Posterior fossa epidural hematoma in children

Posterior fossa epidural hematoma in children

Clinical features

Because of the non-specific symptoms and the potential for rapid and fatal deterioration of Posterior fossa epidural hematoma in children, an early computed tomography (CT) scanning is necessary for all suspicious cases.

In nine cases.The clinical picture was dominated by headache, vomiting, and gait ataxia. An occipital fracture was seen in 77.7% of the patients. In all cases, the diagnosis was made by computed tomography. 1).

Treatment

see Review and Management Guidelines 2).

Although some patients have been successfully treated with conservative approach, most studies support timely management of posterior fossa epidural hematoma by surgical intervention in children.

The absence of an occipital skull fracture or the presence of normal pulse rate and blood pressure should not influence the decision. Lumbar puncture is absolutely contraindicated 3).

Little evidence is available regarding the feasibility of using trephination mini-craniectomy for traumatic PFEDH in children 4).

Outcome

The overall prognosis normally is excellent 5) 6) 7).

Torrential venous bleeding can be a major problem due to rupture of the adjacent sinuses. Timely intervention is crucial for achieving good outcome, keeping in view a low threshold for surgical evacuation 8).

Case series

References

1) , 7)

Ciurea AV, Nuteanu L, Simionescu N, Georgescu S. Posterior fossa extradural hematomas in children: report of nine cases. Childs Nerv Syst. 1993 Jul;9(4):224-8. PubMed PMID: 8402704.
2)

Kaushik S, Sandip C. Posterior Fossa Acute Extradural Hematoma in Children: Review and Management Guidelines. J Pediatr Neurosci. 2018 Jul-Sep;13(3):289-293. doi: 10.4103/JPN.JPN_86_18. Review. PubMed PMID: 30271459; PubMed Central PMCID: PMC6144610.
3)

Arkins TJ, McLennan JE, Winston KR, Strand RD, Suzuki Y. Acute posterior fossa epidural hematomas in children. Am J Dis Child. 1977 Jun;131(6):690-2. PubMed PMID: 868823.
5)

Chaoguo Y, Xiu L, Liuxun H, Hansong S, Nu Z. Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature. J Korean Neurosurg Soc. 2019 Mar;62(2):225-231. doi: 10.3340/jkns.2016.0506.007. Epub 2019 Feb 27. PubMed PMID: 30840978.
6)

Sencer A, Aras Y, Akcakaya MO, Goker B, Kiris T, Canbolat AT. Posterior fossa epidural hematomas in children: clinical experience with 40 cases. J Neurosurg Pediatr. 2012 Feb;9(2):139-43. doi: 10.3171/2011.11.PEDS11177. PubMed PMID: 22295917.
8)

Prasad GL, Gupta DK, Sharma BS, Mahapatra AK. Traumatic Pediatric Posterior Fossa Extradural Hematomas: A Tertiary-Care Trauma Center Experience from India. Pediatr Neurosurg. 2015;50(5):250-6. doi: 10.1159/000438488. Epub 2015 Aug 20. PubMed PMID: 26287640.

Intensive care unit admission

Intensive care unit admission

Currently evidence do not allow to define standardized protocol to guide ICUadmission for acute neurological patients (TBI) patients, postoperative neurosurgical procedures and stroke 1).

Kim et al., enrolled 322 patients with severe trauma and TBI from January 2015 to December 2016. Clinical factors, indexes, and outcomes were compared before and after trauma center establishment (September 2015). The outcome was the Glasgow outcome scale classification at 3 months post-trauma.

Of the 322 patients, 120 (37.3%) and 202 (62.7%) were admitted before and after trauma center establishment, respectively. The two groups were significantly different in age (p=0.038), the trauma location within the city (p=0.010), the proportion of intensive care unit (ICUadmissions (p=0.001), and the emergency room stay time (p<0.001). Mortality occurred in 37 patients (11.5%). Although the preventable death rate decreased from before to after center establishment (23.1% vs. 12.5%), the difference was not significant. None of the clinical factors, indexes, or outcomes were different from before to after center establishment for patients with severe TBI (Glasgow coma scale score ≤8). However, the proportion of inter-hospital transfers increased and the time to emergency room arrival was longer in both the entire cohort and patients with severe TBI after versus before trauma center establishment.

They confirmed that for patients with severe trauma and TBI, establishing a trauma center increased the proportion of ICU admissions and decreased the emergency room stay time and preventable death rate. However, management strategies for handling the high proportion of inter-hospital transfers and long times to emergency room arrival will be necessary 2).


