Extradural Ossification Following Epidural Hematoma in Children

Abstract

There has been a profound increase in the number of patients undergoing head computed tomography after minor injuries and the identification of epidural hematomas has risen concurrently. Although emergent craniotomy and evacuation has been the conventional standard for management, some epidural hematomas can be managed nonoperatively in carefully selected patients. Because of the difficulty in clinically monitoring epidural hematoma absorption and resolution because of the attributed risks of imaging radiation exposure in pediatric patients, the exact incidence of epidural hematoma ossification is unknown. Integrating epidural hematoma calcification into management algorithms is not clearly defined in the literature. The authors report a case of a 2-year-old girl with a calcified epidural hematoma requiring surgical treatment. With the incidence of epidural hematomas rising, providers should be aware of the rare but consequential incidence of epidural hematoma ossification. After literature review and discussion of the pathophysiology, the authors present an algorithmic approach to account for this rare entity. For conservative management of asymptomatic epidural hematomas, providers should consider follow-up magnetic resonance imaging to evaluate resolution in 2 to 3 months. If the magnetic resonance imaging indicates a failure to resolve, a computed tomography scan should then be performed to evaluate ossification and possible need for surgical intervention.

Calcified Epidural Hematoma after Conservative Treatment of Acute Epidural Hematoma in the Pediatric Population: A Systematic Review

“…In combination, these two factors might play a fundamental role in slow EDH growth and minor symptoms as 60% of children and 85% of infants with EDHs show no signs of deterioration at the time of injury and are frequently diagnosed with a chronic form. Conservative management of EDH in asymptomatic children relies on the abovementioned pathophysiological mechanisms [13, 21].…”

“…The exact mechanism of EDH calcification, and the timing thereof, is still a matter of debate [13, 22-39]. Ergodan et al [27] reported early signs of calcification around an EDH 10 days after the trauma, suggesting a role for the acute inflammatory response in EDH calcification [13].…”

“…There has been a progressive increase in the number of EDH diagnoses in asymptomatic patients after minor trauma because of extensive use of CT [6][7][8][9]. When symptomatic, an emergent craniotomy and evacuation of the EDH are routinely performed, while asymptomatic patients are treated conservatively with serial clinical and radiological follow-up using CT or MRI [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”

“…The exact mechanism of EDH calcification, and the timing thereof, is still a matter of debate [13,[22][23][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39]. Ergodan et al [27] reported early signs of calcification around an EDH 10 days after the trauma, suggesting a role for the acute inflammatory response in EDH calcification [13]. The inner layer of the EDH, which is strong-ly connected to the dural surface, might represent the origin of active ossification [13]; Greenwald et al [38] in 2000 demonstrated the fundamental capacity of the immature dura to induce and regulate calvarial ossification.…”

A different aspect of the unexpected death of Mozart at the age of 35 years

“…All these symptoms were noted during Mozart's last illness. Calcification of CSH is found in 0.3-2.7% of CSH cases and generally found in children and young adults, 18 as was likely seen in Mozart at the age of 35.…”