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ORIGINAL ARTICLE
Year : 2015  |  Volume : 10  |  Issue : 2  |  Page : 114-118
 

Supratentorial extradural hematoma in children: An institutional clinical experience of 65 cases


Department of Neurosurgery, SCB Medical College, Cuttack, Odisha, India

Date of Web Publication22-Jun-2015

Correspondence Address:
Pratap Chandra Nath
Department of Neurosurgery, SCB Medical College, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.159192

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   Abstract 

Aim and Objective: To survey the epidemiology, management, and severity of extradural hematoma (EDH) in children. Materials and Methods: All patients of EDH (n = 65) in the age group of 0-16 years admitted to our department during the period of August 13 and July 14 were analyzed retrospectively from the hospital records. In all patients, age, sex, mode of injury, clinical presentation, site of EDH, management, duration of hospitalization, and outcome were evaluated. Observation and Results: Of 65 patients, males were 70.76% with a male to female ratio of 2.4:1, most of the victims (47.69%) were in the age group of 11-16 years. Mean duration of hospitalization was 4.32 days. The most common mode of injury was fall from height in 29 cases (44.61%) followed by road traffic accident (RTA) in 23 cases (35.35%). Temporoparietal EDH was the most common computed tomography finding present in 22 (33.84%) patients. 67.69% patients presented to casualty with minor head injury having Glasgow coma scale (GCS) between 14 and 15. Most common presenting feature was vomiting in 52 cases (80%) and next to it was altered sensorium. The mortality rate was 7.69% (n = 5). Conclusion: Extradural hematoma is a life-threatening entity encountered in pediatric head injury. Timely intervention and diagnosis decrease mortality to a great degree. Most of the mortality is encountered in patients who presented late at the neurosurgical unit with low GCS.


Keywords: Children, extradural hematoma, Glasgow coma scale, Glasgow outcome scale, mortality, supratentorial


How to cite this article:
Nath PC, Mishra SS, Das S, Deo RC. Supratentorial extradural hematoma in children: An institutional clinical experience of 65 cases. J Pediatr Neurosci 2015;10:114-8

How to cite this URL:
Nath PC, Mishra SS, Das S, Deo RC. Supratentorial extradural hematoma in children: An institutional clinical experience of 65 cases. J Pediatr Neurosci [serial online] 2015 [cited 2019 Jul 19];10:114-8. Available from: http://www.pediatricneurosciences.com/text.asp?2015/10/2/114/159192



   Introduction Top


Extradural hematoma (EDH) is one of the life-threatening intracranial pathologies resulting in significant mortality and morbidity in the pediatric population. [1],[2],[3] Without any visible scalp injury, it can be of significant amount needing neurosurgical care though associated scalp hematoma is a common finding among young children. The EDH is rare among the children below 2 years. The peak incidence of pediatric EDH among all head injury has been reported to be in the range of 2.7-4%. [2] In spite of improved diagnostic methods and increased number of skilled neurosurgeons, the mortality and morbidity become unavoidable in some cases due to delayed presentation and delay in diagnosis. In this retrospective study, we tried to find out and analyze different clinical presentation, mechanism of injury, and epidemiological parameters to help in the suspicion and early management of pediatric EDH.

Aims and objectives

Survey of epidemiology, management and severity of EDH in children.


   Materials and Methods Top


All patients of radiologically diagnosed EDH in the age group of 0-16 years admitted in our hospital during the period August 2013 to July 2014 were taken in our study. It does not include

  • The patient who presented with minor injuries having very small EDH and discharged from casualty
  • The patient who presented with low condition and died at casualty before admission
  • And the patient who died at the scene of injury and prehospital duration.


A total of 273 pediatric head injury patients between the age of 0-16 years were admitted and treated. Among them, a radiological diagnosis of EDH was found in 65 cases. In all cases, age and sex distribution, sex, initial presenting clinical symptoms and signs at casualty, mechanism of injury, site and localization of EDH, radiological diagnosis, severity of injury, other associated injuries, management, duration of hospital stay, condition at discharge and Glasgow outcome scale etc., are analyzed from the stored pediatrics master register, computerized discharge tickets, patients profiles, admission register, death register, and bed head tickets. The patients were treated both conservatively and surgically as per the standard protocol for pediatrics head injuries and as per decision of our treating neurosurgeon groups.