In the United States, 20% of patients with mild traumatic brain injury, defined as those with a Glasgow Coma Scale (GCS) of 13-15, presenting to the Emergency Department are admitted to the ICU 3).


Within a prospectiveobservationalmulticenter cohort study 68 hospitals (of which 66 responded), mostly academic (n = 60, 91%) level I trauma centers (n = 44, 67%) in 20 countries were asked to complete questionnaires regarding the “standard of care” for severe neurotrauma patients in their hospitals. From the questionnaire pertaining to ICU management, 12 questions related to admission criteria were selected for this analysis. The questionnaires were completed by 66 centers. The median number of TBI patients admitted to the ICU was 92 [interquartile range (IQR): 52-160] annually. Admission policy varied; in 45 (68%) centers, patients with a Glasgow Come Score (GCS) between 13 and 15 without CT abnormalities but with other risk factors would be admitted to the ICU while the rest indicated that they would not admit these patients routinely to the ICU.

Volovici et al. found no association between ICU admission policy and the presence of a dedicated neuro ICU, the discipline in charge of rounds, the presence of step down beds or geographic location (North- Western Europe vs. South – Eastern Europe and Israel). Variation in admission policy, primarily of mild TBI patients to ICU exists, even among high-volume academic centers and seems to be largely independent of other center characteristics. The observed variation suggests a role for comparative effectiveness research to investigate the potential benefit and cost-effectiveness of a liberal versus more restrictive admission policies 4).


The aim of study was to describe current approaches and to quantify variability between European intensive care units (ICU)s in patients with traumatic brain injury (TBI). Therefore, Huijben et al. conducted a provider profiling survey as part of the ‘Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury‘ (CENTER-TBI) study. The ICU Questionnaire was sent to 68 centers from 20 countries across Europe and Israel. For this study, they used ICU questions focused on 1) hemoglobin target level (Hb-TL), 2) coagulation management, and 3) deep venous thrombosis (DVT) prophylaxis. Sixty-six centers completed the ICU questionnaire. For ICU-patients, half of the centers (N= 34; 52%) had a defined Hb-TL in their protocol. For patients with TBI, 26 centers (41%) indicated a Hb-TL between 70 and 90 g/l and 38 centers (59%) above 90 g/l. To treat trauma related hemostatic abnormalities the use of fresh frozen plasma (N= 48; 73%) or platelets (N= 34; 52%) was most often reported, followed by the supplementation of vitamin K (N= 26; 39%). Most centers reported using DVT prophylaxis with anticoagulants frequently or always (N= 62; 94%). In the absence of hemorrhagic brain lesions, 14 centers (21%) delayed DVT prophylaxis until 72 hours after trauma. If hemorrhagic brain lesions were present, the number of centers delaying DVT prophylaxis for 72 hours increased to 29 (46%). Overall, a lack of consensus exists between European ICUs on blood transfusion and coagulation management. The results provide a baseline for the CENTER-TBI study and the large between-center variation indicates multiple opportunities for comparative effectiveness research 5).

References

1)

Badenes R, Robba C, Taccone FS, Bilotta F. Neuro-ICU patient disposition: optimal venue for acute needs. Curr Opin Crit Care. 2018 Jan 23. doi: 10.1097/MCC.0000000000000482. [Epub ahead of print] PubMed PMID: 29369064.
2)

Kim JS, Jeong SW, Ahn HJ, Hwang HJ, Kyoung KH, Kwon SC, Kim MS. Effects of Trauma Center Establishment on the Clinical Characteristics and Outcomes of Patients with Traumatic Brain Injury : A Retrospective Analysis from a Single Trauma Center in Korea. J Korean Neurosurg Soc. 2019 Mar;62(2):232-242. doi: 10.3340/jkns.2018.0037. Epub 2019 Feb 27. PubMed PMID: 30840979.
3)

Ratcliff JJ, Adeoye O, Lindsell CJ, et al.: ED disposition of the Glasgow Coma Scale 13 to 15 traumatic brain injury patient: analysis of the Transforming Research and Clinical Knowledge in TBI study. Am J Emerg Med 32:844-850, 2014
4)

