Non-traumatic bilateral epidural hematoma in a child with sickle cell anemia: A case report and a review of the literature.

OBJECTIVE: To report a rare case of spontaneous bilateral epidural hematoma (EDH) in a 10-year-old Nigerian child with sickle cell disease (SCD) and review the literature regarding this unusual complication. METHODS: We present a case of a pediatric patient with SCD who developed a spontaneous bilateral EDH and discuss the potential underlying mechanisms, management approaches, and outcomes. We also conducted a literature review of existing cases of spontaneous EDH in patients with SCD. RESULTS: Our patient initially presented with a subgaleal hematoma and underlying bilateral EDH, but she was sent home without any neurosurgical consultation. Two years later, she returned with altered consciousness and left-sided weakness, revealing an increased size of the EDH with a noticeable mass effect. She underwent a successful emergency bilateral craniotomy, with noticeable improvement in her level of consciousness and left-sided weakness post-operatively. In our literature review, we found 40 reported cases of spontaneous EDH in SCD patients, with a male predominance (82.5%). The average age of patients was 15.282 years. The most common hematoma location was bifrontal (20%) and the most reported symptom was headache (47.5%). Most patients (97.5%) were already known cases of SCD. Among those treated, 77.5% survived. CONCLUSION: Spontaneous bilateral EDH in SCD patients is an uncommon complication, with a variety of proposed pathophysiological mechanisms. Prompt recognition and appropriate management, either conservative or surgical, are crucial to improve outcomes. Our case and literature review underscore the importance of considering spontaneous EDH in SCD patients presenting with neurological symptoms, even in the absence of trauma. Further research is needed to elucidate the precise etiology, identify risk factors, and optimize management approaches for this rare complication in SCD patients.

Comparison of burr hole drainage and craniotomy for acute liquid epidural hematoma in pediatric patients.

PURPOSE: To compare the impact of burr hole drainage and craniotomy for acute liquid epidural hematoma (LEDH) in pediatric patients. METHODS: This retrospective study enrolled pediatric patients with LEDH who underwent surgery in the Affiliated Hospital of Nanyang Medical College, China, between October 2011 and December 2019. According to the surgical procedure, patients were divided into the craniotomy group and the burr hole drainage group. RESULTS: A total of 21 pediatric patients were enrolled (14 males, aged 7.19 ± 2.77 years), including 13 cases in the burr hole drainage group and 8 patients in the craniotomy group. The operation time and hospitalization period in the burr hole drainage group were 33.38 ± 6.99 min and 9.85 ± 1.07 days, respectively, which were significantly shorter than that in the craniotomy group (74.25 ± 9.68 min and 13.38 ± 1.71 days, respectively; all p < 0.05). The Glasgow Coma Scale (GCS) score after burr hole drainage was significantly improved than before (median: 15 vs 13, p < 0.05). No serious complications were observed in either group; one patient in the craniotomy group developed an infection at the incision point. All patients were conscious (GCS score was 15) at discharge. CONCLUSION: Compared with craniotomy, burr hole drainage was associated with better clinical outcomes and early recovery in patients with LEDH.

Applications of supraorbital keyhole craniotomy in pediatric cranial trauma: illustrative series of two cases and systematic literature review.

