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 surgery for EDH • incidence highest in the second decade (33.4%) • median length of stay was about 4 days • inhospital mortality 3.5% • complication rate 2.9%
Bir S, Maiti T, Ambekar A, Nanda A.:Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States. Clin Neurol Neurosurg, Vol 138, Nov. 2015, 99-103
Star Trek The Voyage Home
Endovascular management of acute epidural hematomas: clinical experience with 80 cases Peres CM, Caldas JC, Puglia P, et al. Hospital University of São Paulo School of Medicine, São Paulo, Brazil
Mostly temporal location Active contrast leaking Middle meningeal artery - 57.5% Arteriovenous fistulas between the MMA and diploic veins - 10% MMA pseudoaneurysms - 13.6% Embolizations performed under local anesthesia - 80%
J Neurosurg April 14, 2017 Results: - No increase in size of the EDH - Clinical evolution uneventful - No change in Glasgow Coma Scale score - No need for surgical evacuation Any questions? Cooper Trauma
Sunday 3:36 AM
Three family members involved in MVC
Arrived in Trauma Admitting at the same time. Cooper Trauma
Sunday, November 22nd 3:36 AM “We have an 11 month old female in Trauma Admitting with an acute epidural hematoma. Get in the car". Cooper Trauma
24 year old Father deep coma with external signs of severe head trauma and unreactive pupils. Initial neurologic assessment suggested he was unsalvageable.
19 year old Mother 32 weeks pregnant, traumatic subarachnoid hemorrhage - in active labor Cooper Trauma / Family of Four / 4 AM 3 OR’s running simultaneously
EDH SDH tSAH 11 month old Daughter 24 year old Father 19 year old Mother 32 week old neonate Emergency cesarean section by Chief of High Risk Obstetrics. Neonate handed off to Neonatal ICU team in the OR.
Cooper Trauma