- Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
Department of Surgery, Section of Neurosurgery, Aga Khan University Hospital, Karachi, Pakistan
DOI:10.4103/2152-7806.116425Copyright: © 2013 Khan MB This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: 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 13-Aug-2013;4:103
How to cite this URL: 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 13-Aug-2013;4:103. Available from: http://sni.wpengine.com/surgicalint_articles/surgical-management-of-traumatic-extra-dural-hematoma-in-children-experiences-and-analysis-from-24-consecutively-treated-patients-in-a-developing-country/
Background:Children with epidural hematoma (EDH) present differently than adults. The outcome of treatment is also different. We aim to report our experiences with EDH in pediatric age group in terms of mode of injury, presenting features, management, and outcomes. We also aim to identify different prognostic indicators in pediatric patients with EDH.
Methods:We prospectively collected data from 24 consecutively surgically treated pediatric patients. The data collected included presenting features, radiological imaging, details of management, and outcomes. Descriptive analysis was performed and different variables were tested for any statistical significance with Glasgow Outcome Score (GOS).
Results:There were 19 male and 5 female patients. The mean Glasgow Coma Scale (GCS) score at presentation was 9.3 ± 4.4. Falls were the most common cause of EDH. Outcome assessment was done at 3 month follow up. A total of 15 patients had a GOS score of 5, 4 patients had a GOS score of 4, 2 patients had a GOS score of 3, while 3 patients had a GOS score of 1. On univariate analysis, admitting GCS score, patient's age, the time from injury to admission and injury to surgery, anisocoric pupils at presentation and effacement of basal cisterns were significantly associated with the outcome of GOS score.
Conclusion:Falls are the most common mode of injury leading to EDH in children. Lower GCS at presentation, younger age at trauma, increased time since trauma to surgery and admission, anisocoria and effacement of basal cisterns are statistically significant variables in surgically treated pediatric patients of EDH that confer a poorer prognosis. A timely surgical intervention can result in excellent outcomes.
Keywords: Children, craniotomy, epidural hematoma, glasgow coma scale score, prognostic indicators, surgical management
Epidural hematoma (EDH) is a potentially life threatening complication of traumatic brain injury. The incidence of EDH has been reported between 1% and 6% of hospitalized patients following a traumatic brain injury.[
There is scare literature reported on traumatic EDH in the pediatric population from the developing countries where resources are limited. According to an estimate, there is only one neurosurgeon for 1.37 million population and 35 neurosurgical centers in our country, which has a total population of more than 180 million.[
As neurosurgeons in other developing countries would be faced with a similar situation, the aim of this study is to report our experiences with EDH in the pediatric age group in terms of mode of injury, presenting features, management, and outcomes. We also identify prognostic indicators in pediatric patients with EDH.
Between January 2008 and August 2012, 70 pediatric patients (pediatric patients were defined as patients with age less than or equal to 18 years) were managed for EDH at our tertiary care hospital in a developing country. Exclusion criteria included patients managed conservatively, patients who were initially treated at other institutions, patients whose computed tomography (CT) scans were not done at our hospital, and patients who were dead on arrival. For the remaining 24 patients, data were collected prospectively and a database was created. Variables included in the database were demographic details, the time since injury and admission in ER, the cause of injury, the presenting symptoms, Glasgow Coma Scale (GCS) score, pupillary characteristics, any cerebellar signs, facial nerve weakness, cervical tenderness, any other finding on neurological examination, the respiratory pattern, signs of skull base fracture, lucid interval, radiological findings, details of patient management, post operative recovery, complications, and Glasgow Outcome Score (GOS) score at 3-month follow up.
Management and imaging studies
All the patients were treated according to Advanced Trauma Life Support (ATLS) guidelines. Initial resuscitation involved venous access, endotracheal intubation, and mechanical ventilation in some patients. After hemodynamic stabilization, a complete neurological examination was performed. Head CT scan and abdominal ultrasound was performed in all patients. Mannitol, antiepileptics, and antibiotics were administered depending on individual patient characteristics.
The CT scans were interpreted by consultant radiologists and the volume of hematoma was calculated by the Peterson and Espersen equation (A × B × C/2) where A, B, and C represent the largest diameters in the sagittal, axial, and coronal planes.[
The indications for surgery included (i) increase in size of hematoma, (ii) the presence of anisocoria, (iii) clinical deterioration of the patient despite the best supportive measures, and (iv) GCS score of less than 13 post resuscitation. The surgical management involved a craniotomy and evacuation of hematoma. Any surgery done after 12 hours of trauma was considered as delayed surgery.