Minimally invasive (MIS) approaches to neurosurgical diseases continue to increase in popularity due to their association with decreased infection risk, shorter recovery time, and improved cosmesis. Cosmesis and lower morbidity are especially important for pediatric patients. The supraorbital keyhole craniotomy (SOKC) is one MIS approach shown to be effective for both neoplastic and vascular pathologies in pediatric patients. However, it is limited data on its use in pediatric trauma patients. Two cases employing SOKC in pediatric trauma patients are presented here along with a systematic review of the literature. We queried PubMed, Scopus, and Web of Science databases from inception to August 2022 using the Boolean search term: (supraorbital OR eyebrow OR transeyebrow OR suprabrow OR superciliary OR supraciliary) AND (craniotomy OR approach OR keyhole OR procedure) AND (pediatric OR children OR child OR young) AND "trauma". Studies that discussed the use of an SOKC in a pediatric patient having sustained trauma to the frontal calvarium and/or anterior fossa/sellar region of the skull base were included. Details were extracted on patient demographics, trauma etiology, endoscope use, and surgical and cosmetic outcomes. We identified 89 unique studies, of which four met inclusion criteria. Thirteen total cases were represented. Age and sex were reported for 12 patients, 25% of whom were male; the mean age was 7.5 years (range: 3-16). Pathologies included acute epidural hematoma (9), orbital roof fracture with dural tear (1), blowout fracture of the medial wall of the frontal sinus with supraorbital rim fracture (1), and compound skull fracture (1). Twelve patients were treated with a conventional operating microscope, while one underwent endoscope-assisted surgery. Only one significant complication (recurrent epidural hematoma) was reported. There were no reported cosmetic complications. The MIS SOKC approach is a reasonable option for select anterior skull base trauma in the pediatric population. This approach has been used previously for successful frontal epidural hematoma evacuation, which is often treated by a large craniotomy. Further study is merited.

Impact of perioperative factors on short-term outcomes after emergency surgery for acute traumatic extradural hematoma - A retrospective cohort study.

BACKGROUND: Preoperative clinical and imaging findings predict neurological outcomes in patients with traumatic brain injury (TBI). Similarly, intraoperative factors such as blood loss and hypotension can also affect outcomes. However, there is not much data regarding the influence of perioperative variables on clinical outcomes in patients with extradural hematoma (EDH). This study aimed to understand the effect of perioperative factors on short-term neurological outcomes in patients operated for acute traumatic EDH. METHODS: After obtaining institutional ethical approval, we collected data retrospectively from records of patients who underwent emergency surgery for acute traumatic EDH over a two-year period. Data regarding age, gender, preoperative Glasgow coma scale (GCS) score, clinical and imaging findings, surgical and anesthetic details, blood loss and transfusion, duration of hospital stay, and GCS score at discharge were collected. Patients with discharge GCS score of 14-15 were considered to have favorable outcome and <14 as unfavorable outcome. Regression analysis was performed to examine the association between predictors and outcomes. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated. RESULTS: Data of 501 patients were analyzed. Outcome was favorable in 343 (68.5 %) and unfavorable in 158 (31.5 %) patients. On multivariate logistic regression analysis (OR, 95 % CI, p value), age (1.03, 1.01-1.05, 0.01), preoperative GCS score (0.68, 0.61-0.76, <0.001), signs of basal skull fracture (1.9, 1.02-3.61, 0.043) and intraoperative blood loss (2.23, 1.2-4.16, 0.01) were independently associated with unfavorable outcome. Pneumonia, neurological deficits, inotrope use and duration of hospital stay was more in this group. CONCLUSIONS: Older age, poor pre-operative GCS score, signs of basal skull fracture, and intraoperative blood loss were associated with lower discharge GCS score, increased neurological deficits and longer hospital stay in patients operated for acute traumatic EDH.

Intracranial Intraosseous Catheter Placement to Temporize an Epidural Hematoma.

Acute epidural hematomas can lead to rapid neurologic decompensation and death. Epidural hematomas may require emergency surgical clot removal, but many patients live far away from a trauma center. This case report describes a pediatric patient with an acute epidural hematoma with significant neurologic compromise who initially presented to a nontrauma center. The emergency department (ED) had no neurosurgeon or equipment to perform burr hole craniostomy. The emergency physician at the nontrauma ED inserted an intraosseous catheter intracranially to temporarily decompress the hematoma due to long transport times. The patient survived with complete neurologic recovery. This is the youngest known patient in whom an intraosseous catheter was used to drain an intracranial hematoma.

Emergency department burr hole simulation using 3D-printed model.

BACKGROUND: Traumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure. SPECIFIC AIMS: To evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases. MATERIALS AND METHODS: A 3D-printed skull, electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded. RESULTS: Twenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had overall comfort level above 5 post-simulation. CONCLUSION: The 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.

