Pediatric intracranial epidural hematoma outcome

Pediatric intracranial epidural hematoma outcome

Regardless of the intracranial epidural hematoma size, the clinical status of the patients, the abnormal pupillary findings, or the cause of injury, the outcome and prognosis of the pediatric intracranial epidural hematoma are excellent 1).

Mortality can be significantly reduced with gratifying results if operated early. Best motor response at presentation, pupillary abnormalities, time between injury to surgery, and location of hematoma have been identified as the important factors determining outcome in patients of EDH2) 3) 4) 5).

Binder et al., found that immediate as well as delayed surgical evacuation of EDH resulted in excellent outcomes in most cases. Conservative treatment was started in 76% of our cases – however needing in 35% delayed surgical intervention. Overall in all groups excellent final clinical and neurological outcomes could be reached 6).

Of all laboratory data obtained on admission, the blood potassiumpH and glucose test results correlated significantly with prognosis. Prognosis can be adequately and expeditiously estimated by selected markers within a comprehensive evaluation of children with AEH 7).

References

1)

Gerlach R, Dittrich S, Schneider W, Ackermann H, Seifert V, Kieslich M. Traumatic epidural hematomas in children and adolescents: outcome analysis in 39 consecutive unselected cases. Pediatr Emerg Care. 2009 Mar;25(3):164-9. doi: 10.1097/PEC.0b013e31819a8966. PubMed PMID: 19262419.
2)

Faheem M, Jaiswal M, Ojha BK, Chandra A, Singh SK, Srivastava C. Traumatic Pediatric Extradural Hematoma: An Institutional Study of 228 Patients in Tertiary Care Center. Pediatr Neurosurg. 2019 Jul 9:1-8. doi: 10.1159/000501043. [Epub ahead of print] PubMed PMID: 31288223.
3)

Umerani MS, Abbas A, Aziz F, Shahid R, Ali F, Rizvi RK. Pediatric Extradural Hematoma: Clinical Assessment Using King’s Outcome Scale for Childhood Head Injury. Asian J Neurosurg. 2018 Jul-Sep;13(3):681-684. doi: 10.4103/ajns.AJNS_164_16. PubMed PMID: 30283526; PubMed Central PMCID: PMC6159040.
4)

Erşahin Y, Mutluer S, Güzelbag E. Extradural hematoma: analysis of 146 cases. Childs Nerv Syst. 1993 Apr;9(2):96-9. PubMed PMID: 8319240.
5)

Paşaoğlu A, Orhon C, Koç K, Selçuklu A, Akdemir H, Uzunoğlu H. Traumatic extradural haematomas in pediatric age group. Acta Neurochir (Wien). 1990;106(3-4):136-9. PubMed PMID: 2284988.
6)

Binder H, Majdan M, Tiefenboeck TM, Fochtmann A, Michel M, Hajdu S, Mauritz W, Leitgeb J. Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center. Orthop Traumatol Surg Res. 2016 Oct;102(6):769-74. doi: 10.1016/j.otsr.2016.06.003. Epub 2016 Sep 9. PubMed PMID: 27622712.
7)

Ben Abraham R, Lahat E, Sheinman G, Feldman Z, Barzilai A, Harel R, Barzilay Z, Paret G. Metabolic and clinical markers of prognosis in the era of CT imaging in children with acute epidural hematomas. Pediatr Neurosurg. 2000 Aug;33(2):70-5. PubMed PMID: 11070432.

Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Non-traumatic, non-arterial origin delayed Epidural Hematoma after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure.

The possible causes include sudden decompression of ventricular pressure in the supratentorial compartment, rupture of cortical veins in the sitting positioncoagulopathy, hemodynamic fluctuations during surgery, and position-related ischemia 1).

The lowering of the ventricular pressure by the ventricular tapduring the operation may play significant role in the formation of the extradural hematoma.

The younger age of the cases and the long history of increased intracranial pressure were stressed in the literature2).

