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ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 16
| Issue : 2 | Page : 113-118 |
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Clinico-radiological correlation with outcome in traumatic pediatric extradural hematoma: A single institutional experience
Shivender Sobti1, Manuranjan Goyari2, Raghavendra Harpanahalli3, Laxmi Narayan Gupta4, Ajay Choudhary4, Anil Taneja5
1 Department of Neurosurgery, Dayanand Medical College & Hospital, Ludhiana, India
2 NH Narayana Superspeciality Hospital, North Guwahati, Assam, India
3 SG Hospital, Hyderabad, India
4 Department of Neurosurgery, ABVIMS & Dr. RML Hospital, New Delhi, India
5 Department of Radiology, ABVIMS & Dr. RML Hospital, New Delhi, India
| Date of Submission | 01-Apr-2020 |
| Date of Decision | 29-May-2020 |
| Date of Acceptance | 27-Aug-2020 |
| Date of Web Publication | 02-Jul-2021 |
Correspondence Address:
Dr. Shivender Sobti
Department of Neurosurgery, Dayanand Medical College & Hospital, Tagore Nagar, Ludhiana 141001, Punjab.
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jpn.JPN_61_20
 Abstract | | |
Background: Head injury is one of the leading causes of mortality and morbidity in the developing as well as developed countries. Extradural hematoma is seen in 1–2% of cases of head injury patients. Extradural hematoma is infrequent in the pediatric age group (less than 18 years) as duramater is tightly adherent to the inner table of the skull and is present in about 1–3% of all pediatric head injuries. Materials and Methods: The study was a prospective study conducted in the Department of Neurosurgery at PGIMER, Dr. RML Hospital, New Delhi, over a period of 19 months with a follow-up of 6 months. In total, 38 patients were enrolled in the study. All traumatic extradural hematoma below 18 years of age of both sexes were included. Follow-up of all patients was done at 2 weeks, 1, 2, and 6 months. Noncontrast computed tomography (NCCT) head was done in all patients at the time of admission and whenever their neurological status deteriorated. Routine postoperative NCCT head was done. Outcome assessment was done by Glasgow outcome scale. Results: Of the 38 children, 21 were males and 17 were females. The maximum number of patients was between the ages of 1–5 years (55.26%). Fall from height was the most common cause. Loss of consciousness was the most common presenting symptom (78.94%). Thirty-three patients had GCS of 14–15 at the time of presentation. The parietal region was the most common location of EDH in our study (44.74%). Thirty-five patients had supratentorial and three patients had infratentorial EDH. Eighteen patients had associated brain injury, commonest being brain edema. Six patients were operated. There was no mortality in our study. Two patients had limb paresis. Conclusion: Pediatric EDH is a rare entity but a potentially life-threatening condition. Prompt diagnosis and timely intervention decrease morbidity and mortality.
Keywords: Extradural hematoma, Glasgow coma scale, Glasgow outcome score, pediatric
How to cite this article:
Sobti S, Goyari M, Harpanahalli R, Gupta LN, Choudhary A, Taneja A. Clinico-radiological correlation with outcome in traumatic pediatric extradural hematoma: A single institutional experience. J Pediatr Neurosci 2021;16:113-8 |
How to cite this URL:
Sobti S, Goyari M, Harpanahalli R, Gupta LN, Choudhary A, Taneja A. Clinico-radiological correlation with outcome in traumatic pediatric extradural hematoma: A single institutional experience. J Pediatr Neurosci [serial online] 2021 [cited 2023 Sep 28];16:113-8. Available from: https://www.pediatricneurosciences.com/text.asp?2021/16/2/113/320390 |
| Introduction | |  |
Head injury is one of the leading causes of mortality and morbidity in the developing as well as developed countries. Approximately 1.5–2 million people are injured and more than one million die every year due to head injury in India.[1] Motor vehicle accidents are the second most common cause of death among people aged 15–29 years.[2]
Extradural hematoma (EDH) is seen in 1–2% cases of head injury patients and 5–15% of patients with moderate-to-severe head injuries. The maximum incidence is between the ages of 11 and 60 years, being uncommon in young and old age in whom duramater is adherent to the bone firmly. It is usually a result of direct trauma and is commonly associated with overlying skull fracture although it may develop without skull fracture which is usually seen in children due to increased elasticity of bone in them.[3],[4] The source of bleeding is mostly arterial in adolescents and older children while the venous source is commoner in younger children.[5]
Extradural hematoma is infrequent in the pediatric age group (less than 18 years) and is present in about 1–3% of all pediatric head injuries. It occurs rarely in neonates and is associated with delivery by forceps or vacuum extraction.[4]
| Materials and Methods | | |
Type of the study
The study was a prospective observational conducted in the Department of Neurosurgery at PGIMER, Dr. RML Hospital, New Delhi over a period of 19 months. The minimum duration of follow-up was 6 months for each study subject. A total of 38 patients were enrolled in the study. All traumatic extradural hematoma below 18 years of age of both sexes irrespective of the presence or absence of other intracranial injuries were included in this study. Follow-up of all patients was done at 2 weeks, 1, 2, and 6 months. Noncontrast computed tomography (NCCT) head was done in all patients at the time of admission and whenever their neurological status deteriorated.