Age predicts likelihood for surgery for pediatric tbi: an analysis of 1745 hospitlizations from a Chinese Children's Hospital.

PURPOSE: We tested the role of age and sex in surgery following pediatric TBI hospitalization. METHODS: Records of 1745 children hospitalized at a pediatric neurotrauma center in China included age, sex, cause of injury, diagnosis of injury, days of hospitalization, in-house rehabilitation, Glasgow Coma Scale score, mortality, 6-month post-discharge Glasgow Outcome Scale score, and surgery intervention. The children were 0-13 years (M= 3.56 years; SD = 3.06), with 47.4% 0-2 years of age. RESULTS: The mortality rate was 1.49%. Logistic regression on 1027 children with epidural hematoma, subdural hematoma, intracerebral hemorrhage, and intraventricular hemorrhage showed that controlling for other variables, the odds for younger children to receive surgery was statistically lower for epidural hematomas (OR = 0.75; 95% CI = 0.68-0.82), subdural hematomas (OR = 0.59; 95% CI = 0.47-0.74), and intraventricular hemorrhage (OR = 0.52; 95% CI = 0.28-0.98). CONCLUSIONS: While severity of TBI and type of TBI were expected predictors for surgery, a younger age also predicted a significantly lower likelihood of surgery in our sample. Sex of the child was unrelated to surgical intervention.

Head Trauma Associated with Supra- and Infratentorial Epidural Hematoma: Diagnostic and Surgical Considerations.

BACKGROUND: Supra- and infratentorial epidural hematoma (SIEDH) is a rare type of intracranial epidural hematoma. Due to the potential of vigorous hemorrhage from the injured transverse sinus (TS), it poses a challenge for neurosurgeons to evacuate the SIEDH. METHODS: The medical records and radiographic studies were retrospectively reviewed to investigate the clinical and radiographic characteristics, clinical course, surgical findings and outcome in 34 patients with head trauma associated with SIEDH. RESULTS: Patients treated surgically had a lower Glasgow Coma Scale score than those treated conservatively (P = 0.005). The surgical group had statistically larger thickness and volume of the SIEDH than those in the conservative group (P < 0.0001 and P < 0.0001, respectively). Six patients experienced significant intraoperative blood loss, and copious bleeding from the injured TS was noted in 5 (83.3%) of these patients. Five (50%) of 10 patients undergoing simple craniotomy experienced significant blood loss. However, only 1 patient (11.1%) undergoing strip craniotomy experienced significant blood loss, but no intraoperative shock. All patients experiencing massive blood loss and intraoperative shock underwent simple craniotomy. There was no statistical difference in the outcome between the conservative and surgical groups. CONCLUSIONS: When operating on SIEDH, the possibility of vigorous bleeding from the injured TS and intraoperative massive bleeding should be kept in mind. Strip craniotomy that allows hitching the stripped dura to the bone strip overlying the TS may be a better method for the evacuation of SIEDH.

Predictive Factors for Delayed Surgical Intervention in Children With Epidural Hematomas.

