This is a review of a case of an infant admitted to pediatric ICU as a case of epidural hematoma after traumatic brain injury. A brief summary of the most important aspects. Part of the residency teaching program for pediatric residents at the pediatric and neonatology department at Istishari Arab Hospital, Ramallah, Palestine.

1. Epidural, Subdural &
Subarachnoid Hemorrhage: A
Case Review
Hasan Arafat, MD
Rose Najeeb, MD, MRCPCH, DCH
Department of Pediatrics & Neonatology, Istishari Arab Hospital

2. Presentation
A 5-month-old boy from Tulkarm presents to ER due to recurrent
vomiting. The patient fell from the side of bed 3 hours prior to
presentation. The parents reported that the height of the bed
measured approximately 40 cm. Following the fall, the patient returned
to his normal level of activity, did not vomit nor exhibit any abnormal
movement. 2 hours later, the patient condition deteriorated,
developing multiple episodes of vomiting, projectile in nature,
prompting the family to seek medical advice at ER. The patient has a
free past medical, past surgical history, not on any drugs prior to the
event.

3. Presentation
The patient was carried to the ER by his parents, vital signs included
weight of 9, heart rate of 78 beats/min, respiration of 32 breaths/min
and labored, oxygen saturation of 94% on room air, and a temperature
of 37.2 °C. Blood pressure was 140/110. The patient looked sick,
typically developed, tired, not alert but responsive to painful stimuli.
Head, eyes, ears, nose, throat, cardiac and pulmonary exam were
undocumented. Limbs had a full range of passive motion.

4. Presentation
• The patient was suspected to have intracranial trauma as suggested
by history, urgent CT-scan was obtained, results were as follows:

6. • Brain CT-scan showed a massive epidural hematoma with midline
shifting. The neurosurgery team was contacted and the patient was
rushed to OR were he underwent evacuation of hematoma. The
patient underwent a new brain CT-scan post-op to evaluate the
results, findings were as follows:

8. • The patient underwent another evacuation of the hematoma,
another CT-scan was done 6 hours later, results were as follows:

10. • The patient was observed in ICU, underwent another CT scan 12
hours later, results were as follows:

12. • Due to the patient complicated course, he was transferred to our
PICU for continual management.
• From here on, CT-scans showed relatively similar results, the patient
was managed expectantly from there on

13. Space-Occupying Bleeds: Epidural Hematoma
• A collection of blood in a potential space between the skull and dura
mater
• Tend to be the result of arterial bleeds associated with skull fractures
• Classic example: middle meningeal artery tear in context of a
temporal or parietal skull fracture
• Due to its arterial nature: a very high risk of rapid mass effect and
herniation
• Good Lord! Epidural bleeds in peds tend to be much more forgiving in
comparison to adults, reasons are not completely understood

14. Space-Occupying Bleeds: Subdural Hematoma
• A collection of blood between the dura mater and the arachnoid
mater.
• Origin: bridging veins that traverse the space
• Frequent in context of abuse
• Rapid shearing injuries: motor vehicle accidents

15. Space-Occupying Bleeds: Subarachnoid
Hematoma
• A collection of blood in the arachnoid space surrounding the brain
• In contrast to the previous types of bleeds: the arachnoid space is a
normal anatomical space (not a potential space)
• Extremely common in the context of traumatic brain injuries (TBI)
• Frequent cause of seizures

18. Evaluation of a Child with Traumatic Brain
Injury
• Depends largely on initial assessment
• Decreased level of consciousness: evaluate for symptoms of
herniation
• Know your ABC’s

19. Evaluation of a Child with Traumatic Brain
Injury
• History essential, but not detailed:
• Mechanism of trauma
• Seizure
• Altered level of consciousness
• Neck pain: cervical spine injury precautions
• GCS <9/mental status is fluctuating: secure airways
• Imaging modality of choice: computed tomography (CT)

20. Brain CT
• Essential for rapid diagnosis of intracranial bleeding
• Indications:
• Anisocoria
• GCS <12
• Posttraumatic seizures
• Amnesia
• Progressive headache
• Unreliable history or exam
• LOC >5 minutes
• Signs of basilar skull fracture
• Repeated vomiting/vomiting for
>8 hours following injury
• Instability after multiple trauam

21. Brain CT
• Signs of increased intracranial pressure on brain CT:
• Midline shift
• Gyral effacement
• Compression of the lateral ventricle on the side of the hematoma
• Compression of the basilar cisterns
• Focal or generalized loss of gray-white differentiation indicating cerebral
edema
• Uncal, subfalcine, or transtentorial herniation

22. Management of Space-Occupying Bleeds
• A detailed discussion is beyond our scope, every case needs to be
discussed by a multidisciplinary team of pediatricians, neurologists
and neurological surgeons.
• Patients are at a very high risk for elevated intracranial pressure
• We won’t go through the details of clinical findings in each type of
cerebral herniation
• These patients need urgent management in an ICU setting

23. A Word on Prophylactic Antiepileptics
• Risk of posttraumatic seizures in the pediatric patient is
approximately 10%
• Phenytoin & fosphenytoin are the most commonly used medications
• Levetiracetam is an excellent alternative
• Advantages of levetiracetam:
• Intravenous formulation
• No significant protein-bound fraction, no need to monitor its blood level
• No liver metabolism
• Few significant drug interactions

24. A Word on Prophylactic Antiepileptics
• Classification:
• Immediate seizure, <24 hr
• Early seizure, <7 days
• Late seizure, >7 days
• Indications for prophylaxis:
• Clinical/EEG evidence of post-traumatic seizure
• Duration of prophylaxis:
• 7 days
• Antiepileptic prophylaxis does not prevent late post-traumatic seizures

25. Special Considerations: Abusive Head Trauma
• The leading cause of head injury in infants
• Peak age: 2-3 months, rare after 2 years
• Mortality rate: 20%
• 2/3: severe and permanent intellectual and physical impairments

26. Abusive Head Trauma: Presentation
• Infant/toddler with a decreased level of consciousness/seizure
• Conflicting/vague history
• Disconnection between the apparent severity of the injury and the
described mechanism
• Look for inappropriate affect

27. Abusive Head Trauma: Evaluation
• Urgent CT
• Victims frequently have a combination of subdural hemorrhage in
addition to other types of nerve injuries (diffuse injury of axons)
• Skull fractures may be observed, but their absence does not rule out
AHT
• If AHT is suspected, obtain a skeletal survey to look for evidence of
new or old bone fractures and a dilated funduscopic exam to look for
retinal hemorrhage

28. Summary
• Traumatic brain injuries are a leading cause of death and disability in
children
• Decision to obtain a CT scan should be based on the mechanism of
injury and signs and symptoms of the patient
• Children with moderate or severe traumatic brain injury are at high
risk for elevated intracranial pressure, especially if they present with
altered consciousness
• Abusive head trauma is the leading cause of head injury in infants

29. References
• Pediatric Head Trauma: A Review and Update, American Academy of
Pediatrics
• Nelson Textbook of Pediatrics, 21st edition
• Medscape