Utility of Clinical and Radiographic Findings in the Management of Traumatic Epidural Hematoma

Abstract

Background: There are currently no clear guidelines for the management and radiological monitoring of pediatric patients with epidural hematomas (EDH). We aim to compare clinical and radiographic characteristics of pediatric EDH patients managed with observation alone versus surgical evacuation and to describe results of repeat head imaging in both groups. Methods: We performed a retrospective observational study of pediatric patients diagnosed with traumatic EDH at a level II trauma center. Results: Forty-seven cases of EDH were analyzed. Sixty-two percent were managed by observation alone. Patients undergoing surgery were more likely to have an altered mental status (17 vs. 72%, p < 0.001), but there were no other significant clinical differences between the groups. The mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group, respectively (p < 0.001 for both comparisons). Eighty-six percent of the observed and all surgery patients underwent repeat CT imaging. The initial repeat CT scan results led to surgery in 1 patient who was initially treated with observation. Conclusions: Most pediatric patients with EDH can be managed with observation. Mental status and radiographic findings should guide the need for surgical intervention. Multiple repeat CT scans have minimal utility in changing management.

Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma

“…Eighty-four percent of subjects underwent ≥1 repeat CT scan, which was consistent with the findings of authors of previous pediatric studies, who frequently report reimaging rates of >50%. 3,5,7,8,10,17 With our analysis, we did not identify a time frame for peak epidural size. Authors of a previous pediatric series of 11 EDH subjects noted a bimodal distribution in the time to the largest recorded EDH size, with some achieving maximal EDH size in the first several days after injury and others with the peak size occurring 5 to 16 days postinjury.…”

“…The EDH volume was calculated by using the formula for an ellipsoid. 9,10 The reviewers were blinded to the CT scan effect on care management.…”

“…Although authors of previous studies discussed that a meaningful CT scan is infrequent in an otherwise well-appearing patient, we did not find any studies in which the authors provided the data to calculate the rate of meaningful CT scans to compare with our study. 6,7,10,18,27,28 It is important to note that our study, as well as 2 previous studies of pediatric EDH, contained subjects with a change to operative management based solely on worsening CT findings. 10,28 The authors of neither of these previous studies describe if the repeated scans were obtained on the basis of routine practice standards or if the initial CT scan revealed concerning findings that prompted follow-up imaging.…”

“…3, 5, 6, 9 -16 Wide variation in the timing and frequency of reimaging and its impact on case management has been reported. 6,10,17,18 A current lack of strong evidence prevents the creation of guideline recommendations in pediatric TBIs regarding specific indications for reimaging. 19 It is likely that with this paucity of data, children are exposed to excess repeat CT scans with radiation exposure, which increases long-term cancer risk and medical costs without adding value.…”

Conservative Management of Large Traumatic Supratentorial Epidural Hematoma in the Pediatric Population

“…In the pediatric literature, Bejjani et al [15] demonstrated that thickness of EDH of more than 18 mm and a midline shift greater than 4 mm were predictive for surgical therapy. Flaherty et al [16] found in their retrospective study that operated EDHs had a mean thickness of 15.5 mm and suggest that EDH size should influence the decision for surgical intervention. The indication for surgery in these studies likely relates in part to a different patient population, in which the EDHs were symptomatic.…”