BACKGROUND: Optimal treatment of children with traumatic intracranial epidural hematomas (EDHs) is unknown. We sought to identify clinical and radiographic predictors of delayed surgical intervention among children with EDH admitted for observation. METHODS: We retrospectively identified patients younger than 15 years with acute traumatic EDHs evaluated at our level 1 pediatric trauma center. We excluded patients with penetrating head injuries, recent surgical evacuation of EDH, or depressed skull fracture requiring surgical repair and assigned the remaining subjects to the immediate surgery group if they underwent immediate surgical evacuation, to the supportive-therapy-only group if they underwent observation only, and to the delayed surgery group if they underwent surgery after observation. We abstracted clinical and laboratory findings, surgical interventions, and neurological outcome and measured EDH dimensions and volumes, adjusting for cranial size. We compared clinical and radiographic characteristics among groups and performed receiver-operator characteristic analyses of predictors of delayed surgery. RESULTS: Of 172 patients with EDH, 103 patients met the inclusion criteria, with 6 (6%) in the immediate surgery group, 87 (84%) in the supportive-therapy-only group, and 10 (10%) in the delayed surgery group. Headache, prothrombin time of >14 seconds, EDH maximal thickness of ≥1.1 cm, volume of ≥14 mL, EDH thickness/cranial width index of ≥0.08 and EDH volume/cranial volume index of ≥0.18, and mass effect were associated with delayed surgical intervention. There was no difference in length of stay or functional impairment between the immediate and delayed surgery groups. However, patients in delayed surgery group were more likely to have subjective symptoms at discharge than those in immediate surgery group. CONCLUSIONS: Among patients with EDH admitted for observation, larger EDH, mass effect, headaches, and prothrombin time of >14 seconds were associated with delayed surgical intervention. A larger-scale study is warranted to identify independent predictors of delayed surgery in children under observation for EDH.

Traumatic acute convexity interdural hematoma: a case report and literature review.

INTRODUCTION: Interdural hematoma (IDH) is an extremely rare hemorrhage between the outer periosteal dura mater and the inner meningeal dura mater. There are 8 cases of convexity IDH reported previously but none of them were acute post traumatic one. We report the case of a patient with an initial diagnosis of acute epidural hematoma (EDH) that was eventually revealed to be an acute convexity IDH. CASE REPORT: A 57-year-old man presented to the emergency department with a complaint of falling from 2 meters. Imaging findings revealed an expanding intracranial hematoma with a linear skull fracture extending to sagittal suture, which was mistaken as an EDH. Emergent surgical evacuation was performed; the hematoma was lodged between two dural layers. DISCUSSION: This is the first case of acute convexity IDH following trauma that has been reported. In chronic and sub-acute hematomas MRI scans could be very useful, but in acute cases under emergent circumstances, CT scan cannot make a proper differentiation between an EDH and IDH. IDH should be considered during craniotomy when extradural findings do not explain the CT scan findings. This case showed a linear skull fracture expanding to the sagittal suture, and this can be a possible explanation for IDH formation. Surgical evacuation of the hematoma without inner nor outer layer resection and leaving the outer layer open, to connect the interdural space to epidural space was first described in this report.

Extradural hematoma from trauma to midline skull tumour.

We present a case of extradural hematoma resulting from a relatively minor closed injury over the vertex where a plasma cell tumour had invaded the superior sagittal sinus. The patient underwent an emergency craniotomy and evacuation of the hematoma. Hemostasis and prevention of recollection of the hematoma were hampered by the erosion of the sagittal sinus making its direct repair impossible. This was achieved by hitching up the dura lateral to the sinus to become its lateral wall reinforced by hemostatic agents. The patient made a full recovery. Malignant tumours invading the dural venous sinuses and eroding the skull can cause life-threatening intracranial bleeding after relatively minor trauma.

Isolated pediatric retroclival epidural hematoma following a minor blunt head trauma: a case report with review of the literature.

Post-traumatic clival hematomas are a rare entity and almost exclusive to the pediatric population. Those of retroclival location are exceptionally rare. This entity was first described in 1941 by Coleman and Thomson, and since then, less than 30 cases have been reported in the literature. Clinically, these hematomas are usually silent and slow, but clinical state worsening may be sudden and rapidly fatal by the onset of obstructive hydrocephalus in the absence of prompt treatment. Here, the authors report a new case of pediatric post traumatic retroclival epidural hematoma following a minor blunt head trauma in a 03-year-old male patient with good outcomes. The authors will proceed with a review of the literature regarding the pathophysiology and mechanisms of occurrence of such post-traumatic injury.

Vertex epidural hematoma: Diagnosis, therapeutic consideration and outcome.

