Acute Epidural Hemorrhage (EDH) in Children Following Trauma
1. Cause and Etiology
Cause:
Acute epidural hemorrhage in children is most commonly caused by head trauma, typically due to falls, motor
vehicle accidents, sports injuries, or non-accidental trauma (e.g., child
abuse). In children, minor falls (e.g., from a short height or stairs) can
still cause EDH because of anatomical vulnerabilities.
Etiology:
- The
most frequent vascular source
is injury to the middle meningeal
artery (MMA), which runs between the dura mater and the inner
table of the skull.
- Skull
fractures, especially temporal bone
fractures, are commonly associated with EDH.
- Less
commonly, EDH may arise from venous bleeding (e.g., diploic or dural sinus
injury), particularly in infants or very young children.
2. Pathophysiology
- The
epidural space is a
potential space between the inner table
of the skull and the dura
mater.
- In
trauma, the MMA or adjacent vessels may tear, leading to the accumulation of
blood in the epidural space.
- The
tight adhesion of the dura
to the skull in certain regions (especially at sutures) restricts blood
spread, producing a biconvex or
lentiform shape on imaging.
- As
the hematoma expands, it increases intracranial
pressure (ICP), which may cause brain compression, herniation, and death if not
promptly treated.
- In
children, because the cranial
sutures are more elastic, the hematoma may not expand as rapidly,
but the risk of delayed deterioration still exists.
3. Epidemiology
- EDH
accounts for approximately 1–4% of
all traumatic brain injuries (TBIs) in children.
- It
is more common in school-aged
children and adolescents, but can occur in infants and toddlers.
- Males are more frequently
affected than females due to higher rates of trauma.
- In
children under 2 years old, EDH is less
common but has a higher
morbidity and mortality due to late recognition and atypical
presentation.
4. Clinical Presentation
Clinical signs of EDH
vary with age and hematoma size but often include:
- History of head trauma
(e.g., fall, impact)
- Lucid interval: transient loss of
consciousness followed by a brief period of normalcy and then neurological
deterioration (seen in ~20% of EDH cases)
- Symptoms:
- Persistent
or worsening headache
- Vomiting
- Irritability or lethargy
in young children
- Seizures
(may be focal or generalized)
- Loss of consciousness
or coma in severe cases
- Signs:
- Focal
neurological deficits (e.g., hemiparesis)
- Ipsilateral pupillary dilation
due to uncal herniation
- Signs
of increased ICP (e.g., bulging fontanelle in infants)
5. Imaging Features
Modality of
choice: Non-contrast CT scan of the head
Characteristic
findings on CT:
- Biconvex (lentiform), hyperdense (bright)
collection between skull and dura
- Typically
localized and does not
cross sutural margins (due to tight dural attachment)
- May
show associated skull fracture,
often overlying the hematoma
- Mass effect: midline shift, ventricular
compression
- Herniation signs in severe cases (e.g.,
effacement of basal cisterns)
MRI:
May be used in subacute/chronic phases, but is less practical for acute EDH
diagnosis.
6. Treatment
Treatment depends on
the hematoma size, patient condition,
and neurological status:
A. Conservative management (select cases):
- Small
hematoma (<10–15 mm thick, <5 mm midline shift)
- GCS
≥ 14, neurologically stable
- No
signs of raised ICP or herniation
- Close
monitoring in the ICU with serial neuro exams and repeat imaging
B. Surgical evacuation:
- Indications:
- Hematoma
thickness >15 mm
- Midline
shift >5 mm
- Decreased
GCS or neurological deterioration
- Signs
of herniation (e.g., anisocoria, coma)
- Procedure:
- Craniotomy or burr hole evacuation
- Simultaneous
repair of skull fractures and bleeding vessels if needed
Adjunctive care:
- ICP
monitoring
- Antiepileptic
therapy if seizures are present
- Supportive
care: oxygen, fluids, mannitol, hypertonic saline for raised ICP
7. Prognosis
- Overall good prognosis
with early recognition and intervention
- Mortality
rate in children is <10%
with timely surgery
- Factors
associated with poor prognosis:
- Delayed
diagnosis
- Coma
on presentation (GCS ≤ 8)
- Bilateral
fixed pupils
- Large
hematoma with herniation
- Most
children recover with minimal
neurological deficits if treated before significant secondary
injury occurs
Summary Table
|
Aspect |
Key Points |
|
Cause |
Head trauma with
skull fracture, MMA tear |
|
Etiology |
Most commonly, middle
meningeal artery injury |
|
Pathophysiology |
Bleeding between
skull and dura → biconvex hematoma, ↑ ICP |
|
Epidemiology |
1–4% of pediatric
TBI, more in males |
|
Clinical Signs |
Headache, vomiting,
lucid interval, seizures, focal deficits |
|
Imaging |
CT: Biconvex
hyperdensity, no crossing sutures |
|
Treatment |
Observation vs.
surgical evacuation (based on size/neurology) |
|
Prognosis |
Excellent with early
diagnosis; poor if herniation or coma |
=====================================
Case Study: A 3-Year-Old Boy with Vomiting After a Fall
Epidural Hematoma
History and Imaging
-
A 3-year-old boy presented to the emergency department after falling backward down a flight of stairs at home, sustaining blunt trauma to the right frontal region.
