Surgical options for treatment of traumatic subdural hematomas in children younger than 2 years of age

Clinical article

View More View Less
  • 1 Department of Pediatric Neurosurgery and
  • 3 Pediatric Neurosurgical Intensive Care Unit, Hôpital Universitaire Necker–Enfants Malades, Assistance Publique Hôpitaux de Paris, and Université Paris Descartes, Paris, France; and
  • 2 Pediatric Neurosurgical Unit, Hospital Pediátrico Martagão Gesteira Liga Alvaro Bahia Contra a Mortalidade Infantil, Salvador da Bahia, Brazil
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Subdural hematoma (SDH) is the most common finding on cranial CT in pediatric victims of abusive head trauma (AHT). The hematomas are commonly bilateral and sometimes associated with interhemispheric hyperdensity and/or convexity hemorrhages. There is no consensus regarding the best surgical treatment in such cases nor are there standardized surgical protocols. The authors report their experience and discuss the routine surgical options in the management of traumatic SDH at a Level 1 Pediatric Trauma Center.

Methods

In this paper, the authors describe a cross-sectional study with consecutive revision of data described in the medical records of Hôpital Universitaire Necker–Enfants Malades between January 2008 and January 2013. During this period, all children younger than 2 years of age who were admitted with a traumatic SDH identified on CT scans were included in this study.

Results

One hundred eighty-four children who had SDH and were younger than 2 years of age were included. Their median age was 5.8 months (range 5 days–23 months), and 70% of the children were male. On admission CT scans, the SDH was bilateral in 52% of cases and homogeneously hypodense in 77%. Neurosurgical treatment was undertaken in 111 children (60%) with an admission Glasgow Coma Scale score of 12 or less, bulging fontanels, or other signs suggestive of intracranial hypertension. The first surgical option was craniotomy in 1.8% (2) of these 111 cases, decompressive craniectomy in 1.8% (2), transcutaneous subdural puncture in 15% (17), external subdural drainage in 16% (18), subdural-subgaleal shunt placement in 17% (19), and subdural-peritoneal shunt placement in 48% (53). In 82% of the children initially treated with transcutaneous subdural puncture and in 50% of those treated with external subdural drainage, increase or persistence of the SDH, CSF or skin infection, or shunt system malfunction was observed and further surgical intervention was required. There was a 26% rate of complications in patients initially treated with a subdural-peritoneal shunt. Although 52% of the patients had bilateral SDH, bilateral drainage was only required in 9.4%.

Conclusions

The choice of treatment should be determined by the clinical and radiological characteristics of the individual case. Although effective on an emergency basis, subdural puncture and external subdural drainage are frequently insufficient to obtain complete resolution of SDH, and temporary placement of a subdural-peritoneal shunt is needed in most cases.

Abbreviations used in this paper:AHT = abusive head trauma; GCS = Glasgow Coma Scale; ICH = intracranial hypertension; SDH = subdural hematoma; TCD = transcranial Doppler.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: José Roberto Tude Melo, M.D., Ph.D., Rua Jose Duarte 114 CEP 40.000, Pediatric Neurosurgical Unit/2nd Fl., Salvador da Bahia, Brazil. email: robertotude@gmail.com.

Please include this information when citing this paper: published online February 21, 2014; DOI: 10.3171/2014.1.PEDS13393.

  • 1

    Adamsbaum C, , Grabar S, , Mejean N, & Rey-Salmon C: Abusive head trauma: judicial admissions highlight violent and repetitive shaking. Pediatrics 126:546555, 2010

    • Search Google Scholar
    • Export Citation
  • 2

    Bourgeois M, , Di Rocco F, , Garnett M, , Charron B, , Boddaert N, & Soufflet C, : Epilepsy associated with shaken baby syndrome. Childs Nerv Syst 24:169173, 2008

    • Search Google Scholar
    • Export Citation
  • 3

    Bradford R, , Choudhary AK, & Dias MS: Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. Clinical article. J Neurosurg Pediatr 12:110119, 2013