Wolfsberger et al., stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 3).

Avci et al., from Mersin, reported a case during removal of a huge Posterior fossa dermoid cyst 4).

Pandey et al., from Bangalore reported in 2008 a large bifrontal extradural hematoma following posterior fossa surgery for a vermian medulloblastoma5).

Tsugane et al., reported five cases of the supratentorial extradural hematomas secondary to the posterior fossa craniectomy.

The site of the hematoma was far from the operative field and two cases showed acute course and three were rather mild. The symptoms of this complication were the unsuspected sensorium disturbance, anisocoria and the non-functioning ventricular drainage. Two cases died of this complication and two were severely disabled 6).

Multiple Supratentorial Epidural Hematomas

Tyagi et al., from Bangalore published Multiple Remote Sequential Supratentorial Epidural Hematoma7).

Wolfsberger et al., from Vienna published a 31-year-old female who presented with a history of chronic hydrocephalus due to fourth-ventricular plexus papilloma. Following resection of the posterior fossa tumor with intraoperative placement of a ventricular drainage, she consecutively developed four supratentorial epidural haematomas at different locations, all necessitating evacuation. The clinical manifestations ranged from subtle neurological deficits to signs of tentorial herniation; the ultimate outcome was complete recovery. Rapid tapering of CSF pressure after long-standing hydrocephalus and clotting disorders could be implicated as causative factors. They stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 8).

References

1) , 5)

Pandey P, Madhugiri VS, Sattur MG, Devi B I. Remote supratentorial extradural hematoma following posterior fossa surgery. Childs Nerv Syst. 2008 Jul;24(7):851-4. doi: 10.1007/s00381-007-0573-5. Epub 2008 Jan 31. PubMed PMID: 18236051.
2) , 6)

Tsugane R, Sugita K, Sato O. [Supratentorial extradural hematomas following posterior fossa craniectomy (author’s transl)]. No Shinkei Geka. 1976 Apr;4(4):401-3. Japanese. PubMed PMID: 944882.
3) , 8)

Wolfsberger S, Gruber A, Czech T. Multiple supratentorial epidural haematomas after posterior fossa surgery. Neurosurg Rev. 2004 Apr;27(2):128-32. Epub 2003 Dec 2. PubMed PMID: 14652780.
4)

Avci E, Dagtekin A, Baysal Z, Karabag H. Intraoperative supratentorial epidural haematoma during removal of a huge posterior fossa dermoid cyst. Neurol Neurochir Pol. 2010 Nov-Dec;44(6):609-13. PubMed PMID: 21225525.
7)

Tyagi G, Bhat DI, Indira Devi B, Shukla D. “Multiple Remote Sequential Supratentorial Epidural Hematomas – An Unusual and Rare Complication Following Posterior Fossa Surgery”. World Neurosurg. 2019 May 6. pii: S1878-8750(19)31225-2. doi: 10.1016/j.wneu.2019.04.228. [Epub ahead of print] PubMed PMID: 31071445.

Temporal epidural hematoma surgical technique

Temporal epidural hematoma surgical technique

Surgical safety checklist

Preoperative antibiotic prophylaxis

Skin Preparation

Positioning

The supine position is used with the patient‘s head rotated for temporal access. Extremes of head rotation can obstruct the jugular venous drainage, and a shoulder roll can combat this problem or lateral positioning (park bench position).

Skin incision

Craniotomy

Technical issues

1. clot removal: lowers ICP and eliminates focal mass effect. Blood is usually thick coagulum, thus exposure must provide access to most of clot. Craniotomy permits more complete evacuation of hematoma than e.g. burr holes.

2. hemostasis:coagulate bleeding soft tissue (dural veins & arteries). Apply bone wax to intradiploic bleeders (e.g. middle meningeal artery). Also requires large exposure

3. prevent reaccumulation: (some bleeding may recur, and dura is now detached from inner table) place dural tack-up sutures to edges of craniotomy and use central “tenting” suture.

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