventually died. Unfortunately, the limited number of our cases makes the extraction of any statistically meaningful conclusions regarding the outcome predictive value of TINS scoring scale impossible. The temporo-parietal area was the most common anatomical location of EDH in our study. Our findings demonstrated that anatomical location was not associated with outcome. Similarly, Ersahin et al. [13] and Pasaoglu et al. [12] reported that temporo-parietal and temporal regions were the most common locations in their series; again, no relationship between anatomical location of EDH and outcome was established. Previous investigators, however, have postulated that temporal location might contribute to increased mortality due to predisposition to uncal herniation [21–24].

The treatment of choice in the majority of acute traumatic EDHs remains to be surgical evacuation via a flap craniotomy [11–14]. In our series, 85.7% of the cases were surgically evacuated, while only 14,2% were treated conservatively. However, it must be emphasized that our centers are tertiary neurosurgical centers, so our population might represent a somewhat preselected one, consisting of patients referred to our facilities due to their larger sized hematomas or their poor clinical condition. The criteria for selecting patients for conservative vs surgical treatment have remained controversial [25–28]. Chen et al. suggested that a hematoma volume larger than 30 ml, with thickness of more than 15 mm, and a midline shift more than 5 mm constitute strong indications for surgical evacuation [25].

Our mortality rate (7,1%) is similar to that reported by Beni-Adani et al. [14] (9.1%) in their infantile series. Rocchi et al. [11] reported a mortality rate of 5.5% in pediatric patients having solely epidural hematomas. Similarly, Ersahin et al. [13] reported mortality of 6% in their pediatric series. Pasaoglu et al. [12], in their series, reported mortality rate of 12% in patients with pure epidural hematomas. However, a large number of their patients were treated in the pre-CT era, a fact that could significantly delay the diagnosis and the prompt management of EDH [12]. Our long-term morbidity rate was only 3.5% (one patient with chronic seizures, well controlled with medications). The limited data of our study regarding the neuropsychological development of these infants revealed no long-term consequences. Nevertheless, the psychomotor and cognitive development of infants sustaining EDH is an area that requires further study.

Conclusion

Authors consider that EDH in infants is an emergency and can be managed by surgery in cases with poor neurological status or in cases in which the neuroimagistic signs shows brain compression, brain shift more than 0,5 cm or size of hematoma greatest than 2 cm. In these cases, the surgical treatment must be per- formed early in order to obtain a good outcome. The CT scan must be performed as soon as possible after admission, usually in the first 3 hours to realize the optimal management in EDH in infants. The patients’ neurological condition, the size of the EDH, and the presence of midline shift on head CT scans are the most commonly employed criteria for making a decision between surgical or conservative treatment.

 

 

 

References 

  1. Ammirati M, Tomita T (1985) Epidural hematomas in infancy and childhood. J Pediatr Neurosci 12:123–128
  2. Choux M, Grisoli G, Peragut JC (1974) Extradural hematomas in children. Childs Brain 1:337–347
  3. Gallagher JP, Browder EJ (1968) Extradural hematoma: experience with 167 patients. J Neurosurg 29:1–12
  4. Mazza C, Pasqualin A, Feriotti G, Da Pian R (1982) Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir (Wien) 65:67–80
  5. Pillay R, Peter JC (1995) Extradural haematomas in children. S Afr Med J 85:672–674
  6. Choux M, Grisoli F, Peragut JC (1975) Extradural hematomas in children. 104 cases. Childs Brain 1:337–347
  7. Dhellemmes P, Lejeune JP, Christiaens JL, Combelles G (1985) Traumatic extradural hematomas in infancy and childhood. Experience with 144 cases. J Neurosurg 62:861–864
  8. Gutierrez FA, Mc Lone DG, Raimondi AJ (1981) Epidural hematomas in infancy and childhood. In: American Society for Pediatric Neurosurgery (ed) Concepts in pediatric neurosurgery. Karger, Basel, Switzerland, pp 188–201
  9. Zuccarello M, Fiore DL, Trinicia G, Pardatscher K, Andrioli GC (1982) Epidural haematoma at the vertex. Acta Neurochir (Wien) 66:195–206
  10. Zuccarello M, Fiore DL, Zmpieri P, Pardatscher K, Trincia G, Andioli GC (1983) Epidural hematomas in the infant. Zentralbl Neurochir 44:11–14
  11. Rocchi G, Caroli E, Raco A, Salvati M, Delfini R (2005) Traumatic epidural hematoma in children. J Child Neurol 20:569–572
  12. Pasaoglu A, Orhon C, Koc K, Selcuklu A, Akdemir H, Uzunoglu H (1990) Traumatic extradural haematomas in pediatric age group. Acta Neurochir (Wien) 106:136–139
  13. Ersahin Y, Mutluer S, Guzelbag E (1993) Extradural hematoma: analysis of 146 cases. Childs Nerv Syst 9:96–99
  14. Beni-Adani L, Flores I, Spektor S, Umansky F, Constantini S (1999) Epidural hematoma in infants: a different entity? J Trauma 46:306–311
  15. Abraham RB, Lahat E, Sheinman G, Feldman Z, Barzilai A, Harel R, Barzilay Z, Paret G (2000) Metabolic and clinical markers of prognosis in the era of CT imaging in children with acute epidural hematomas. Pediatr Neurosurg 33:70–75 
  16. Maggi G, Aliberti F, Petrone G, Ruggiero C (1998) Extradural hematomas in children. J Neurosurg Sci 42:95–99
  17. Mazza C, Pasqualin A, Feriotti G, Da Pian R (1982) Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir (Wien) 65:67–80
  18. McKissock W, Taylor JC, Bloom WH, Till K (1960) Extradural hematoma. Observations on 125 cases. Lancet 2:167–172
  19. Browne GJ, Lam LT (2002) Isolated extradural hematoma in children presenting to an emergency department in Australia. Pediatr Emerg Care 18:86– 90
  20. Raimondi AJ, Hirschauer J (1984) Head injury in the infant and toddler. Coma scoring and outcome scale. Childs Brain 11:12–35 340 Childs Nerv Syst (2007) 23:335–341
  21. Jamieson KG, Yelland JD (1968) Extradural hematoma: report of167 cases. J Neurosurg 29:13–23
  22. McLaurin RL, Ford LE (1964) Extradural hematoma. Statistical survey of forty-seven cases. J Neurosurg 21:364–371
  23. Ford LE, McLaurin RL (1963) Mechanisms of extradural hematomas. J Neurosurg 20:760–769
  24. Cordobes F, Lobato RD, Rivas JJ, Munoz MJ, Chillon D, Portillo JM, Lamas E (1981) Observations on 82 patients with extradural hematoma. Comparison of results before and after the advent of computerized tomography. J Neurosurg 54:179–186
  25. Chen TY, Wong CW, Chang CN, Lui TN, Cheng WC, Tsai MD, Lin TK (1993) The expectant treatment of asymptomatic supratentorial epidural hematomas. Neurosurgery 32:176–179
  26. Ciquini O Jr, dos Santos AL, Manreza LA, Plese JP, Marino R Jr (1992) Conservative treatment of laminar extradural hematomas in children. Arq Neuropsiquiatr 50:501–506
  27. Shirasaka A, Shinohara Y, Kuwahara T, Sumiya K, Ninchoji T, Uemura K (1992) Long-term prognosis of nonoperative acute epidural hematoma in children. No Shinkei Geka 20:955–958
  28. Pang D, Horton JA, Herron JM, Wilberger JE Jr, Vries JK (1983) Nonsurgical management of extradural hematomas in children. J Neurosurg 59:958–971