    • Search Google Scholar
    • Export Citation
  • 4

    Case ME: Abusive head injuries in infants and young children. Leg Med (Tokyo) 9:8387, 2007

  • 5

    Case ME, , Graham MA, , Handy TC, , Jentzen JM, & Monteleone JA: Position paper on fatal abusive head injuries in infants and young children. Am J Forensic Med Pathol 22:112122, 2001

    • Search Google Scholar
    • Export Citation
  • 6

    Csókay A, , Emelifeonwu JA, , Fügedi L, , Valálik I, & Láng J: The importance of very early decompressive craniectomy as a prevention to avoid the sudden increase of intracranial pressure in children with severe traumatic brain swelling (retrospective case series). Childs Nerv Syst 28:441444, 2012

    • Search Google Scholar
    • Export Citation
  • 7

    Ewing-Cobbs L, , Prasad M, , Kramer L, , Louis PT, , Baumgartner J, & Fletcher JM, : Acute neuroradiologic findings in young children with inflicted or noninflicted traumatic brain injury. Childs Nerv Syst 16:2534, 2000

    • Search Google Scholar
    • Export Citation
  • 8

    Fanconi M, & Lips U: Shaken baby syndrome in Switzerland: results of a prospective follow-up study, 2002–2007. Eur J Pediatr 169:10231028, 2010

    • Search Google Scholar
    • Export Citation
  • 9

    Feldman KW, , Bethel R, , Shugerman RP, , Grossman DC, , Grady MS, & Ellenbogen RG: The cause of infant and toddler subdural hemorrhage: a prospective study. Pediatrics 108:636646, 2001

    • Search Google Scholar
    • Export Citation
  • 10

    Gabaeff SC: Challenging the pathophysiologic connection between subdural hematoma, retinal hemorrhage and shaken baby syndrome. West J Emerg Med 12:144158, 2011

    • Search Google Scholar
    • Export Citation
  • 11

    Galarza M, , Gazzeri R, , Barceló C, , Mantese B, , Arráez C, & Alfieri A, : Accidental head trauma during care activities in the first year of life: a neurosurgical comparative study. Childs Nerv Syst 29:973978, 2013

    • Search Google Scholar
    • Export Citation
  • 12

    Gerber P, & Coffman K: Nonaccidental head trauma in infants. Childs Nerv Syst 23:499507, 2007

  • 13

    Ghahreman A, , Bhasin V, , Chaseling R, , Andrews B, & Lang EW: Nonaccidental head injuries in children: a Sydney experience. J Neurosurg 103:3 Suppl 213218, 2005

    • Search Google Scholar
    • Export Citation
  • 14

    Jacobi G, , Dettmeyer R, , Banaschak S, , Brosig B, & Herrmann B: Child abuse and neglect: diagnosis and management. Dtsch Arztebl Int 107:231239, 2010

    • Search Google Scholar
    • Export Citation
  • 15

    Josan VA, & Sgouros S: Early decompressive craniectomy may be effective in the treatment of refractory intracranial hypertension after traumatic brain injury. Childs Nerv Syst 22:12681274, 2006

    • Search Google Scholar
    • Export Citation
  • 16

    Kesler H, , Dias MS, , Shaffer M, , Rottmund C, , Cappos K, & Thomas NJ: Demographics of abusive head trauma in the Commonwealth of Pennsylvania. J Neurosurg Pediatr 1:351356, 2008

    • Search Google Scholar
    • Export Citation
  • 17

    Kurschel S, , Puget S, , Bourgeois M, , Zerah M, , Ofner P, & Renier D: Factors influencing the complication rate of subduroperitoneal shunt placement for the treatment of subdural hematomas in infants. J Neurosurg 106:3 Suppl 172178, 2007

    • Search Google Scholar
    • Export Citation
  • 18

    Larionov SN, , Sorokovikov VA, & Novozilov VA: Management of acute subdural hematomas in infants: intrathecal infusion streptokinase for clot lysis combined with subdural to subgaleal shunt. Childs Nerv Syst 24:437442, 2008

