Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas
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.
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.
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.
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.
KeywordsTBI Follow-up imaging EDH
Compliance with ethical standards
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
- 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
- 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
- 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
- 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.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
- 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
- 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
- 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.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