Top

Child's Nervous System

Published in:

01-11-2019 | Central Nervous System Trauma | Original Article

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas

Authors: D. Clay Samples, Michael T. Bounajem, David J. Wallace, Lillian Liao, Izabela Tarasiewicz

Published in: Child's Nervous System | Issue 11/2019

Abstract

Introduction

Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making.

Methods

A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon.

Results

Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline.

Conclusion

Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.

Flaherty BF, Moore HE, Riva-Cambrin J, Bratton SL (2017) Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment. J Pediatr Surg 52(2):334–339. https://doi.org/10.1016/j.jpedsurg.2016.09.005 CrossRefPubMed

Flaherty BF, Moore HE, Riva-Cambrin J, Bratton SL (2018) Repeat head CT for expectant management of traumatic epidural hematoma. Pediatrics 142(3):e20180385. https://doi.org/10.1542/peds.2018-0385 CrossRefPubMed

Flaherty BF, Loya J, Alexander MD, Pandit R, Ha BY, Torres RA, Schroeder AR (2013) Utility of clinical and radiographic findings in the management of traumatic epidural hematoma. PNE 49(4):208–214. https://doi.org/10.1159/000363143 CrossRef

Holsti M, Kadish HA, Sill BL, Firth SD, Nelson DS (2005) Pediatric closed head injuries treated in an observation unit. Pediatr Emerg Care 21(10):639–644. https://doi.org/10.1097/01.pec.0000181426.25342.a9 CrossRefPubMed

Ryan ME, Jaju A, Ciolino JD, Alden T (2016) Rapid MRI evaluation of acute intracranial hemorrhage in pediatric head trauma. Neuroradiology 58(8):793–799. https://doi.org/10.1007/s00234-016-1686-x CrossRefPubMed

Sheng H-S, You C-G, Yang L, Zhang N, Lin J, Lin FC, Wang MD (2017) Trephination mini-craniectomy for traumatic posterior fossa epidural hematomas in selected pediatric patients. Chin J Traumatol 20(4):212–215. https://doi.org/10.1016/j.cjtee.2017.01.004 CrossRefPubMedPubMedCentral

Pang D, Horton JA, Herron JM, Wilberger JE, Vries JK (1983) Nonsurgical management of extradural hematomas in children. J Neurosurg 59(6):958–971. https://doi.org/10.3171/jns.1983.59.6.0958 CrossRefPubMed

Erşahin Y, Mutluer S, Güzelbag E (1993) Extradural hematoma: analysis of 146 cases. Childs Nerv Syst 9(2):96–99. https://doi.org/10.1007/BF00305316 CrossRefPubMed

Balmer B, Boltshauser E, Altermatt S, Gobet R (2006) Conservative management of significant epidural haematomas in children. Childs Nerv Syst 22(4):363–367. https://doi.org/10.1007/s00381-005-1254-x CrossRefPubMed

10.

Bejjani GK, Donahue DJ, Rusin J, Broemeling LD (1996) Radiological and clinical criteria for the management of epidural hematomas in children. Pediatr Neurosurg 25(6):302–308. https://doi.org/10.1159/000121144 CrossRefPubMed

11.

Binder H, Majdan M, Tiefenboeck TM, Fochtmann A, Michel M, Hajdu S, Mauritz W, Leitgeb J (2016) Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center. Orthop Traumatol Surg Res 102(6):769–774. https://doi.org/10.1016/j.otsr.2016.06.003 CrossRefPubMed

12.

Champagne P-O, He KX, Mercier C, Weil AG, Crevier L (2017) Conservative management of large traumatic supratentorial epidural hematoma in the pediatric population. PNE 52(3):168–172. https://doi.org/10.1159/000455925 CrossRef

13.

Ciurea AV, Kapsalaki EZ, Coman TC, Roberts JL, Robinson JS III, Tascu A, Brehar F, Fountas KN (2007) Supratentorial epidural hematoma of traumatic etiology in infants. Childs Nerv Syst 23(3):335–341. https://doi.org/10.1007/s00381-006-0230-4 CrossRefPubMed

14.

Duthie G, Reaper J, Tyagi A, Crimmins D, Chumas P (2009) Extradural haematomas in children: a 10-year review. Br J Neurosurg 23(6):596–600. https://doi.org/10.3109/02688690902978157 CrossRefPubMed

15.

Flannery AM (2009) Cautions in the conservative management of epidural hematomas. Pediatr Neurosurg; Basel 45(3):185CrossRef

16.

Jamous MA, Abdel Aziz H, Al Kaisy F, Eloqayli H, Azab M, Al-Jarrah M (2009) Conservative management of acute epidural hematoma in a pediatric age group. Pediatr Neurosurg 45(3):181–184. https://doi.org/10.1159/000218200 CrossRefPubMed

17.

Khan MB, Riaz M, Javed G (2014) Conservative management of significant supratentorial epidural hematomas in pediatric patients. Childs Nerv Syst 30(7):1249–1253. https://doi.org/10.1007/s00381-014-2391-x CrossRefPubMed

18.

Skadorwa T, Zygańska E, Eibl M, Ciszek B (2013) Distinct strategies in the treatment of epidural hematoma in children: clinical considerations. PNE 49(3):166–171. https://doi.org/10.1159/000359954 CrossRef

19.

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL (2009) Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 374(9696):1160–1170. https://doi.org/10.1016/S0140-6736(09)61558-0 CrossRefPubMed

20.

