Aim: The aim of this study was to assess the surgical outcome and prognostic importance of clinical and radiological data from children operated on under emergency conditions due to an extra-axial hematoma causing brain herniation. Methods: This retrospective study included 25 children operated on due to herniated traumatic extra-axial hematomas from January 2000 to December 2010. Results: Of those 25 children, 17 (68%) were diagnosed with subdural hematoma (SDH), 7 (28%) with epidural hematoma (EDH) and only 1 patient (4%) suffered from both SDH and EDH. Overall mortality from a herniated extra-axial hematoma was 44%. The mortality rate for herniated SDH patients was 52.9%, and only 1 patient died from a herniated EDH (14.2%). Low Glasgow coma scale scores at admission, high postoperative intracranial pressure (ICP) values, longer intervals from trauma to surgery, longer durations of brain herniation, the presence of intraoperative brain swelling, larger and thicker hematomas and more displacement of the midline structures and obliteration of the basal cisterns were all correlated with mortality and an unfavorable outcome. Conclusions: Brain herniation is a serious consequence of traumatic extra-axial hematomas in children, and approximately one third of these patients have the potential for a favorable outcome. We recommend postoperative ICP monitoring to predict outcome and early decompressive surgery when possible for promising results.

1.
Parslow RC, Morris KP, Tasker RC, Forsyth RJ, Hawley CA: Epidemiology of traumatic brain injury in children receiving intensive care in the UK. Arch Dis Child 2005;90:1182-1187.
2.
Tehli O, Kazanci B, Türkoğlu E, Solmaz I: Subdural hematomas and emergency management in infancy and childhood: a single institution's experience. Pediatr Emerg Care 2011;27:834-836.
3.
Jayawant S, Parr J: Outcome following subdural haemorrhages in infancy. Arch Dis Child 2007;92:343-347.
4.
Paiva WS, Andrade AF, Mathias Júnior L, Guirado VM, Amorim RL, Magrini NN, Teixeira MJ: Management of supratentorial epidural hematoma in children: report on 49 patients. Arq Neuropsiquiatr 2010;68:888-892.
5.
Petersen OF, Espersen JO: Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology 1984;26:363-367.
6.
Jennett B, Bond M: Assessment of outcome after severe brain damage. Lancet 1975;i:480-484.
7.
Servadei F: Prognostic factors in severely head injured adult patients with acute subdural haematoma's. Acta Neurochir (Wien) 1997;139:279-285.
8.
Servadei F: Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien) 1997;139:273-278.
9.
Skoglund TS, Nellgård B: Long-time outcome after transient transtentorial herniation in patients with traumatic brain injury. Acta Anaesthesiol Scand 2005;49:337-340.
10.
Qureshi AI, Geocadin RG, Suarez JI, Ulatowski JA: Long-term outcome after medical reversal of transtentorial herniation in patients with supratentorial mass lesions. Crit Care Med 2000;28:1556-1564.
11.
Brendler SJ, Selverstone B: Recovery from decerebration. Brain 1970;93:381-392.
12.
Zervas NT, Hedley-Whyte J: Successful treatment of cerebral herniation in five patients. N Engl J Med 1972;286:1075-1077.
13.
Verderber L, Maciunas R, Morris J: Rapid management of intracranial hypertension to reverse transtentorial herniation. J Tenn Med Assoc 1990;83:119-123.
14.
Andrews BT, Pitts LH: Functional recovery after traumatic transtentorial herniation. Neurosurgery 1991;29:227-231.
15.
Nussbaum ES, Wolf AL, Sebring L, Mirvis S: Complete temporal lobectomy for surgical resuscitation of patients with transtentorial herniation secondary to unilateral hemispheric swelling. Neurosurgery 1991;29:62-66.
16.
Ben Abraham R, Lahat E, Sheinman G, Feldman Z, Barzilai A, Harel R, Barzilay Z, Paret G: Metabolic and clinical markers of prognosis in the era of CT imaging in children with acute epidural hematomas. Pediatr Neurosurg 2000;33:70-75.
