Surgical Outcome of EDH in Children: Our Observation in DMCH

Background: Epidural hematoma (EDH) is accumulation of blood between the inner table of the skull and thedural membrane due to trauma and predominantly consists of venous blood in case ofchildren.Children with extradural hematoma (EDH) present differently than adults and outcome would also be different. Methods and Materials : This is a prospective interventional study done in the Department of Neurosurgery, Dhaka Medical College and Hospital (DMCH) in between period of January 2016 to December 2019. Children of both sex below 12 years of age with EDH were included after fulfilling inclusion and exclusion criteria. Follow up period was 1 month after surgery. Results: Among 90 patients, 73.3% were male and 26.7% were female. Age 5 - 12 years is most commonly affected among all age groups, attributing to 58.9%, fall from height was the most common cause (58.9%) followed by road traffic accident (32.2%), fall of heavy object over head (7.8%) etc. The most common symptom was vomiting which was present in 85.6% of patients followed by altered consciousness in 72.2%, headache in 60% and scalp swelling in 25.6% of patients. The follow-up of our patients was 1 month after surgery. Most of our patients made good recovery. Among them 73 patients (81.1%) were neurologically intact (GOS 5), 10 (11.1%) patients had some deficit but could do their daily activity independently (GOS 4), 03 patients (3.3%) was dependant on other for daily activity with cognitive deficit (GOS 3) and 4 patients (4.4%) died. Conclusion: EDH in children can be managed by surgery with good outcomes. Even in the presence of poor initial clinical and radiologic conditions, timely intervention can lead to a good recovery.


Introduction
Extra Dural Hematoma (EDH) is a unique type of neurotrauma which is potentially lethal, yet easily remediable if diagnosed early and treated timely 1 . Epidural hematomas (EDH) account for about 2-3% of all head injuries in children and represent 1-6% of all diagnoses in paediatric patients hospitalized after traumatic brain injury 2 . the impact response of the infant head depends not only on its unique geometry, but also on the age-dependent mechanical properties of the skull and sutures. The paediatric skull differs markedly from the adult skull in geometry, structure and material properties 3 . The skull of a neonate is a loose aggregate of thin plates of pliable bone connected by sutures. The compliant structure is capable of substantial deformation during childbirth, as well as during traumatic impact loading. At birth, the cranial bones are thin, flexible, and contain no diploe. As the child grows, the cranial bone differentiates into inner and outer layers of compact bone that enclose a middle layer of cancellous bone. As cranial sutures develop during infancy, cranial adjustment to the expanding brain takes place by bone deposition at the sutural margins. Mature sutures are highly interdigitated and capable of absorbing energy during impact loading 4 .
It is recognized that EDH in children differs from EDH in adults in that the hematoma may follow a trivial injury, the symptoms are different, the course is more insidious, associated skull fracture is infrequent, and prognosis is better 5 . The Brain Trauma Foundation (BTF) has produced informative guidance on the management of EDH. The criteria laid out for conservative management consists of patients who are non-comatose, lack of focal neurological deficit, have EDH volumes of less than 30 ml, thickness of less than 15mm and an associated midline shift of less than 5 mm. The BTF recommends that all patients with an EDH volume of greater than 30 cc should undergo surgical evacuation regardless of Glasgow Coma Scale (GCS) 6.7 .It is strongly recommended that patients with an acute EDH and GCS<9 and anisocoria undergo surgical evacuation as soon as possible 1 .
Considering the cause of EDH in Children; Fall is the most common.Road Traffic Accidents Caused more commonly in older age groups. Age 5yr to 12yr is most commonly affected among children 8 . The fracture in the skull was more common in children Less than two years of age than older butfracture did not affect the outcome. Children aged less than 5 years had a better outcome than older age group. Low GCS at admission did not always accurately predict the outcome for EDH in children. Patients with less than 20 ml usually not require surgery unless there is anisocoria or gross neuro deficit, cases with volume 20-30 ml required surgery based on assessment on serial neuro evaluation and cases more than 30ml required surgery. Patients with Posterior Fossa EDH more than 15 ml required surgery 9 .