The data was entered into and analyzed using the SPSS software version 17 (IBM, Armonk, New York). The data is presented as proportions for categorical variables and means ± SD for continuous variables. A Mann-Whitney U test was used to check the statistical significance of sex, anisocoric pupils, effacement of basal cisterns, presence of contusions, abnormal respiratory movements, delayed surgery, and presence of skull base fractures on CT with GOS score at 3 months. A Spearman's correlation was used to quantify the association between admitting GCS, age at trauma, hematoma volume, midline shift, time since injury and surgery, and time since injury and admission with GOS outcomes. A P value of less than 0.05 was considered statistically significant.
Out of the 24 patients that were included in this analysis, 19 were male and 5 were female [
The location of hematoma was predominantly frontal in 11 cases, temporal in 6 cases, parietal in 8 cases, and occipital in 9 cases [
Management and outcomes
Thirteen patients required intubation. Mannitol was administered in 15 patients while phenytoin was administered for epilepsy prophylaxis in all the patients. Two patients required cardiopulmonary resuscitation on admission. All the patients underwent craniotomy and evacuation of hematoma.
Overall mortality occurred in three (12.5%) patients. Postoperatively two (8.3%) patients had seizures while infections occurred in five patients (20.8%). Four (16.7%) patients had residual hematoma on post operative CT scans. On one month follow up, 15 (62.5%) patients had a GOS score of 5, 4 (16.7%) patients had a GOS score of 4, 2 (8.3%) patients had a GOS score of 3, while 3 (12.5%) patients had died (GOS = 1).
A Spearman's correlation was used to quantify the relationship between admitting GCS score and GOS score on 1 month. The admitting GCS was highly prognostic of outcome (ρ=0.566, P = 0.006). Age at trauma was also significantly linked to outcome GOS ((ρ=0.471, P = 0.021). Time since injury and surgery ((ρ=0.451, P = 0.028) and the time since injury and admission ((ρ=0.512, P = 0.027) were statistically significantly related to GOS at one month. Anisocoric pupils at presentation (P = 0.004) and effacement of basal cisterns (P = 0.017) were related to significantly worse outcome. Delayed surgeries were significantly associated with a poorer outcome (P = 0.021) [
We failed to find a statistically significant correlation between the mode of injury and age in our sample of patients (P = 0.798). There was also no association between the location of hematoma and outcomes (P = 0.753).
All other variables had no statistically significant relationship with GOS score on univariate analysis.
The mortality following EDH in children has been reported between 0% and 12%.[
We found that time since trauma and surgery and time since trauma and admission to emergency room were directly related to outcomes and that surgical delay beyond 12 hours resulted in statistically significant worse outcomes. Once the patients presented to the emergency room, the median time from initial evaluation and imaging to the beginning of surgery was 30 minutes (Q1 = 25 min, Q3 = 37 min, IQR = 12 min). Since all the patients included in this series underwent emergent surgeries according to the above time schedules, we believe that time from trauma to admission and time from trauma to surgery are equivalent in this case. Further as there was an almost equal difference in both variables for each patient, the results of statistical analysis were also similar. Absence of effective emergency transport meant that many of our patients presented quite a while after the initial trauma. Thus in our opinion, better outcomes can be achieved with earlier diagnosis and rapid referral to centers with neurosurgical expertise.
The incidence of EDH in children is less than that in adults.[
In this study, we found that the GCS score at admission, age of the patient, and the time from injury to surgery were significantly related to outcome. These findings are consistent with other reports in literature.[
The most common presenting complaints in our patients was unconsciousness (70.8%) followed by vomiting (45.8%). These findings are in accordance with other reports in literature.[
There are significant differences in the clinical course of EDH between children and adults. Simpson et al.[
The most common location of hematoma in our study was frontal followed by occipital. Other studies have reported the temporal,[
The relationship between cranial fractures and outcomes remains controversial. Cranial fractures were present in 79% of our patients. The reported incidence of fractures with EDH in literature is between 45% and 90%.[
It is our institutional practice to offer surgery in pediatric patients when the hematoma is rapidly expanding, the presenting GCS score is less than 13, the presence of anisocoria, or when there is clinical neurological deterioration despite the best supportive measures. There is no uniform consensus on when to operate in a child with EDH.[
Falls are the most common mode of injury leading to EDH in children. Lower GCS at presentation, younger age at trauma, increased time since trauma to surgery and admission, anisocoria and effacement of basal cisterns are statistically significant variables in surgically treated pediatric patients of EDH that confer a poorer prognosis. A timely surgical intervention can result in excellent outcomes.
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