17.
Levin HS, Aldrich EF, Saydjari C, Eisenberg HM, Foulkes MA, Bellefleur M, Luerssen TG, Jane JA, Marmarou A, Marshall LF, et al: Severe head injury in children: experience of the Traumatic Coma Data Bank. Neurosurgery 1992;31:435-443.
18.
Luerssen TG, Klauber MR: Outcome from pediatric head injury: on the nature of prospective and retrospective studies. Pediatr Neurosurg 1995;23:34-40.
19.
Pasaoglu A, Orhon C, Koc K, Selcuklu A, Akdemir H, Uzunoglu H: Traumatic extradural haematomas in pediatric age group. Acta Neurochir (Wien) 1990;106:136-139.
20.
Ersahin Y, Mutluer S, Guzelbag E: Extradural hematoma: analysis of 146 cases. Childs Nerv Syst 1993;9:96-99.
21.
Joshua SP, Agrawal D, Sharma BS, Mahapatra AK: Papilloedema as a non-invasive marker for raised intra-cranial pressure following decompressive craniectomy for severe head injury. Clin Neurol Neurosurg 2011;113:635-638.
22.
Yatsushige H, Takasato Y, Masaoka H, Hayakawa T, Otani N, Yoshino Y, Sumiyoshi K, Sugawara T, Miyawaki H, Aoyagi C, Takeuchi S, Suzuki G: Prognosis for severe traumatic brain injury patients treated with bilateral decompressive craniectomy. Acta Neurochir Suppl 2010;106:265-270.
23.
Williams RF, Magnotti LJ, Croce MA, Hargraves BB, Fischer PE, Schroeppel TJ, Zarzaur BL, Muhlbauer M, Timmons SD, Fabian TC: Impact of decompressive craniectomy on functional outcome after severe traumatic brain injury. J Trauma 2009;66:1570-1574.
24.
American Association for the Surgery of Trauma; Child Neurology Society; International Society for Pediatric Neurosurgery; International Trauma Anesthesia and Critical Care Society; Society of Critical Care Medicine; World Federation of Pediatric Intensive and Critical Care Societies; National Center for Medical Rehabilitation Research; National Institute of Child Health and Human Development; National Institute of Neurological Disorders and Stroke; Synthes USA; International Brain Injury Association: Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. J Trauma 2003;54:S235-S310.
25.
Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DW: Guidelines for the management of severe traumatic brain injury. VI. Indications for intracranial pressure monitoring. J Neurotrauma 2007;24:S37-S44.
26.
Lobato RD, Rivas JJ, Cordobes F, Alted E, Perez C, Sarabia R, Cabrera A, Diez I, Gomez P, Lamas E: Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma. J Neurosurg 1988;68:48-57.
27.
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE: Surgical management of acute epidural hematomas. Neurosurgery 2006;58:S7-S15.
28.
Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE: Surgical management of acute subdural hematomas. Neurosurgery 2006;58:S16-S24.
29.
Karasu A, Civelek E, Aras Y, Sabanci PA, Cansever T, Yanar H, Sağlam G, Imer M, Hepgül KT, Taviloğlu K, Canbolat A: Analyses of clinical prognostic factors in operated traumatic acute subdural hematomas. Ulus Travma Acil Cerrahi Derg 2010;16:233-236.
30.
Tian HL, Chen SW, Xu T, Hu J, Rong BY, Wang G, Gao WW, Chen H: Risk factors related to hospital mortality in patients with isolated traumatic acute subdural haematoma: analysis of 308 patients undergone surgery. Chin Med J (Engl) 2008;121:1080-1084.
31.
Cohen JE, Montero A, Israel ZH: Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma 1996;41:120-122.
32.
Haselsberger K, Pucher R, Auer LM: Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988;90:111-116.
33.
Nelson JA: Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma. Acad Emerg Med 2011;18:78-85.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.