   Observation and Results Top


Total number of head injury patients admitted from August 2013 to July 2014 was 2072 cases. Total numbers of pediatric head injury admitted during the period were 273 cases, out of which a radiological diagnosis of EDH were found in 65 (23.80%) cases. The age of the patients ranged between 6 months and 16 years with a mean age of 8.99 years. We found that the number of EDH cases increases in a directly proportionate manner with an increase in age. Children in the age group of 11-16 suffer more than the other groups. But it is found that least number of children with EDH belongs to 3-5 years group. Of 65 cases, 70.76% (n = 46) were boys and 29.23% (n = 19) were girls [Table 1]. Of 65 cases, 89.23% (n = 52) patients got primary treatment at any rural hospital or district or capital hospital or a private center and were referred to our hospital. Only 7 patients (10.76%) reached our hospital directly.
Table 1: Different epidemiological parameters

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Fall from height was the most common mode of injury found in 44.4% (n = 29), followed by road traffic accident (RTA) 35.35% (n = 23), then 5 cases had sports related injury, 4 cases due to assault, 2 due to fall on ground, another 2 due to fall of coconut in one and cement slab overhead in other [Graph 1 [Additional file 1]].

On initial computed tomography (CT) scan of brain, temporoparietal region (33.84%) was the most common site showing EDH followed by frontal, parietal, occipital, and temporal, respectively. Left sides are commonly affected than the right side. Left-sided EDH were found in 56.92% (n = 37), right sided in 32.30% (n = 21) and bilateral lesion is found in 10.76% (n = 7) cases. Associated skull fracture was found as CT scan finding in 28 cases (48.07%) and acute subdural hematoma (ASDH) in 4 cases, parenchymal contusion in 16 cases and diffuse cerebral edema found in 9 cases [Graph 2 [Additional file 2]]. Some typical CT scan showing EDH in different sites are shown in [Figure 1],[Figure 2],[Figure 3] and [Figure 4].
Figure 1: Left frontal huge extradural hematoma with mass effect

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Figure 2: Left parietal huge extradural hematoma with mass effect

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Figure 3: Right temporoparietal extradural hematoma with mass effect

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Figure 4: Left temporal extradural hematoma

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In our study, it is found that most common presenting symptom was vomiting found in 80% (n = 52) cases, and next to it was altered sensorium found in 70.76% (n = 46). Scalp hematoma found in 22 cases. Gross pallor found in 8 cases. Early posttraumatic seizure was found in only 5 cases. One case had presented with right-sided hemiparesis, and one case had left facial nerve paresis. Pupillary abnormality like bilateral dilated pupil with sluggish reaction to light was found in 2 cases. Unilateral dilated pupil with sluggish reaction to light was found in 3 cases. Bilateral or unilateral constricted pupils were found in 5 cases. Others had bilateral normal size pupil with normal reaction to light [Graph 3 [Additional file 3]].

Most of the patients presented to casualty as mild head injury having Glasgow coma scale (GCS) in between 14 and 15. GCS on presentation to casualty ranged between 14 and 15 in 44 (67.69%) cases, 9-13 in 12 (18.46%) cases, and 3-8 in 9 (13.84%) cases [Graph 4 [Additional file 4]].

Of 65 cases, the operative intervention was done in 31 (47.69%) cases. Two cases were managed by only burr hole and evacuation of liquefied frontal EDH, 2 cases were managed by a new technique of craniotomy and evacuation designed by us "lever techniques of evacuation of EDH in children bellow 2 years," 3 cases were managed by trephine craniotomy with evacuation of EDH and plate screw fixation, 5 cases were managed with free bone flap with evacuation and fixation, 4 had compound wound which were debrided with evacuation and 15 cases were managed with osteoplastic flap with evacuation of EDH. During the period of hospitalization, tracheostomies were done in 3 cases, mostly in the postoperative periods. It is also found that time interval between the occurrence of head injury and operative intervention was quite high ranging from 6 to 144 h with an average of 43 h. Again it was found that only 16 cases were operated within 24 h of occurrence of head injury having EDH. More than 50% cases were managed conservatively with the volume of EDH being <30 ml. These patients were assessed clinically and with 48 h CT scan and it is found that in 6 cases, operation was done due to increase in volume of EDH and deterioration of clinical condition.

The duration of hospitalization ranged from 1 to 45 days and mean duration of stay was 4.32 days. We also found that patients requiring hospitalization <7 days were 89.23% (n = 58) and >7 days were 11.11% (n = 7). More specifically patients requiring ≤3 days were 67.69% (n = 44) and requiring >14 days was only one case.