-
He had no significant past medical history. Although there was a brief episode of loss of consciousness, he was fully alert upon arrival at the hospital.
-
He complained of a headache and experienced two episodes of vomiting.
-
There were no focal neurological deficits noted on examination.
-
An emergency CT scan of the brain was performed.
 |
|
Quiz
1. What is the typical shape of an epidural hematoma (EDH) on brain CT?
A. Crescent-shaped
B. Biconvex or lentiform
C. Circular
D. Flat and laminar
Explanation: An epidural hematoma typically appears as a biconvex (lentiform) hyperdense lesion on CT, located between the inner table of the skull and the dura mater. The rigid attachment of the dura at the suture lines limits the spread of blood, resulting in its characteristic shape. This feature distinguishes it from subdural hematomas, which are crescent-shaped.
2. Which vessel is most commonly injured in an epidural hematoma?
A. Dural venous sinus
B. Subependymal vein
C. Middle meningeal artery
D. Cortical vein
Explanation: The majority of epidural hematomas result from trauma that causes a skull fracture, leading to laceration of the middle meningeal artery. The arterial bleeding is often rapid and can create a mass effect, frequently requiring emergent surgical evacuation.
3. What is the clinical term for the pattern in EDH where the patient's consciousness initially improves and then deteriorates?
A. Lucid interval
B. Vegetative interval
C. Vasovagal response
D. Decerebrate posturing
Explanation: A classic feature of epidural hematoma is the "lucid interval," where the patient briefly regains full consciousness after initial trauma, only to deteriorate later as intracranial pressure increases. This pattern is a key clinical clue and underscores the need for early recognition and intervention.
Findings and Diagnosis
Findings:
-
A hyperdense, biconvex-shaped lesion consistent with an epidural hematoma is noted in the right frontal region.
-
Midline structures are preserved, though the size of the hematoma raises concern for potential mass effect.
Diagnosis:
-
Epidural Hematoma (EDH) – Acute epidural hemorrhage following pediatric head trauma.
Differential Diagnosis
-
Subdural Hematoma (SDH)
-
Shape: Crescent-shaped
-
Location: Between the brain surface and the dura mater
-
Etiology: Typically due to venous injury
-
-
Intracerebral Hemorrhage (ICH)
-
Shape: Irregular hyperdensity within the brain parenchyma
-
Etiology: Severe trauma or vascular malformation
-
-
Subarachnoid Hemorrhage (SAH)
-
Imaging: Hyperdensity in cortical sulci and ventricles
-
Etiology: Trauma or ruptured aneurysm
-
-
Traumatic Brain Edema
-
Imaging: Localized hypodensity with ventricular compression
-
Etiology: Direct parenchymal injury and cytotoxic swelling
-
Discussion
Epidural Hematoma (EDH)
Epidural hematoma is a critical condition, especially in pediatric patients following traumatic brain injury. In children, the skull is thinner and more pliable, and the middle meningeal artery is relatively more exposed, making it more susceptible to injury even with seemingly minor trauma.
In this case, a fall down the stairs—a common domestic incident—resulted in a hematoma with potentially life-threatening neurological implications. One of the hallmark clinical features of EDH is the lucid interval, during which a child may regain consciousness temporarily before neurological deterioration sets in due to increasing intracranial pressure.
Imaging revealed a clearly defined hyperdense, biconvex lesion, consistent with EDH. Given the clinical history and associated vomiting, an emergent diagnosis was made. The need for neurosurgical intervention depends on the size of the hematoma, the patient’s neurological status, and whether signs of herniation are present.
Treatment options range from conservative observation and serial imaging in stable cases to emergent surgical evacuation (e.g., craniotomy or burr hole drainage) in cases of deterioration or large hematoma burden. Early diagnosis and management are key to preventing long-term neurological sequelae.
References
(Please include appropriate references as per your institution’s guidelines. Below are suggested sources.)
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Lee KS. "Epidural Hematoma: A Review of 81 Cases." Korean Journal of Neurotrauma. 2012; 8(2): 79–84. https://kjnt.org/pdf/10.13004/kjnt.2012.8.2.79
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Osborn AG. Osborn's Brain: Imaging, Pathology, and Anatomy. Elsevier Health Sciences; 2017.
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Barkovich AJ. Pediatric Neuroimaging. 5th ed. Lippincott Williams & Wilkins; 2012.
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American College of Radiology. ACR Appropriateness Criteria®: Head Trauma.
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Gentry LR. "Imaging of Head Trauma." Radiology. 1994; 191(1): 1–17.
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