Approach to neurosurgical management of children with acute intracranial epidural hematoma

CT: computed tomography; EDH: epidural hematoma; GCS: Glasgow coma scale; ICH: intracranial hypertension.

* Signs of ICH include one or more of the following: severe headache, persistent vomiting, irritability (infants), or Cushing triad (bradycardia or tachycardia, respiratory disturbance, and elevated blood pressure).

¶ Signs of brain herniation include: pupillary abnormalities (unequal, sluggishly responding, or fixed and dilated), focal neurologic findings, or decorticate or decerebrate posturing.

Δ The "swirl sign" refers to dark swirls within an EDH on CT that indicate rapid arterial bleeding.

◊ Children who have small posterior fossa epidural hematomas and minimal to no mass effect may also receive nonoperative management with close inpatient observation and serial neuroimaging as for small supratentorial epidural hematomas. However, evidence is lacking to provide specific CT findings that are associated with successful observation.

§ Patients with EDH thickness >10 mm or computed EDH volume ≥15 mL can successfully undergo nonoperative management but are more likely to have enlargement of the EDH and clinical deterioration during observation. For such patients, the decision to perform surgery versus nonoperative management is made on a case-by-case basis and according to the values and preferences of the child's parents/primary caregivers.