    • Search Google Scholar
    • Export Citation
  • 19

    Matschke J, , Herrmann B, , Sperhake J, , Körber F, , Bajanowski T, & Glatzel M: Shaken baby syndrome: a common variant of nonaccidental head injury in infants. Dtsch Arztebl Int 106:211217, 2009

    • Search Google Scholar
    • Export Citation
  • 20

    Meyer PG, , Ducrocq S, , Rackelbom T, , Orliaguet G, , Renier D, & Carli P: Surgical evacuation of acute subdural hematoma improves cerebral hemodynamics in children: a transcranial Doppler evaluation. Childs Nerv Syst 21:133137, 2005

    • Search Google Scholar
    • Export Citation
  • 21

    Paiva WS, , Soares MS, , Amorim RL, , de Andrade AF, , Matushita H, & Teixeira MJ: Traumatic brain injury and shaken baby syndrome. Acta Med Port 24:805808, 2011

    • Search Google Scholar
    • Export Citation
  • 22

    Reece RM, & Sege R: Childhood head injuries: accidental or inflicted?. Arch Pediatr Adolesc Med 154:1115, 2000

  • 23

    Scavarda D, , Gabaudan C, , Ughetto F, , Lamy F, , Imada V, & Lena G, : Initial predictive factors of outcome in severe non-accidental head trauma in children. Childs Nerv Syst 26:15551561, 2010

    • Search Google Scholar
    • Export Citation
  • 24

    Sieswerda-Hoogendoorn T, , Boos S, , Spivack B, , Bilo RAC, & van Rijn RR: Educational paper: Abusive head trauma Part I. Clinical aspects. Eur J Pediatr 171:415423, 2012

    • Search Google Scholar
    • Export Citation
  • 25

    Sun DTF, , Zhu XL, & Poon WS: Non-accidental subdural haemorrhage in Hong Kong: incidence, clinical features, management and outcome. Childs Nerv Syst 22:593598, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Trenchs V, , Curcoy AI, , Morales M, , Serra A, , Navarro R, & Pou J: Retinal haemorrhages in- head trauma resulting from falls: differential diagnosis with non-accidental trauma in patients younger than 2 years of age. Childs Nerv Syst 24:815820, 2008

    • Search Google Scholar
    • Export Citation
  • 27

    Tude Melo JR, , Di Rocco F, , Blanot S, , Oliveira-Filho J, , Roujeau T, & Sainte-Rose C, : Mortality in children with severe head trauma: predictive factors and proposal for a new predictive scale. Neurosurgery 67:15421547, 2010

    • Search Google Scholar
    • Export Citation
  • 28

    Tude Melo JR, , Di Rocco F, , Lemos-Júnior LP, , Roujeau T, , Thélot B, & Sainte-Rose C, : Defenestration in children younger than 6 years old: mortality predictors in severe head trauma. Childs Nerv Syst 25:10771083, 2009

    • Search Google Scholar
    • Export Citation
  • 29

    Vinchon M, , de Foort-Dhellemmes S, , Desurmont M, & Delestret I: Confessed abuse versus witnessed accidents in infants: comparison of clinical, radiological, and ophthalmological data in corroborated cases. Childs Nerv Syst 26:637645, 2010

    • Search Google Scholar
    • Export Citation
  • 30

    Vinchon M, , Desurmont M, , Soto-Ares G, & De Foort-Dhellemmes S: Natural history of traumatic meningeal bleeding in infants: semiquantitative analysis of serial CT scans in corroborated cases. Childs Nerv Syst 26:755762, 2010

    • Search Google Scholar
    • Export Citation
  • 31

    Vinchon M, , Noulé N, , Soto-Ares G, & Dhellemmes P: Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases. J Neurosurg 95:249255, 2001

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 636 426 51
Full Text Views 407 38 1
PDF Downloads 383 27 0
EPUB Downloads 0 0 0