Nonsurgical management of extradural hematomas in children

Abstract

With the advent of computerized tomography (CT), an increasing number of patients with only minimal neurological symptoms and no signs of brain herniation are found to harbor subacute or chronic extradural hematomas (EH's). The authors present the cases of 11 symptomatic but neurologically normal children with medium to large EH's managed by close observation. These EH's were discovered 4 hours to 6 days after injury; three were in the posterior fossa, seven over the frontoparietal convexity, and one in the temporal fossa. These clots were followed by serial CT scans. Nine children recovered without surgery from 4 to 18 days after injury, and all had evidence on CT of spontaneous clot resorption. Of these nine EH's, five clots displayed volume expansion from 5 to 16 days after injury before final resorption occurred. Expansion correlated with persistence or increase in symptoms, whereas resorption correlated with improvement. Two patients showed gradual uncal herniation on Days 6 and 8, respectively, presumably during the "expansile phase" of their clots. Both had emergency craniotomy and recovered without morbidity. It is hypothesized that the resorption dynamics of the subacute or chronic EH are similar to that of the chronic subdural hematoma, with predictable volume changes, and the outcome of each lesion depends on the interplay between the patient's intracranial pressure buffering capacity and the rate of volume change. If subtle signs of brain dysfunction are adopted to signal the failure of conservative treatment and the need for craniotomy, these patients may be safely, and many successfully, managed without surgery. Factors that influence outcome of medical treatment include the size, location, configuration, and the rapidity of accumulation of the clot, the presence of associated intradural lesions, the extracranial decompression of blood through skull diastases, and the age of the patient. These factors, the criteria for patient selection, and the indications for immediate operative intervention are discussed.

A Novel Surgical Approach to Traumatic Intracranial Epidural Hematoma

“…Fever was treated with intravenous Dexamethason whereas headache was alleviated by release of occluded drain. It is believe that when fibrinolytic activity takes place the expansion phase of the clot occurs causing some degree of fluctuation in intracranial volume and pressure, resulting headache [19]. Patients with re-bleeding complained of severe pulsatile headache and gradually neurological deterioration occurred leading to immediate conventional craniotomy.…”

“…Bullock et al reported that the resolution of hematoma took 3 -15 weeks in the conservative management [12]. During the conservative management the reabsorption phase is always accompanied with expansive phase of clot due to fibrinolytic activity and in some cases latter phase may be predominant [19]. The major drawback of conservative treatment is prolong inpatient close monitoring and always remains high chance of re-bleeding.…”

Spontaneous Slow Drainage of Epidural Hematoma Into the Subgaleal Space Through a Skull Fracture in an Infant -Case Report-

“…In infants, the dura is firmly attached to the skull, but the connection between extracranial tissues is loose and easily detachable. 9) Such loose connection may allow spontaneous drainage of EDH into the subgaleal space through a skull fracture despite the absence of a substantial pressure gradient. Whereas spontaneous drainage of EDH through the skull fracture was completed within 24 hours after head trauma in all the previously reported cases, 1,3,4,6-8,10,11) the hematoma in our case continued to drain for more than 48 hours.…”

“…In addition, skull fractures in infants tend to form a jagged line rather than a straight line, because of the pliability and unevenness of the cranial flat bones. 9) Our patient showed an omega-shaped fracture that might have acted as a``hinge'' to facilitate discharge into the subgaleal space without a high pressure gradient.…”

Traumatic extradural hematoma — role of non-surgical management and reasons for conversion

“…Traumatic epidural hematomas which are minimally symptomatic do not require surgical intervention. Despite the well performed clinical studies and the experience of many neurosurgeons using prompt evacuation of EDH, there have been number of reports suggesting nonoperative management of selective EDH [11][12][13][14][15][16][17][18]. The use of CT scan in head trauma revealed a new class of EDH patients who may be treated conservatively.…”