On outcome evaluation, it was found that good recovery was found in 54 (83.07%) cases, and moderate disability is found in 6 cases, persistent vegetative state found in only one case. The number of death was 5 with a mortality rate of 7.69% [Table 2].
Table 2: Outcome analysis as per glasgow outcome score

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   Discussion Top


Radiological diagnosis of EDH was found in 23.80% (65) cases in our study which was quite high in respect to other reported series. Most of the literature stated that the incidence of EDH in pediatric head injury is very low ranging from 2% to 3%. [3],[4],[5] But in some recent series study, it is found that EDH in pediatric head injury ranges from 9% to 22%. [6] Many of the studies were done on surgically managed EDH cases which showed a low rate of incidence. In our study, only 31 cases out of 273 pediatric head injury patients underwent surgery for EDH which accounted for 11.35% of pediatric head injury which is also comparable to other studies. [1] In our study, pediatric head injury with EDH is 3.13% (n = 65) of all head injury patients admitted irrespective of age which is comparable with a study of Maggi et al. [7] where they stated it to be 3%.

The age of the patients ranged between 6 months and 16 years with a mean age of 8.99 years which is comparable to other study. [1] We found that the number of EDH cases increases in a directly proportionate manner with an increase in age. Children in the age group of 11-16 suffer more than the other groups. But it is found that least number of children with EDH belongs to 3-5 years group. Of 65 cases, 70.76% (n = 46) were boys and 29.23% (n = 19) were girls. It is consistent with other reported series. [1],[2],[6],[8]

Fall from height was the most common mode of injury found in 44.4% (n = 29), followed by RTA 35.35% (n = 23) in our series is comparable with many series studies. [1],[2],[6],[8]

Temporoparietal region (33.84%) was the most common site showing EDH followed by frontal, parietal, occipital, and temporal, respectively, is consistent with other series. [1] Left-sided EDH were found in 56.92% (n = 37), right-sided in 32.30% (n = 21) and bilateral lesion is found in 10.76% (n = 7) cases. Left sides are commonly affected than the right side is inconsistent with one study described by Paiva et al. [3] Associated skull fracture was found as CT scan finding in 28 cases (48.07%) and ASDH in 4 cases, parenchymal contusion in 16 cases and diffuse cerebral edema found in 9 cases. Associated skull fracture with EDH is lower than other described series like Paiva et al. [3] and Chowdhury et al., [1] where they described it as 61% and 62%, respectively. These reported data in our study is low possibly due to including conservative cases where direct visualization of skull fracture is not possible.

In our study, it is found that most common presenting symptom was vomiting found in 80% (n = 52) cases and next to it was altered sensorium found in 70.76% (n = 46) which is not consistent with other literature like Chowdhury et al., [1] Khan et al., [2] Paiva et al., [3] Jamjoom et al. [6] Early posttraumatic seizure was found in only 5 (7.6%) cases which was too low as compared to Chowdhury et al. [1] but high enough as compared to Khan et al. [2] one case had presented with right-sided hemiparesis and one case had left facial nerve paresis. Pupillary abnormality like bilateral dilated pupil with sluggish reaction to light was found in 2 cases. Unilateral dilated pupil with sluggish reaction to light or fixed was found in 3 cases. Bilateral or unilateral constricted pupils were found in 5 cases. Others had bilateral normal size pupil with normal reaction to light. In respect to Jamjoom et al. [6] reported 33% patients with unilateral or bilateral fixed pupil, our study shows quite less number (4.7%).

Most of the patients presented to casualty as mild head injury having GCS in between 14 and 15. GCS on presentation to casualty ranged between 14 and 15 in 44 (67.69%) cases, 9-13 in 12 (18.46%) cases, and 3-8 in 9 (13.84%) cases.

Of 65 cases, operative intervention was done in 31 (47.69%) cases. 2 cases were managed by only burr hole and evacuation of liquefied frontal EDH, 2 cases were managed by a new technique of craniotomy and evacuation designed by us "lever techniques of evacuation of EDH in children below 2 years," [9] 3 cases were managed by trephine craniotomy with evacuation of EDH and plate screw fixation, 5 cases were managed with free bone flap with evacuation and fixation, 4 had compound wound which were debrided with evacuation and 15 cases were managed with osteoplastic flap with evacuation of EDH. During the period of hospitalization, tracheostomies were done in 3 cases, mostly in the postoperative periods. It is also found that the time interval between the occurrence of head injury and operative intervention was quite high ranging from 6 to 144 h with an average of 43 h. Again it was found that only 51.61% (n = 16) cases were operated within 24 h of occurrence of head injury having EDH. Of 65 cases, 89.23% (n = 52) patients got primary treatment at any rural hospital or district or capital hospital or a private center and referred to our hospital. Only 7 patients (10.76%) reached our hospital directly. As described in Jamjoom et al. [6] 46% patients were operated within 24 h is comparable with our data. We also found that time of trauma to that of surgery is not the single important independent factor in respect to outcome. It was also found that more than 50% patients with EDH <30 ml were managed conservatively though the conversion to operative was done in 6 cases.