Indications of surgery
- All patients who had hematoma of more than 25 mL, midline shift of more than 5 mm, and thickness of hematoma more than 15 mm with moderate-to-severe mass effect in supratentorial EDH.
For infratentorial EDH, a volume of 10 mL, midline shift more than 5 mm, and clot thickness more than 15 mm with mass effect (cisterns effaced, ventricles displaced, and compressed with development of hydrocephalus).
- Poor neurological status [according to the Glasgow coma scale (GCS)] along with significant radiological findings correlating the clinical findings.
The volume of hematoma was calculated by using the following formula:
Follow-up
Patients were evaluated using GCS/pediatric Glasgow coma scale, presence of any neurological deficit, noncontrast CT scan, and thereafter all patients were followed up after 2 weeks, 1, 2, and 6 months and in each visit patients were evaluated by using GCS and neurological examination.
For assessment of outcome, Glasgow outcome score (GOS) was used and patients were evaluated at 2 weeks, 1, 2, and 6 months.
| Observations and Results | | |
In total, 38 patients aged less than 18 years, with traumatic extradural hematoma (documented by NCCT scan Head) were enrolled for this study. The maximum number of patients in our study is between 1 and 5 years (55.26%), followed by 5 and 18 years (36.85%) and less than 1 year (7.89%). Twenty-one (55%) were males and 17 (45%) were females. There was a slight male preponderance. Most of the injuries in our study were found to be following fall from height (from stairs followed by roof and bed) (78.9%) and then followed by road traffic accident (RTA) (18.5%) and rarely physical assault (2.6%). There was no patient with shaken baby syndrome in our study.
Clinical presentation
The most common presentation in our study was a loss of consciousness (78.9%), followed by vomiting (52.6%), ENT bleed (52.6%), headache (39.5%), seizure (15.8%), and focal neurological deficits (5.8%). Cephalhematoma was another common clinical sign, which occurred in 42.10% of our patients [Table 1].
Lucid interval
Out of 38 patients, the lucid interval was present in four (10.53%) patients only.
GCS score at the time of presentation
GCS score assessed at the time of presentation showed that 33 had a score of 14 or 15, whereas four had a score between 9 and 13 and one had a score below 9.
Pupil
Asymmetry of the pupil was found in only four patients (10.52%) and in these four patients, pupil ipsilateral to the EDH was dilated.
Location of EDH
The most common location of EDH in our study was the parietal region (44.74%), followed by frontal (39.47%), temporal (13.16%), occipital (13.16%), and posterior fossa (7.89%). On CT scan, it was seen that six patients (17%) had a supratentorial hematoma of volume more than 25 mL and 29 patients (82%) had hematoma volume less than 25 mL.
Three patients out of 38 had infratentorial hematoma of less than 10 mL. None had infratentorial hematoma of more than 10 mL.
Clot thickness
Thickness of the clot seen in the CT scan was less than 15 mm in 32 (84%) patients and more than 15 mm in six (16%) patients. Midline shift was present in 14 (37%) patients. Six patients were operated.
Status of associated intracranial injuries
Of the 38 patients, 18 had associated intracranial injuries, the most common of which was brain edema (26.3%), followed by parenchymal contusion (21.05%), subdural hematoma and subarachnoid hemorrhage were present in 5.27% patients each, and pneumocephalus was present in 9.89% patients [Table 2].
Skull bone fracture
Twenty-three patients had skull bone fracture. Among those who had skull bone fracture, nine (23.68%) patients had a fracture in the parietal bone, followed by frontal bone in six (15.79%), temporal bone in five (13.16%), and occipital bone in three (7.89%) patients. Five patients with parietal EDH had associated fractures. A 3D CT scan was not done to identify fractures.
In our study, the posttreatment neurological deficit was found only in two (5.26%) patients in the form of limb paresis. The remaining patients had a satisfactory recovery.