Rocchi G, Caroli E, Raco A, Salvati M, Delfini R (2005) Traumatic epidural hematoma in children. J Child Neurol 20(7):569–571. https://doi.org/10.1177/08830738050200070501 CrossRefPubMed

21.

Babl FE, Oakley E, Dalziel SR, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Donath S, Hearps S, Molesworth C, Crowe L, Bressan S, Lyttle MD (2018) Accuracy of clinician practice compared with three head injury decision rules in children: a prospective cohort study. Ann Emerg Med 71(6):703–710. https://doi.org/10.1016/j.annemergmed.2018.01.015 CrossRefPubMed

22.

Babl FE, Lyttle MD, Bressan S, Borland M, Phillips N, Kochar A, Dalziel SR, Dalton S, Cheek JA, Furyk J, Gilhotra Y, Neutze J, Ward B, Donath S, Jachno K, Crowe L, Williams A, Oakley E, PREDICT research network (2014) A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr 14(1):148. https://doi.org/10.1186/1471-2431-14-148 CrossRefPubMedPubMedCentral

23.

Simon B, Letourneau P, Vitorino E, McCall J (2001) Pediatric minor head trauma: indications for computed tomographic scanning revisited. J Trauma 51(2):231–237 discussion 237-238CrossRef

24.

Durham SR, Liu KC, Selden NR (2006) Utility of serial computed tomography imaging in pediatric patients with head trauma. J Neurosurg Pediatr 105(5):365–369. https://doi.org/10.3171/ped.2006.105.5.365 CrossRef

25.

Givner A, Gurney J, O’Connor D, Kassarjian A, LaMorte WW, Moulton S (2002) Reimaging in pediatric neurotrauma: factors associated with progression of intracranial injury. J Pediatr Surg 37(3):381–385. https://doi.org/10.1053/jpsu.2002.30825 CrossRefPubMed

26.

Kochanek PM, Carney N, Adelson PD et al (2012) Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 13(Suppl 1):S1–S82. https://doi.org/10.1097/PCC.0b013e31823f435c

27.

Teichert JH, Rosales PR Jr, Lopes PB, Enéas LV, da Rocha TS (2012) Extradural hematoma in children: case series of 33 patients. PNE 48(4):216–220. https://doi.org/10.1159/000345849 CrossRef

28.

Patel SK, Gozal YM, Krueger BM, Bayley JC, Moody S, Andaluz N, Falcone RA Jr, Bierbrauer KS (2018) Routine surveillance imaging following mild traumatic brain injury with intracranial hemorrhage may not be necessary. J Pediatr Surg 53(10):2048–2054. https://doi.org/10.1016/j.jpedsurg.2018.04.027 CrossRefPubMed

29.

Tabori U, Kornecki A, Sofer S, Constantini S, Paret G, Beck R, Sivan Y (2000) Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma. Crit Care Med 28(3):840–844CrossRef

30.

Figg RE, Stouffer CW, Vander Kolk WE, Connors RH (2006) Clinical efficacy of serial computed tomographic scanning in pediatric severe traumatic brain injury. Ped Surg Int 22(3):215–218. https://doi.org/10.1007/s00383-005-1560-0 CrossRef

31.

Stippler M, Smith C, McLean AR et al (2012) Utility of routine follow-up head CT scanning after mild traumatic brain injury: a systematic review of the literature. Emerg Med J 29(7):528–532. https://doi.org/10.1136/emermed-2011-200162 CrossRefPubMed

32.

Buttram SDW, Garcia-Filion P, Miller J, Youssfi M, Danielle Brown S, Dalton HJ, David Adelson P (2015) Computed tomography vs magnetic resonance imaging for identifying acute lesions in pediatric traumatic brain injury. Hosp Pediatr 5(2):79–84. https://doi.org/10.1542/hpeds.2014-0094 CrossRefPubMed

33.

Cohrs G, Huhndorf M, Niemczyk N, Volz LJ, Bernsmeier A, Singhal A, Larsen N, Synowitz M, Knerlich-Lukoschus F (2018) MRI in mild pediatric traumatic brain injury: diagnostic overkill or useful tool? Childs Nerv Syst 34(7):1345–1352. https://doi.org/10.1007/s00381-018-3771-4 CrossRefPubMed

34.

Huisman TAGM (2005) Intracranial hemorrhage: ultrasound, CT and MRI findings. Eur Radiol 15(3):434–440. https://doi.org/10.1007/s00330-004-2615-7 CrossRefPubMed

Title: Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas
Authors: D. Clay Samples
Michael T. Bounajem
David J. Wallace
Lillian Liao
Izabela Tarasiewicz
Publication date: 01-11-2019
Publisher: Springer Berlin Heidelberg
Keywords: Central Nervous System Trauma
Hematoma
Epidural Hematoma
Published in: Child's Nervous System / Issue 11/2019
Print ISSN: 0256-7040
Electronic ISSN: 1433-0350
DOI: https://doi.org/10.1007/s00381-019-04236-7

At a glance: The STEP trials

Springer Medicine

Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas

Abstract

Introduction

Methods

Results

Conclusion

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 11/2019

Acute post-traumatic hydrocephalus in children due to aqueductal obstruction by blood clot: a series of 6 patients

Removal of a minimal amount of subdural hematoma is effective and sufficient for term neonates with severe symptomatic spontaneous parenchymal hemorrhage

Imaging in craniosynostosis: when and what?

Shunt independence in pediatric hydrocephalus

Transsphenoidal surgery for pituitary adenomas in pediatric patients: a multicentric retrospective study

Pediatric endoscopic endonasal skull base surgery—where do we stand and where are we going?