The duration of hospitalization ranged from 1 to 45 days with mean duration of stay was 4.32 days. We also found that patients requiring hospitalization <7 days were 89.23% (n = 58) and >7 days were 11.11% (n = 7). More specifically, patients requiring ≤3 days were 67.69% (n = 44) and requiring >14 days was only one case. It was found that EDH patients if operated in good general condition spent less days in hospital than conservatively managed EDH patients.

On outcome evaluation, it was found that good recovery was found in 54 (83.07%) cases, and moderate disability is found in 6 cases, persistent vegetative state was found in only one case. The number of deaths was 5 with a mortality rate of 7.69%. Our mortality rate is consistent with reported mortality rate by Chowdhury et al., [1] but higher than other literature. [7],[2],[10] Mortality ranged in between 0% and 12% with zero mortality described by some literature. [10] It was also found that 4 out of 5 deaths were admitted with GCS <6 and 4 deaths were postoperative. One postoperative case with GCS −15 died after one episode of convulsion and aspiration pneumonia, other three postoperative were admitted with GCS <6. One nonoperative death was admitted with GCS 3, and bilateral dilated pupil died just before operation.


   Conclusion Top


Extradural hematoma is a life-threatening entity encountered in pediatric head injury. Timely intervention and diagnosis decrease mortality in large number though all EDH do not require surgery. For conservatively managed patients repeat CT scan with volumetric analysis and close observation of clinical signs are required for conversion into operative management. Most of the mortality was encountered in patients who presented late to the neurosurgical unit with low GCS. Time interval between trauma and intervention is not the single most independent factor for good outcome. The severity of injury, site of injury, presenting condition, early diagnosis, and intervention are the other important factors that affect the outcome.

 
   References Top

1.
Chowdhury SN, Islam KM, Mahmood E, Hossain SK. Extradural haematoma in children: Surgical experiences and prospective analysis of 170 cases. Turk Neurosurg 2012;22:39-43.  Back to cited text no. 1
    
2.
Khan MB, Riaz M, Javed G, Hashmi FA, Sanaullah M, Ahmed SI. Surgical management of traumatic extra dural hematoma in children: Experiences and analysis from 24 consecutively treated patients in a developing country. Surg Neurol Int 2013;4:103.  Back to cited text no. 2
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3.
Paiva WS, Andrade AF, Mathias Júnior L, Guirado VM, Amorim RL, Magrini NN, et al. Management of supratentorial epidural hematoma in children: Report on 49 patients. Arq Neuropsiquiatr 2010;68:888-92.  Back to cited text no. 3
    
4.
Parslow RC, Morris KP, Tasker RC, Forsyth RJ, Hawley CA, UK Paediatric Traumatic Brain Injury Study Steering Group, et al. Epidemiology of traumatic brain injury in children receiving intensive care in the UK. Arch Dis Child 2005;90:1182-7.  Back to cited text no. 4
    
5.
dos Santos AL, Plese JP, Ciquini Júnior O, Shu EB, Manreza LA, Marino Júnior R. Extradural hematomas in children. Pediatr Neurosurg 1994;21:50-4.  Back to cited text no. 5
    
6.
Jamjoom A, Cummins B, Jamjoom ZA. Clinical characteristics of traumatic extradural hematoma: A comparison between children and adults. Neurosurg Rev 1994;17:277-81.  Back to cited text no. 6
    
7.
Maggi G, Aliberti F, Petrone G, Ruggiero C. Extradural hematomas in children. J Neurosurg Sci 1998;42:95-9.  Back to cited text no. 7
    
8.
Jung SW, Kim DW. Our experience with surgically treated epidural hematomas in children. J Korean Neurosurg Soc 2012;51:215-8.  Back to cited text no. 8
    
9.
Nath PC, Deo RC, Mishra SS, Jena SP. Lever technique - A new surgical technique for evacuation of extra dural haematoma in infants and children below two years. Indian J Neurotrauma 2014;11:134-7.  Back to cited text no. 9
    
10.
Schutzman SA, Barnes PD, Mantello M, Scott RM. Epidural hematomas in children. Ann Emerg Med 1993;22:535-41.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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