Morbidity and mortality
At the end of study with a minimum follow-up period of 6 months, all patients in our study showed good recovery in both treatment groups [surgical (six patients) and medical (32 patients)] [Table 3]. Of the 38 patients, 36 (94.74%) had a GOS score 5 and two (5.26%) had GOS score 4. There was no mortality in our study. Three patients had irritability and two patients had upper limb monoparesis.
| Discussion | | |
Extradural or epidural hematoma (EDH) is an accumulation of blood in a potential space between the inner table of cranial bone and periosteal duramater. The classical location of EDH in adults is the temporal region and most commonly due to tear of the middle meningeal artery secondary to overlying temporal bone fracture. In more than half of patients, the middle meningeal artery is the source of bleeding but in approximately 30% of patients middle meningeal vein is the source. The source of bleeding is anterior ethmoidal artery in the frontal region and transverse sinus in the occipital region and posterior fossa EDH.[6],[7],[8]
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. The criteria for using surgical evacuation vs. conservative management have remained ill-defined.
The maximum number of patients were between 1 and 5 years of age in our study. Langloiset al.[7] reported the maximum number of cases in patients aged between 1 year and 8 years and the mean age of presentation in their study was 10 years.
In our current study, slight male preponderance in incidence (55% males vs 45% females) was found. Extradural hematoma is prevalent in young adult males with a male to female ratio of 4:1 as shown by Oertal et al.[9] Dhellemmes et al.[10] reported a definite male predominance in the incidence of traumatic EDH in children.
Fall from height was the most common mode of injury in our study, constituting 78.94%, followed by road traffic accidents (18.5%) and physical assaults (2.6%). Seeling et al.[11] reported fall as the most common cause (70%) of extradural hematoma in the pediatric age group. Maggi et al.[12] reported the most common cause of head trauma causing EDH was accidental falls in children under 5 years of age, whereas bicycle, pedestrian, and car accidents are the main type of injury in older children. Our finding is in agreement with previous reports. Pasaoglu et al.[13] and Ersahin et al.[14] found that fall was the most common underlying mechanism in 63% and 62% patients, respectively.
Loss of consciousness was the most common presentation found in our study followed by vomiting, ENT bleed, seizure episode, and neurological deficits. Jamieson and Yelland[15] reported a loss of consciousness as the most common presentation in 2.4% of the patients. The description of deterioration in consciousness level, i.e., concussion followed by a lucid interval followed again by unconsciousness, is usually thought to be the only classical sign of extradural hematoma in a significant number of patients as shown by McKissock et al.[16] to be as high as 26% and Jamieson and Yelland[15] showed it to be 12%. But it was observed in only four (10.52%) patients in our study. So, the description of a lucid interval as the only sign for extradural hematoma seems to be overemphasized.
Persistent headache and vomiting sometimes may be the only presenting complaints in patients with EDH, especially in infants and younger children. In the present series, 15 (39%) patients presented with headache and vomiting after trauma as the sole complaints.
The appearance of moderate pallor in young patients upon admission was a characteristic sign of major diagnostic significance. Pasaoglu et al.[13] reported that pallor and anemia occurred in 90% of their infantile cases. Anemia, associated with pallor, has been identified before finding acute EDH in infants. Cephalhematoma was another common clinical sign, which occurred in 42.10% of our patients.
In our study, four (11%) patients presented with a lucid interval. Pasaoglu et al.,[13] however, reported that 32% of their pediatric patients presented with a typical lucid interval.
Ersahin et al.[14] and Pasaoglu et al..[13] concluded in their studies that the GCS scoring system accurately assessed the neurological condition even in infants and was associated with the outcome in a statistically significant fashion. Rocchi et al.[3] found that the preoperative neurological status examined by GCS had a significant impact on the outcome.
The parietal area was the most common anatomical location of EDH in our study. Our findings demonstrated that anatomical location was not associated with the outcome.
Ersahin et al.[14] and Pasaoglu et al.[13] reported that temporoparietal and temporal regions were the most common locations in their series. No relationship between the anatomical location of EDH and the outcome was established in their study. Rivas et al.[17] postulated that temporal location might contribute to increased mortality due to the predisposition to uncal herniation.
In the present study, there were four (9.5%) patients with rapid clinical deterioration and all of them had EDH volume of more than 25 mL and midline shift of more than 0.5 cm. All these four patients underwent craniotomy and evacuation of EDH. Patients with mild to moderate head injury (GCS 8–14) have a significantly higher incidence of initial loss of consciousness, skull fracture, abnormal CT findings, need for hospital admission, delayed neurological deterioration, and need for operation than patients with a GCS of 15/15.[14],[18],[19] Kudy et al.[20] have reported that lower GCS at presentation correlates with an unfavorable outcome. Our study also confirmed a similar finding. In the current study, most of the patients had good GCS score at presentation. Thirty-three (86.84%) patients presented with a GCS score of 14–15; four (10.53%) with 9–13 and one (2.63%) with 3–8.
