Pediatr Radiol (2008) 38:316–318 DOI 10.1007/s00247-007-0652-5
CASE REPORT
Spontaneous extracranial decompression of epidural hematoma John C. Neely II & Blaise V. Jones & Kerry R. Crone
Received: 5 July 2007 / Revised: 20 August 2007 / Accepted: 4 September 2007 / Published online: 26 October 2007 # Springer-Verlag 2007
Abstract Epidural hematoma (EDH) is a common sequela of head trauma in children. An increasing number are managed nonsurgically, with close clinical and imaging observation. We report the case of a traumatic EDH that spontaneously decompressed into the subgaleal space, demonstrated on serial CT scans that showed resolution of the EDH and concurrent enlargement of the subgaleal hematoma.
ments, with subsequent redistribution into the lower pressure subgaleal space. We report a case of a traumatic EDH that decompressed into the subgaleal space within seven hours of initial presentation. We also review the literature and discuss the implications for management of EDH in the pediatric population.
Case report Keywords Epidural hematoma . Child . Spontaneous decompression . Subgaleal
Introduction Spontaneous decompression of an epidural hematoma (EDH) into the subgaleal space is a rare event. Although EDH has been traditionally attributed to bleeding from a branch of a meningeal artery, the source of hemorrhage in these cases may actually be the diploic space of the calvarium, resulting in initial bleeding into both compart-
J. C. Neely II (*) Marshall University School of Medicine, 2930 Auburn Rd., Building H, Apt. 12, Huntington, WV 25704, USA e-mail:
[email protected] B. V. Jones Department of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA K. R. Crone Division of Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
A 2½-year-old girl came to the emergency department after being struck on the left side of the head by a softball. She was observed to have a decreased level of activity since the injury, but there was no reported loss of consciousness or seizure activity. Physical examination revealed a boggy soft-tissue swelling over the left parietal bone and a Glasgow coma scale score of 15, without focal neurologic deficit. A CT scan performed without contrast approximately 3 h after injury (Fig. 1) showed a mildly depressed fracture of the left parietal bone with a moderate-size overlying subgaleal hematoma and an underlying EDH. The EDH measured approximately 5.5 cm in diameter, with a maximum depth of 1 cm, exerting a mild mass effect upon the adjacent parenchyma. The subgaleal hematoma measured approximately 1 cm in depth, with a diameter of 6.6 cm. A subcentimeter hemorrhagic contusion was identified in the left frontal lobe just anterior to the EDH. The child was admitted for observation. A repeat CT scan performed 7 h later (Fig. 2) showed essentially complete resolution of the EDH; the subgaleal hematoma diameter had increased to approximately 9.5 cm. Follow-up CT studies at 36 h and 30 days after the trauma showed no recurrence of the EDH and resolution of the parenchymal contusion. No neurologic signs or symptoms developed during the follow-up period.
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Fig. 1 Axial CT non-contrast images. a Image obtained 3 h after injury shows a left-side EDH (e) with mild mass effect on the underlying frontal lobe with a minimally displaced linear fracture (arrow). b More inferior image shows a moderatesize subgaleal hematoma (g)
Discussion Urgent surgical evacuation of EDH was long considered a neurosurgical dictum; however, the increased utilization of CT imaging has led to a large number of diagnoses of posttraumatic intracranial hemorrhage that might otherwise have gone undetected. Further, the ready availability of rapid CT scanning has simplified close imaging follow-up of these cases. In 1983, Pang et al. [1] reported their experience in nonsurgical management of EDH in children, suggesting that surgery can be avoided in those children with an improving clinical course and absence of associated intradural lesions or midline shift. Subsequent reports have confirmed the validity of nonoperative or “expectant” management of EDH in children [2, 3] and suggest that Fig. 2 Axial CT images at the same level as Fig. 1 performed 10 h after injury. a Image shows near-complete resolution of the EDH. b Image at the same level as Fig. 1b shows a significant increase in the size of the subgaleal hematoma. All images are at a slice thickness of 5 mm
strict imaging criteria such as hematoma size and amount of mass effect are less crucial in the decision-making process than close clinical observation for signs of deterioration. In this case, the lack of neurologic symptoms led to the initial decision to observe rather than operate; the subsequent resolution of the intracranial component of the hematoma reinforced that decision. Posttraumatic hematoma in the epidural space is classically attributed to bleeding from a torn meningeal artery branch. The high pressure of the arterial system is thought to be necessary to cause elevation of the dura, which is tightly adherent to the inner table of the skull. However, EDHs of nonarterial origin occur at a higher frequency in children than in adults [3]. Observations at surgery suggest that a frequent source of bleeding in the infant with a small
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EDH is the skull itself. The diploë or medullary cavity of the skull is a significant potential source of hemorrhage, and the skull of a child has a relatively large diploic space when compared to an adult. The adherence of the dura to the bone is weaker in young children also, allowing lower pressure collections to form in the epidural space [3]. Spontaneous decompression of EDH into the subgaleal space has been reported in six adults and four children [4– 8]. Reaccumulation of blood in the epidural space was not present in any of the reported patients. Malek et al. [4] suggest that the hemorrhage in these patients originates in the subgaleal space and initially passes into the epidural space via the fracture, reversing direction as the pressure in the subgaleal compartment decreases. However, no case of a subgaleal hematoma decompressing into the epidural space has been reported. Moreover, there is no reported evidence for significant changes in the pressure of the subgaleal space in the posttraumatic period. It is reasonable to postulate that bleeding from the diploë could extend into both the epidural and subgaleal spaces of a child with a skull fracture. The potential for further expansion and accommodation of volume is greater in the subgaleal space due to the looser adherence of the galea to the outer table. In addition, the epidural space is obliterated at the cranial sutures, a restriction that does not apply to the subgaleal space. As greater volume is achieved in the subgaleal space, the blood in the more restricted epidural space can move into it. Pulsatility of the intracranial contents would provide the necessary forces to drive the blood through the fracture, even if intracranial pressure is not elevated. This explanation does not require reversal of the direction of flow over time. In our institution, children with an EDH detected on CT scan who are neurologically stable without drowsiness, headache, or vomiting are admitted for observation. Those considered to be at higher risk because of the mechanism of injury or imaging findings are observed in an intensive care unit, with hourly neurologic evaluations. Repeat CT studies are performed 6–12 h after the initial CT examination. If the second CT examination is unchanged, a third CT study is
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performed 24 h later. If there is development of focal deficits or decreased sensorium, or if follow-up imaging demonstrates a significant increase in hematoma size, they are taken for surgical evacuation. If the hematoma is stable on consecutive studies and there is no clinical worsening, the patient is discharged and has follow-up evaluation by neurosurgery in 2 weeks. In summary, spontaneous decompression of an EDH into the subgaleal space is an uncommon favorable sequela of cranial trauma that may be identified with greater frequency due to the increased practice of expectant management of EDH. We postulate that bleeding from the diploic space of the calvarium initially extends into both the subgaleal and epidural compartments in these patients, with the blood preferentially decompressing into the subgaleal space as it increases in volume in the immediate posttraumatic period, aided by CSF pulsation.
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