Surgical options for treatment of traumatic subdural hematomas in children younger than 2 years of age

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker–Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days–23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.</jats:p></jats:sec>

Abusive head trauma: an epidemiological and cost analysis

“…Fifty-eight children required 101 surgical or bedside procedures, with the majority of them being directed at the management of subdural collections, which is in agreement with other publications. 15 Our mortality rate was 3.3% (7 of 213 patients); all of the patients who died had subdural hematomas with widespread areas of bilateral cerebral infarction and poor neurological examination findings at presentation. Our mortality rate was significantly lower than the rates in other reports, such as those of Scribano et al (19%), 23 Esernio-Jenssen et al (18%), 4 and King et al (19%).…”

Intracranial hemorrhage following surgery for occult spinal dysraphism: a case-based update

“…Three of the five pediatric patients were submitted to craniotomy, two for epidurals [8,18] and the other for a massive bilateral subdural hematoma [14], being the other two managed conservatively and kept under close observation [1]. In our patient, surgery was ruled out due to his GCS score of 15 and to the small size of the subdural hematoma [12]. As the presumed main cause of this complication consists of the excessive CSF loss, attention should also be directed towards the dural defect considering the option of dural repair if deemed necessary.…”

Update on abusive head trauma

“…GCS 12). Melo et al [43] described their own experiences treating 184 children younger than 2 years admitted to the neurosurgical PICU with traumatic SDH on CT concerning for AHT. Sixty percent underwent emergency neurosurgical intervention.…”