Original Paper
Pediatr Neurosurg 2019;54:237–244
DOI: 10.1159/000501043
Traumatic Pediatric Extradural
Hematoma: An Institutional Study
of 228 Patients in Tertiary Care Center
Mohd Faheem a Manish Jaiswal b Bal Krishna Ojha b Anil Chandra b
Sunil Kumar Singh b Chhitij Srivastava b
a Department of Neurosurgery, Uttar Pradesh University of Medical Sciences, Etawah, India;
b Department
of Neurosurgery, King George’s Medical University, Lucknow, India
Keywords
Extradural hematoma · Head Injury · Traumatic brain injury ·
Pediatric head injury
Abstract
Background: Extradural hematoma (EDH) is one of the most
common causes of mortality and morbidity after traumatic
brain injury in pediatric patients. Early surgical intervention
in these patients produces excellent results. Objective: We
reviewed surgical experience at our center, examining and
presenting symptomatology and outcome analysis. Materi-
als and Methods: A retrospective study of 228 pediatric pa-
tients of EDH from July 2007 to August 2017 was performed.
Patients were evaluated in terms of demographic profile,
clinical features, pupillary size and reaction, computed to-
mography findings, operative measures, and several other
parameters. Neurological status was assessed using motor
component (M) of Glasgow Coma Scale score. Best motor
response was considered as a criterion to classify severity of
traumatic brain injury and for the assessment of outcome.
Results: Most of the patients were in the age group of 13–
© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/pne
Received: March 18, 2019
Accepted: May 19, 2019
Published online: July 9, 2019
18 years (n = 122, 53.5%). Majority of them were male (n =
182, 79.8%). The commonest mode of injury was fall from
height (n = 116, 50.9%) followed by road traffic accident (n =
92, 40.4%). Most common site of hematoma was frontal re-
gion (n = 66, 28.9%) followed by parietal region (n = 54,
23.7%). The volume of hematoma was between 30 and
50 mL in majority of the patients (n = 186, 81.6%), and most
of the patients had a motor responses of M5 (n = 88, 38.6%)
and M6 (n = 108, 47.4%). The association between hemato-
ma site and volume was not significant (χ2 = 5.910, p = 0.749),
whereas statistically significant association was noted be-
tween volume of hematoma and motor response (χ2 =
93.468, p ≤ 0.001), volume and age (χ2 = 7.380, p ≤ 0.05), and
volume to time between trauma and surgery (χ2 = 8.469, p ≤
0.05). Maximum mortality was in patients of low motor (M1–
M3) response and who were operated 24 h after injury. Con-
clusion: Mortality in patients of EDH can be significantly re-
duced with gratifying results if operated early. Best motor
response at presentation, pupillary abnormalities, time be-
tween injury to surgery, and location of hematoma have
been identified as the important factors determining out-
come in patients of EDH. © 2019 S. Karger AG, Basel
East Carolina University - Laupus Library
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Dr. Manish Jaiswal
Department of Neurosurgery
King George’s Medical University
Chowk, Lucknow 226003, Uttar Pradesh (India)
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E-Mail manishjaiswal @ kgmcindia.edu
 Introduction Table 1. Age specific distribution of injury

Extradural hematoma (EDH), an accumulation of Age group, years n (%)

blood between the inner table of skull and periosteal 13–18 122 (53.5
dura, is one of the most rewarding surgery if performed 7–12 60 (26.3)
timely and meticulously. In India, 40% of over 1,250 mil- <6 46 (20.2)
lion people belong to pediatric age group and around 25– Total 228 (100.0)
27% of all head injury victims are children [1, 2]. The
incidence of EDH in pediatric age group ranges between
2 and 3% [3]. There is not much literature available re-
Table 2. Mode of injury and motor response
garding pediatric EDH from the Indian subcontinent.
Being a tertiary care center, we used to cater an extreme- Mode of n (%) Motor response (M)
ly large number of patients with traumatic brain injury. injury
Therefore, this retrospective study, which is one of the M1–M2 M3–M4 M5–M6
largest comprising 228 patients, was planned. We re- FFH 116 (50.9) 7 11 98
viewed our 10-year surgical experience including clinico- RTA 92 (40.4) 6 3 83
radiological profile and analyzed the outcome on the ba- Assault 20 (8.8) 1 4 15
sis of best motor response (M) at the time of presentation Total 228 (100) 14 18 196
to the hospital.
FFH, fall from height; RTA, road traffic accident.

