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Child's Nervous System

, Volume 35, Issue 11, pp 2195–2203 | Cite as

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

  • D. Clay Samples
  • Michael T. BounajemEmail author
  • David J. Wallace
  • Lillian Liao
  • Izabela Tarasiewicz
Original Article

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.

Keywords

TBI Follow-up imaging EDH 

Notes

Compliance with ethical standards

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

References

  1. 1.
    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 CrossRefPubMedGoogle Scholar
  2. 2.
    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 CrossRefPubMedGoogle Scholar
  3. 3.
    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 CrossRefGoogle Scholar
  4. 4.
    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 CrossRefPubMedGoogle Scholar
  5. 5.
    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 CrossRefPubMedGoogle Scholar
  6. 6.
    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 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    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 CrossRefPubMedGoogle Scholar
  8. 8.
    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 CrossRefPubMedGoogle Scholar
  9. 9.
    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 CrossRefPubMedGoogle Scholar
  10. 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 CrossRefPubMedGoogle Scholar
  11. 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 CrossRefPubMedGoogle Scholar
  12. 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 CrossRefGoogle Scholar
  13. 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 CrossRefPubMedGoogle Scholar
  14. 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 CrossRefPubMedGoogle Scholar
  15. 15.
    Flannery AM (2009) Cautions in the conservative management of epidural hematomas. Pediatr Neurosurg; Basel 45(3):185CrossRefGoogle Scholar
  16. 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 CrossRefPubMedGoogle Scholar
  17. 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 CrossRefPubMedGoogle Scholar
  18. 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 CrossRefGoogle Scholar
  19. 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 CrossRefPubMedGoogle Scholar
  20. 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 CrossRefPubMedGoogle Scholar
  21. 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 CrossRefPubMedGoogle Scholar
  22. 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 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 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 237-238CrossRefGoogle Scholar
  24. 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 CrossRefGoogle Scholar
  25. 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 CrossRefPubMedGoogle Scholar
  26. 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. 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 CrossRefGoogle Scholar
  28. 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 CrossRefPubMedGoogle Scholar
  29. 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):840–844CrossRefGoogle Scholar
  30. 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 CrossRefGoogle Scholar
  31. 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 CrossRefPubMedGoogle Scholar
  32. 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 CrossRefPubMedGoogle Scholar
  33. 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 CrossRefPubMedGoogle Scholar
  34. 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 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of NeurosurgeryUniversity of Texas Health - San AntonioSan AntonioUSA
  2. 2.Long School of MedicineUniversity of Texas Health - San AntonioSan AntonioUSA
  3. 3.Division of Trauma and Emergency Surgery, Department of SurgeryUniversity of Texas Health - San AntonioSan AntonioUSA

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