Methods and Materials
This current study was a prospective interventional study carried out in between the period of January 2016 to December 2019. Children (up to 12 years) with extradural hematoma attending in the Department of Neurosurgery, Dhaka Medical College and Hospital, Dhaka. Diagnosed case of traumatic EDH(with or without skull fracture) underwent surgical intervention, aged up to 12 years of both sex were included in this study. Patients above 12-yearold age, EDH with diffuse axonal injury, subdural hematoma or brain contusion or polytrauma (Major Chest/ Blunt abdominal trauma/ major trauma to limb and pelvis) were excluded from this study. Clinicoradiological findings at admission with preoperative GCS, pre and post-operative CT findings, time interval to surgery since trauma are vital parameters. Patients were followed-up for a total of 1 month post-operatively. Follow-up of the patients were done on indoor basis up to discharge and on OPD at 1 month. During follow up the patients were assessed using the post-operative GCS, check CT on first postoperative day. Postoperative data of Day 1, 3 and discharging date were recorded. Outcome was measured by using Glasgow Outcome Scale (GOS) during discharge and after 1 month.

Ethical clearance: Ethical clearance was taken from Ethical Review Committee of Dhaka Medical
College. Table I shows 90 patients were included in this study; they were divided into 3 groups. Age range was 0 to12 year. It was observed that, majority 53(58.9%) patients were 5-12 years of age followed by 28(31.1%) in 2-5 years, 09(10.0%) in below 2 years of age group. This table also shows sex distribution of the study patients. In the study, male predominance was observed. Majority 66(71.1%) patients were male and 24 (28.9%) patients were female. Male-female ratio was 2.8:1.

Discussion
Extradural hematoma (EDH) in children is a potentially life-threatening com plication resulting from head injuries. These intracrani al lesions in children represent 2 to 3% of all head injury complications 4 . Though EDH in children is an acute neurosurgical emergency and potentially life-threatening condition, it can be managed with excellent outcomes as a consequence of access to modern imaging modalities to neurosurgical and ICU treatment 10 . The prognosis of patients with EDH depends upon a number of factors. The Glasgow Coma Scale at presentation is the most important factor which determines the prognosis 11 . The present study was carried out to identify the factors associated post-operative clinical improvement of children with extradural hematoma.
In our series, the age of the patients ranged from 0 year to 12 years. Our analysis has identified that EDH is more frequent among children of 5-12 years 53(58.9%). These data are correlated with other reported series of EDH in children 8 .
There were 66(73.3%) males and 24 (26.7%) female patients; the ratio between them was 2.8:1. It is similar to other reported series of EDH in children [12][13][14] . It was reflecting the natural tendency of males to expose to outside world.
In our study, fall from height were the predominant mode of injury 53 (58.9%) followed by road traffic accidents 29 (32.2%), fall of heavy object over head 7(7.8%) and assault in 1(1.1%) cases. Similar results have been reported by other authors 18-20 but other study found that 64% patients with EDH had been involved RTA and other causes had occurred less frequently 12,16 .
In this study, we observed that most of the patients had multiple clinical presentation. Vomiting 77(85.6%) as the commonest presenting feature followed by  27,28 .
In this series, the parietal region 29 (32.2%) was the commonest site for hematoma followed by frontal region 21(23.3%). Other study also revealed similar result of hematoma location 14,15 .
Skull fractures are relatively uncommon in childhood.
In younger children skull bones are relatively elastic and differences in the elastic coefficient between the dura and bone cause dural detachment during impact. This lead to formation of EDH without a fracture. In the present series 34.5% of children with EDH has skull fracture in compared to adult 29 .
Majority patients 55(61.1%) underwent surgery within 12-24 hours to trauma followed by 11(12.2%) within 12 hours and 24(26.7%) more than 24 hours after trauma. Timing of surgery has a clear influence on clinical deterioration 30 .
The outcome of children is distinctly better when compared to their adult counterpart with similar GCS score at surgery 29 . In the present series favorable outcome is 92.2% and unfavorable outcome is 7.8%. Themortality is 4(4.4%) in our study.Narasimhan et al. also found good outcome in 97% cases and mortality in 3% cases 16 .

Conclusion
EDH in children can be managed by surgery with good outcomes. Even in the presence of poor initial clinical (low GCS, poor neurological status) and radiologic conditions (large hematoma volume, midline shift) timely intervention can lead to a good recovery because of the elasticity of brain, pliability of the skull of the children and opening of the fontanelle in case of children below 2 years.

Source of fund:
Not funded by any institute or any group.