Volovici V, Ercole A, Citerio G, Stocchetti N, Haitsma IK, Huijben JA, Dirven CMF, van der Jagt M, Steyerberg EW, Nelson D, Cnossen MC, Maas AIR, Polinder S, Menon DK, Lingsma HF. Intensive care admission criteria for traumatic brain injury patients across Europe. J Crit Care. 2018 Nov 8;49:158-161. doi: 10.1016/j.jcrc.2018.11.002. [Epub ahead of print] PubMed PMID: 30447560.
5)

Huijben JA, van der Jagt M, Cnossen MC, Kruip MJHA, Haitsma I, Stocchetti N, Maas A, Menon D, Ercole A, Maegele M, Stanworth SJ, Citerio G, Polinder S, Steyerberg EW, Lingsma H. Variation in blood transfusion and coagulation management in Traumatic Brain Injury at the Intensive Care Unit: A survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. J Neurotrauma. 2017 Aug 21. doi: 10.1089/neu.2017.5194. [Epub ahead of print] PubMed PMID: 28825511.

Fall

Fall

To drop or descend under the force of gravity, as to a lower place through loss or lack of support.

A study of Eom included 540 men and 364 women. The age distributions in the male and female groups were statistically significantly different. The most common cause of trauma was a fall and diagnosis was acute subdural hematoma. The incidence was the highest in men aged 80-84 years and in women aged 75-79 years. The most common time of arrival to hospital after TBIwas within 1 hour and 119 rescue team provided first aid earliest to patients with TBI. The mortality rate stratified according to the cause of trauma was significantly different, with mortality rates of 3.77% in fall and 11.65% in traffic accident. The mortality rates according the severity of brain injury, Glasgow Coma Scale score, and treatment were statistically significant.

This study is the first to focus on elderly patients with TBI in Korea and particularly investigate mortality and characteristics related to TBI-related death based on data from the Korean Neuro-Trauma Data Bank System (KNTDBS). Although the study has some limitations, the results may be used to obtain useful information to study targeted prevention and more effective treatment options for older TBI patients and establish novel treatment guidelines and health polish for the geriatric population 1).


Falls are common in older adults with psychiatric disorders, but the epidemiological findings have been inconsistent. A meta-analysis examined the prevalence of falls in older psychiatric patients and its moderating factors. PubMedEMBASEWeb of Science and PsycINFO databases were independently searched by three investigators from their inception date to Nov 31, 2017. The random effects meta-analysis was used to synthesize the prevalence of falls, while meta-regression and subgroup analyses were conducted to explore the moderating factors. Sixteen of the 2061 potentially relevant papers met the entry criteria for the meta-analysis. The pooled lifetime prevalence of falls was 17.25% (95% confidence interval: 13.14%-21.35%). Neither univariate and nor multivariate meta-regression analyses revealed any moderating effects of the study region, duration, sample size, and quality on the prevalence of falls (P values > 0.05). Falls in older adults with psychiatric disorders are common 2)


Despite the growing epidemic of falls, the true incidence of peripheral nerve injury (PNIs) in this patient population remains largely unknown.


In total, 28 epidemiological studies on TBI from 16 European countries were identified in the literature. A great variation was found in case definitions and case ascertainment between studies. Falls and road traffic accidents (RTA) were the two most frequent causes of TBI, with falls being reported more frequently than RTA 3).

References

1)

Eom KS. Epidemiology and Outcomes of Traumatic Brain Injury in Elderly Population : A Multicenter Analysis Using Korean Neuro-Trauma Data Bank System 2010-2014. J Korean Neurosurg Soc. 2019 Mar;62(2):243-255. doi: 10.3340/jkns.2018.0017. Epub 2019 Feb 27. PubMed PMID: 30840980.
2)

Rao WW, Zeng LN, Zhang JW, Zong QQ, An FR, Ng CH, Ungvari GS, Yang FY, Zhang J, Peng KZ, Xiang YT. Worldwide prevalence of falls in older adults with psychiatric disorders: A meta-analysis of observational studies. Psychiatry Res. 2018 Dec 31;273:114-120. doi: 10.1016/j.psychres.2018.12.165. [Epub ahead of print] PubMed PMID: 30641340.
3)

Peeters W, van den Brande R, Polinder S, Brazinova A, Steyerberg EW, Lingsma HF, Maas AI. Epidemiology of traumatic brain injury in Europe. Acta Neurochir (Wien). 2015 Oct;157(10):1683-96. doi: 10.1007/s00701-015-2512-7. Epub 2015 Aug 14. PubMed PMID: 26269030.
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