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[Epidural hematoma in the child]
Insights
Extradural hematomas in children can present with varied symptoms, including anemia and bradycardia. Prompt surgical intervention is crucial for extradural hematoma (EDH) in pediatric patients, especially with signs of brainstem compression.
Area of Science:
- Pediatric Neurosurgery
- Emergency Medicine
Background:
- Extradural hematomas (EDH) are a significant concern in pediatric head injuries.
- Understanding diverse clinical presentations is vital for timely diagnosis and treatment.
Observation:
- Clinical data from 13 pediatric patients (12 operated, 1 conservative) with EDH were analyzed.
- Varied initial signs included anemia, bradycardia, stupor, and altered respiration, sometimes without pupillary dilation or focal neurological deficits.
- Delayed deterioration after a lucid interval, signs of brainstem compression (fixed dilated pupil, decerebrate posture), and missed skull fractures on initial imaging were noted.
Findings:
- Four cases of classical EDH required surgery, with missed skull fractures in three.
- Two patients developed delayed EDH, and one presented with posterior fossa EDH.
- Emergency burr holes were performed in a comatose child with signs of brainstem compression.
- One small EDH resolved with conservative management.
Implications:
- CT scans, while standard, can delay critical intervention in EDH with brainstem compression.
- Early recognition of subtle signs and prompt surgical management are key to improving outcomes in pediatric EDH.
- Missed or delayed diagnosis of skull fractures associated with EDH can lead to severe neurological compromise.
Abstract:
The different modes of presentation of extradural haematomas in children are discussed, based on the clinical data of 13 patients (12 operated and one conservatively treated). In a 12-month-old infant, anaemia and bradycardia were the first signs of the haematoma, whereas stupor and apnoeic respiration pattern were seen in a 5-year-old boy. Both children had neither pupillary dilatation nor focal neurological signs. Four children were operated on a classical extradural haematoma. In 3 cases the skull fracture was missed in the peripheral referring hospital. A secondary deterioration of the level of consciousness after a free interval was discovered late in one patient, who had already a unilaterally fixed and dilated pupil and developed a decerebrate posture. In this child with a radiologically proven skull fracture on the side of the pupillary dilatation, who became comatose after a lucid interval, we performed emergency burr holes in casualty. Although CT-scan is the method of choice for the diagnosis of intracranial haematomas, it would be a dangerous loss of time to submit patients with the typical features of an extradural haematoma who present with signs of brainstem compression to this examination. 2 EDH developed under a depressed skull fracture. In a haemophiliac child, a radiologically not detected skull fracture was discovered during surgery. In two patients who were again deteriorating after 4 and 12 days a second CT scan showed a delayed extradural haematoma. Another patient was referred on the 7th day with a posterior fossa EDH. A small epidural bleeding resolved spontaneously under conservative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)