Aggressive or conservative management in extradural hematomas in children – a challenging neurosurgical choice

Abstract

Abstractepidural hematomas (EDH) in children appear as a consequence of head trauma. Although emergency surgical intervention was the classical neurosurgical treatment for EDH, lately there has been observed a tendency to replace operation by conservative management, whenever the neurological status and imaging appearance allows it. The aim of this article is to present our experience in treating EDH in children 0-3 years old and to establish a management protocol for EDH in infants, by evaluating the clinical and neuroimaging status, of both surgically and conservatively treated patients, from hospital admission to discharge. Retrospective study includes 52 patients diagnosed with an extradural hematoma, admitted in the First Neurosurgery Department of the Clinical Hospital ‘Bagdasar-Arseni’ in Bucharest, from January 2004 to December 2013. The patients were identified by diagnosis from the clinic’s database; clinical and imaging data was extracted from the patient’s individual records and crosschecked with the operating protocols. Cerebral CT scan was the preferred imaging investigation for diagnosis. Our study includes 52 patients (26 boys and 26 girls), with a mean age of 14.5 months (range 6 weeks - 3 years old). 25 patients were surgically treated, while the other 27 received symptomatic medication and were monitored clinically and by imaging exams. The most frequent clinical manifestations were intracranial hypertension (21 patients) and psychomotor agitation (19 patients). The traumatic mechanisms were: accidental falling (38 patients), blunt head trauma (3 patients), road accident (2 patients), unspecified (8 patients) other causes (1 patient). Based on the Glasgow Coma Scale classification of TBI, 39 patients suffered a mild TBI, 7 a moderate TBI and 6 patients suffered a severe TBI. Most of the patients had a good recovery; there was a total of two deaths. The most common location for the EDHs was parietal (20 patients) and temporal-parietal (11 patients). Both surgical treatment and conservative management of EDH have a good clinical outcome. Clinical and neuroimaging evaluation at admission/reevaluation plays an imperative role in deciding the appropriate therapeutic attitude for each patient.