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Epidural Hematoma Pediatric Emergency

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Epidural Hematoma Pediatric Emergency Epidural Hematoma Pediatric Emergency Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Disclosures • No financial issues. • I am not a pediatric neurosurgeon (I do emergency pediatric neurosurgery). Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's white (dense) on a cat scan? anterior • Hyperdense – whiter than brain • Isodense R - same as brain L • Hypodense - darker than brain Orientation posterior Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's white (dense) on a cat scan? • Calcium –bone Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's white (dense) on a cat scan? • Calcium –bone • Metal Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's white (dense) on a cat scan? • Calcium –bone • Metal –blood • Iron Hemoglobin • Contrast Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's black (hypodense) on a cat scan? • Air • Fat • CSF Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Symmetry Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Gray matter / White matter Differentiation Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Normal? Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Emergent Neurosurgical Intervention Intracranial Hypertension • Hemorrhage • Edema – Epidural – Trauma – Subdural – Infection • simple – Stroke • complex – Tumor – Intraparenchymal • Tumor • traumatic • Hydrocephalus • spontaneous Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's wrong with high ICP? Decreased Perfusion CPP = MABP - ICP Alan R. Turtz, MD Department. of Neurosurgery 1995 Cooper University Hospital GUIDELINES for the Management of Severe Head Injury The Brain Trauma Foundation The American Association of Neurological Surgeons The Joint Section on Neurotrauma and Critical Care 1 9 9 5 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Medical Management • Cerebral Perfusion Pressure • Cerebral Blood Volume • Cerebral Blood Flow • Cerebral Metabolism • Cerebral Temperature • Cerebral Dehydration • Cerebral Oxygenation Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital GUIDELINES for the Management of Severe Head Injury The Brain Trauma Foundation The American Association of Neurological Surgeons The Joint Section on Neurotrauma and Critical Care 1 9 9 5 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Guidelines for CPP • Standard - insufficient data • Guidelines - insufficient data Options (Level III) – cerebral perfusion pressure > 70 mm Hg (1995 – 2005)* *2007 Level III 50 – 70 mmHg *2016 Level II 60 – 70 mmHg Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Guidelines for Pediatric CPP 2012 • Level III – A minimum CPP of 40 mm Hg may be considered A CPP threshold 40 to 50 mm Hg may be considered. There may be age-specific thresholds with infants at the lower end and adolescents at the upper end of this range. Kochanek PM, Carney N, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents - second edition. Pediatr Crit Care Med. 2012 Jan; 13 (Suppl 1):S1-82 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Medical Management Strategy Optimize CPP CPP = MABP – ICP BLOOD BRAIN CSF Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Medical Management Strategy Optimize CPP CPP = MABP – ICP Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital What's wrong with high ICP? Decreased Perfusion Mechanical Pressure Alan R. Turtz, MD Department. of Neurosurgery masses in spaces Cooper University Hospital Pathologic Masses in Anatomic Spaces Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Pediatric Epidural Hematoma Mean age between 6 & 10 years Pathogenesis falls (49%) traffic accidents (34%) Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Epidural Hematoma LOC > 50% Cranial fractures present 70 – 95% Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al: Surgical management of acute epidural hematomas. Neurosurgery 58 (3 Suppl):S7–S15, Si–Siv, 2006 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Epidural Hematoma Netter A report of 102 pediatric patients: venous ~1/3, unidentified ~1/3 Mohanty A, Kolluri V et al. Prognosis of extradural haematomas in children Pediatr Neurosurg 23:57-63,1995 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Epidural Hematoma Alan R. Turtz, MD ? ER? Netter Department. of Neurosurgery Cooper University Hospital Why do we operate emergently? Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Reticular Activating System Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Why do we operate emergently? Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Anatomic Compartments superior posterior anterior Alan R. Turtz, MD Department. of Neurosurgery inferior Cooper University Hospital Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital anterior Alan R. Turtz, MD lucid / 3rd Department. of Neurosurgery posterior Cooper University Hospital anterior Alan R. Turtz, MD lucid / 3rd Department. of Neurosurgery posterior Cooper University Hospital Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Clinical Features Lucid Interval Unconscious – Awake – Unconscious Observed in ~ half of surgical EDH’s Coma prior to surgery (22 – 56%) No loss of consciousness (12 – 42%) Pupillary abnormalities (18 – 44%) Seizure (8%) Hemiparesis, decerebrate posturing No neurologic problem (3 – 27%) Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al: Surgical management of acute epidural hematomas. Neurosurgery 58 (3 Suppl):S7–S15, Si–Siv, 2006 Pediatric Outcome ~ 5% mortality Pre-op GCS best predictor across all age groups: GCS 3 – 5 36% mortality GCS 6 – 8 9% mortality Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al: Surgical management of acute epidural hematomas. Neurosurgery 58 (3 Suppl):S7–S15, Si–Siv, 2006 Eye Opening Response (4) Adults, children > 2 years SCORE Under 2 years Spontaneous 4 Spontaneous Opens to voice 3 Opens to voice Opens to pain 2 Opens to pain No eye opening 1 No eye opening Verbal Response (5) Adults, children > 2 years SCORE Under 2 years Oriented 5 Coos or babbles (normal activity) Disoriented 4 Irritable / continually cries Inappropriate responses 3 Cries to pain Incomprehensible sounds 2 Moans to pain No verbal response 1 No verbal response Motor Response (6) Adults, children > 2 years SCORE Under 2 years Follows commands 6 Moves spontaneously Localizes 5 Withdraws from touch Withdraws 4 Withdraws from pain Decorticate (flexion) 3 Decorticate Decerebrate (extension) 2 Decerebrate No motor response 1 No motor response Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital GUIDELINES for the Management Surgicalof SevereManagement Head Injury of The Brain Trauma Foundation TraumaticThe American Association Brain of Neurological Surgeons The Joint SectionInjury on Neurotrauma and Critical Care 2006 1 9 9 5 Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Surgical Management of Epidural Hematoma • Surgery > 30 cc regardless of GCS • Non-operative option < 30 cc < 15 mm thickness < 5 mm MLS GCS > 8 no focal deficit Mass Volume Measurement ABC method • Ve = 4/3 pi (A/2)(B/2)(C/2) = ABC/2 • Identify the CT slice with A the largest area of B hemorrhage (slice 1) • A: largest diameter (cm) • B: largest diameter 900 to A in slice 1 slice 1 Mass Volume Measurement ABC method C: count number of 10mm slices • compare each 0.5 0.5 1 slice with slice 1 • if clot > 75% count as 1 • if clot 25% - 75% count as 0.5 • if < 25% don’t slice 1 1 1 count the slice • add total C 1 1 0.5 Mass Volume Measurement ABC method C: count number of 10 mm slices • add total C • 0.5 + 0.5 + 1 + 1 +1 0.5 0.5 1 + 1 + 1 + 1 + 0.5 = 7.5 slice 1 1 1 1 1 0.5 Mass Volume Measurement ABC method A = 4.28 B = 1.76 C = 7.5 0.5 0.5 1 Ve = (4.28)(1.76)(7.5) 2 slice 1 1 1 28 cc 1 1 0.5 Trauma Epidural Hematoma Pedestrian hit by a car GCS E3-V3-M5 = 11 Combative Management Strategy Alan R. Turtz, MD Department. of Neurosurgery Cooper University Hospital Surgical Management of Epidural Hematoma • Surgery > 30 cc regardless of GCS • Non-operative option < 30 cc < 15 mm thickness < 5 mm MLS GCS > 8 no focal deficit intubated /sedated for control Epidural Hematoma Conservative Option 15 yo M fall off bicycle w/o helmet GCS 15 • Surgery > 30 cc regardless of GCS • Non-operative option < 30 cc < 15 mm thickness < 5 mm MLS GCS > 8 no focal deficit EDH Nonsurgical Management • 69 patients • GCS > 9 • 64 not in temporal region Bullock et al: Neurosurgery 16:602-606, 1985 Cuccinello et al: Acta Neurochir (Wien) 120:47-52, 1993 Trauma Epidural Hematoma 1/23/08 2/20/08 Surgical Management of Traumatic Posterior Fossa Mass Lesions • mass effect – 4th ventricle – basal cisterns – hydrocephalus or • neurologic dysfunction or • deterioration Assault with brick 95 minutes Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States • retrospective analysis • Nationwide Inpatient Sample from 2003 to 2010 • 5189 patients undergoing
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