OBJECTIVE: Vertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging. MATERIALS AND METHODS: A retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome. RESULTS: Patients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively (p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional "simple craniotomy". No patients undergoing "strip craniotomy" experienced massive bleeding. Thrombocytopenia (p = 0.008), headache (p = 0.015), consciousness disturbance (p = 0.043), pupil reactivity (p = 0.010), GCS score (p < 0.0001) and the relationship between skull fracture and the SSS (p = 0.037) were significant prognostic factors. CONCLUSION: Our study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.

Prognostic Factors and Outcome of Surgically Treated Supratentorial versus Infratentorial Epidural Hematoma in Pediatrics: A Comparative Study of 350 Patients at a Tertiary Center of a Developing Country.

PURPOSE: In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients. METHODS: This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score. RESULTS: Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups. CONCLUSIONS: Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.

Short-term outcome of treatment of elderly patients with epidural hematomas.

INTRODUCTION: There is substantial literature data dedicated to intracranial epidural hematomas affecting young and middle-aged individuals, but studies focusing on their characteristics in elderly patients are scarce, assuming that old age is a poor prognostic factor.

Mortality And Prognostic Factors In Patients Operated For Acute Epidural Hematoma.

Background: Epidural hematoma is one of the most common surgical emergencies encountered in neurosurgery. This study was conducted to determine the mortality and prognostic factors in patients operated for traumatic intracranial epidural hematoma in a resource-constrained setting from a developing country. Methods: This retrospective study was conducted in the Department of Neurosurgery at Ayub Teaching Hospital Abbottabad from 1st January 2019 to 31st Dec 2021. Inclusion and exclusion criteria were created. The medical record of 116 patients admitted and operated on for traumatic extradural hematoma was retrospectively reviewed. Information was recorded using a standardized structured questionnaire. The outcome was measured in terms of the Glasgow coma outcome score. Results: Out of 116 patients, 93 were male and 23 were female.19 (16.4%) patients were in the age range 0-5 years, 42 (36.2%) were in the age range 6-15, 35(31.0%) were in the age range 16-30, 11 (9.5%) were in the age range 31-45 years, 7 (6.0%) were in the age range 46-60 years while only one patient included in this study was above 60 years. Overall mortality was 4.3%. Mortality was higher in females and in those aged less than 5 years (3.4%). 4 out of 16 patients died with GCS less than 8, while none of the patients died when GCS was above 12. Mortality was significantly higher in the presence of associated lesions (4.4% vs. 0%) and anisocoria (2.6% vs.1.7%). Patients who operated within 6 hours of trauma resulted in better outcomes with a mortality rate of 0.0% and functional recovery of 57.8 % while for those who operated after 6 hours, mortality was significantly higher (4.3%) and functional recovery was significantly low (15.5%). Conclusion: Good surgical outcomes can be achieved with early operative intervention if indicated. Female gender, low preoperative GCS score, presence of pupillary dilatation, presence of associated lesions, delayed surgical intervention and age less than 5 years are significant predictors for poor outcomes.

[Craniotomy/ICP Sensor Insertion].

Traumatic injuries in infants tend to be concentrated in the head due to the large volume ratio of the head to the trunk, and the injury mechanisms change from passive(e.g., crashes and falls from a certain height due to caregiver negligence, or child abuse)to automatic(e.g., playground equipment and bicycle accidents, crashes and falls from heights)as the child grows and develops. Subsequently, as mobility increases, injuries from traffic accidents, sports-related trauma, and self-inflicted injuries increase. In addition, there are many cases that require urgent surgical treatment for forms of injury unique to the pediatric age, such as epidural hematoma, depressed fractures and penetrating traumatic brain injury. Since pediatric head injury is a broad category encompassing all of these changes, it is necessary to appropriately address the anatomical and physiological changes in the central nervous system, and detailed treatment that takes into account the individual background can lead to a better functional prognosis. This article describes craniotomies for head injury seen in pediatric age other than acute subdural hematoma(acute epidural hematoma, open depressed fracture, and penetrating traumatic brain injury)and also describes the technique of intracranial pressure sensor insertion, which is key to intensive care for intracranial hypertension.