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Implementation of a Clinical Pathway for the Treatment of Chronic Subdural Hematoma of Infancy
Hunter S Futch1, Katherine Chandler1, Jennifer Wheelus2
1Departments of Neurosurgery, Emory University, Atlanta , Georgia , USA.
Insights
This study developed a clinical pathway for infant chronic subdural hematoma, prioritizing less invasive treatments like anterior fontanelle taps over shunts.
Area of Science:
- Pediatric Neurosurgery
- Clinical Pathway Development
- Infant Health
Background:
- Limited evidence-based guidelines exist for managing chronic subdural hematoma in infants.
- A consensus-based clinical pathway was created by pediatric neurosurgeons.
- The principle was to use the least invasive treatment possible.
Purpose of the Study:
- To establish a stepwise clinical pathway for managing chronic subdural hematoma in infants.
- To reduce the need for invasive procedures like shunt insertion.
Main Methods:
- A literature search and consensus building generated the pathway.
- Infants with chronic/mixed-density subdural hematoma and specific symptoms were enrolled.
- Treatment followed a stepwise approach: anterior fontanelle taps, burr hole drainage, then shunt insertion if needed.
Main Results:
- 16 infants were enrolled; 11 completed the study.
- 6 infants were successfully treated with anterior fontanelle taps.
- 4 infants required burr hole drainage, and 1 needed a subdural shunt.
Conclusions:
- The developed stepwise pathway effectively managed chronic subdural hematoma in infants.
- This approach resulted in a lower rate of shunt insertion compared to existing literature.
Background And Objectives:
There is a paucity of evidence-based recommendations to manage chronic subdural hematoma in infancy. A consensus-based clinical pathway was developed among 6 board-certified pediatric neurosurgeons under the principle of treating the children with the least invasive method possible.
Methods:
Between April and June 2019, a clinical pathway was generated based on literature search and consensus building. Children with chronic or mixed-density subdural hematoma were enrolled if he/she presented with 2 or more of the following: bulging anterior fontanelle (AF), head circumference above the 95th percentile, progression of the subdural hematomas on imaging, or presence of symptoms from elevated intracranial pressure. The patients were treated based on the following stepwise pathway: AF taps, escalated to burr hole drainage with drain placement, if necessary, then subdural to peritoneal shunt insertion if both previously mentioned interventions failed. The protocol was initiated in July 2019. Each patient would have at least 6 months of follow-up, including head circumference measurements and head imaging completed after intervention.
Results:
A total of 16 patients were enrolled in the clinical pathway, and 11 completed the study. Of the remaining 11 patients, 6 were successfully treated with single or repeated AF taps, 4 patients by burr hole drainage with placement of a subdural drain, and 1 patient eventually required subdural shunt insertion.
Conclusion:
Use of our stepwise treatment pathway led to a decreased rate of shunt insertion compared with that reported in the literature.
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