Management of epidural hematoma in the pediatric age group

Abstract

Background: Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane, which has been stripped from the overlying bone both by the direct trauma and by the hydrostatic force of blood. Pediatric EDH presented with both age-specific and/or atypical manifestations when compared with EDH in adults. Objectives: The aim of this study is to determine the management protocol of choice for pediatric EDH patients that can lead to an early diagnosis, effective treatment, and a good outcome for both operative and nonoperative groups of patients. Surgical management for EDH is the decision of choice for most cases, but still, there is a role for conservative management in selected cases. Materials and Methods: In this prospective study, 210 cases of pediatric EDH under the age of 18 years were studied during a 10-year period in the Neurosurgical Department of Hilla Teaching Hospital in Babylon, Iraq, from 2008 to 2018. This study considered the following parameters: characteristics of patients, clinical manifestations, mechanism of head injury with age-specific distribution, radiological findings, associated pathologies, management, source of bleeding in operated cases, correlated pathologies in dead patients, and outcome. Categorical variables are presented in the form of frequencies and percentages. Results: The age group >6-12 years have the highest incidence 33%. Males constituted 75% of the victims whereas females 25%. Accidental fall had the highest incidence of 47.1%. The classic clinical course of lucid interval was present in only 7% of cases. Supratentorial EDHs comprised 91% whereas infratentorial EDHs (posterior fossa) only 9%. Skull fracture was present in 92.2% of cases. Surgical evacuation was done in 110 cases whereas 100 cases were managed conservatively. Middle meningeal artery or vein was identified as a source of bleeding in 50% of the operated cases. Glasgow outcome scale was applied to assess the outcome and to compare the outcome in both operative and conservative groups. The overall mortality was 6.7%. Conclusion: EDH is a life-threatening entity in the pediatric age group, so that special attention and a high index of suspicion are required. Clinical and neuroimaging assessments by computed tomography scan have a fundamental role for optimal therapeutic decision. Both surgical and conservative management should have excellent outcome if they accomplished on solid basis. Conservative management should be achieved in specialized neurosurgical centers that can assure rapid conversion to surgical intervention in case of neurological deterioration. In borderline cases, surgical evacuation of EDH may spent less hospital stay time with better cost–benefit ratio than conservative management. Judicious surgical intervention can result in excellent long-term outcome.