Pang et al.[21] in their study found most of their patients (76.8%) presenting with GCS score 13–15. Gutierrez et al.[22] reported that more than 80% of their patients had a GCS score of more than 13 at presentation. Pillay et al.[23] in their series of pediatric EDH concluded that the most important factor determining the outcome was pretreatment neurological status. Patients operated at poor GCS scores had consistently poor outcomes.
In this study, volume of hematoma was found ranging from 8 to 40 mL and mean volume was 14.81 mL. Of 38 patients, 35 (82%) had EDH in a supratentorial compartment and three (8%) had EDH in an infratentorial compartment. Of the supratentorial EDH, six patients had hematoma volume more than 25 mL and 29 had hematoma volume less than 25 mL. According to one study by Mazza et al.,[24] volume of hematoma up to 30 mL in the young age group (less than 5 years) can be compatible with survival and low morbidity. According to Bezirciogle et al.,[25] patients with EDH less than 30 mL can be treated conservatively except when hematoma is in the temporal region. Our study included five patients of temporal hematoma and all of them had hematoma volume less than 25 mL and hence managed medically. All of them recovered satisfactorily. Similarly, three patients with posterior fossa EDH had a volume less than 10 mL, so they were managed medically. Rivas et al.[17] also found an unfavorable outcome in deteriorating patients and a hematoma volume of more than 30 mL. Lobato et al.[26] also reported a similar result. In contrast, Van den Brink et al.[27] found no correlation between EDH volume, GCS, and outcome at 6 months. The present study shows that if a patient has a good GCS, the hematoma volume is expected to be small and vice versa. In our study, 86.84% of patients had GCS 13-15 and 82.85% of patients had hematoma volume of less than 25 mL.
Clot thickness found was between 2 and 25 mm with a mean clot thickness of 8.84 mm. Thickness was less than 15 mm in 32 patients (84.21%) and only six patients (15.79%) had clot thickness of more than 15 mm. Gutierrez et al.[22] and Bezirciogle et al.[25] studied patients of traumatic extradural hematoma in children and they concluded that clot thickness alone has no direct correlation with outcome.
Skull bone fracture was found in 18 (47%) patients in our study. Many studies describe the incidence between 32 and 70%. In the series of Phonprasert et al.,[28] the incidence was 38%. Its’ value in the diagnosis of extradural hematoma could not be established as 53% of the patients did not have fractures on skull X-rays. A similar view has been expressed by Crook et al.[29] who reported that X-ray skull is of no use in the diagnosis of extradural hematoma as 68% of X-rays were reported normal in their study.
In the present study, the postoperative CT scan was done in all six patients. None of our patients required re-exploration although one patient did not show significant improvement but the residual collection was not significant and there was only edema.
Associated intracranial injuries
Associated intracranial injuries were seen in 18 (47%) patients in the present study. Pillay et al.[23] in their study of 64 patients with traumatic EDH in children concluded that associated intracranial injuries are common and present in more than half of patients. The overall outcome was good when there were least or no other intracranial injuries and bad when there were associated intracranial injuries. Gutierrez et al.[22] concluded in their study of pediatric extradural hematoma that associated intracranial injuries directly affect the overall outcome.
Our result also showed that the outcome was better when there were no associated intracranial injuries than those in whom other intracranial injuries were there. Patients in whom posttreatment neurological deficits were there had associated intracranial injuries other than EDH.
Treatment
EDH in six (16%) patients in our study were surgically evacuated, while 32 (84%) were treated conservatively.
Mortality and morbidity
The reported mortality rates associated with EDH in infants and children are different from one clinical series to another. Mortality rate of 9.1% was reported by Beni-Adani et al.[30] in their infantile series. Rocchi et al.[3] reported a mortality rate of 5.5% in pediatric patients having solely epidural hematomas. Similarly, Ersahin et al.[14] reported a mortality rate of 6% in their pediatric series. There was no mortality in our study at the end of minimum 6 months follow-up. All patients managed either medically or surgically had a good recovery. Our morbidity rate was only 13.15% (three patients were irritable and two had U/L monoparesis).
These discrepancies may be due to
Overall good GCS at presentation
Short-time lapse between injury and hospital admission
Early diagnosis using CT scan
Early intervention (medical or surgical where indicated)
There were certain limitations in our study like
- Cognitive function was not assessed
- The minimum follow-up period was only 6 months
- Brain trauma foundation guidelines suggest that EDH volume of greater than 30 cm3 should be evacuated.[31]
| Conclusion | | |
Traumatic extradural hematoma in children is an uncommon trauma sequel. Pediatric EDH is potentially a life-threatening condition and a high index of suspicion is necessary for early diagnosis and timely intervention. Early NCCT head is the investigation of choice to diagnose acute traumatic EDH. The GCS score at presentation is the most important factor determining the outcome.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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