Materials and Methods

This retrospective study was conducted from July 2007 to Results

­ ugust 2017 at department of Neurosurgery, King George’s Med-
A
ical University and Uttar Pradesh University of Medical Sciences,
Uttar Pradesh, India. A total of 503 pediatric patients (up to 18
years of age) were enrolled for study, but only 228 patients were
operated and included in the study.
Inclusion Criteria
• EDH volume >30 mL.
• EDH thickness >15 mm.
• Midline shift >5 mm in any motor response.
• Symptomatic posterior fossa EDH.
Exclusion Criteria
• Patients managed conservatively
• Associated other intraparenchymal lesions (contusion, subdu-
ral hematoma, intra-parenchymal hematoma, and diffuse axo-
nal injury).
We have excluded the patients with other coexistent intrapa-
renchymal lesion so as to have the outcome specifically related to
isolated EDH. The clinical record of these 228 patients were ana-
lyzed for demographic profile, mode of injury, location of hema-
toma, pupil size and reaction, best motor response (M) at the time
of admission and discharge, and mortality. Best motor response
(M) was considered as a criteria to classify the severity and out-
come of pediatric EDH.
Statistical Analysis
An analysis of data was performed using SPSS version 16. Cat-
egorical data were analyzed by Chi-square test (χ2), whereas con-
tinuous variables were evaluated by Student t test. A p value of
<0.05 was considered as statistically significant.
Age and Sex
The age group that was found to be the most vulner-
able to injury was of 13–18 year (n = 122, 53.5%) followed
by 7–12 year (n = 60, 26.3%) and <7 year (20.2%; Table
1). There were 182 males (79.8%) and 46 females (20.2%),
with a male-to-female ratio of 3.96:1.
Mode of Injury
The commonest mode of injury was fall from a height
(n = 116, 50.9%), followed by road traffic accident (RTA;
n = 92, 40.4%) and lastly due to an assault (n = 20. 8.8%)
Each mode of injury had maximum number of patients
in M5 and M6 responses whereas least in M1 and M2 re-
sponses. The relationship between mode of injury and
motor response was not found to be significant (χ2 =
21.886, p = 0.111; Table 2).
Location of EDH
Frontal (n = 66, 28.9%) and parietal (n = 54, 23.7%)
were the commonest location, whereas it was least com-
mon in bifrontal region, frontoparietal region, and poste-
rior fossa accounting for 3.5% in each location. Moreover,
right-sided preponderance was noted at all locations ex-
cept for the temporal region, whereas hematoma was
equally distributed in posterior fossa (Fig. 1).
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DOI: 10.1159/000501043 Srivastava
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 Color version available online
70
■ Right ■ Left
60

26
50

23
40

19
30

16
20 40
31

10 21 6
14
3 4
8
5 4
0
Frontal Parietal Temporo parietal Temporal Fronto temporal Frontoparietal Posterior fossa

Fig. 1. Distribution of hematoma at various locations.

Source of Bleeding Table 3. Volume of hematoma in relation with location, motor re-
The source of bleeding was arterial in 196 patients, sponse, age, and time between trauma to surgery
whereas it was due to the partial tear of dural venous
Location of hematoma Volume of hematoma, mL
­sinuses in 8 patients. The source of bleeding could not be
identified in 24 patients as bleeding had already stopped 30–50 >50 mL
(n = 186) (n = 42)
due to compression by the hematoma.
Frontal 54 12
Volume of Hematoma Parietal 38 16
Temporo-parietal 36 4
Majority of the patients (n = 186, 81.6%) had a hema- Temporal 26 4
toma size of 30–50 mL, whereas it was >50 mL in only 42 Fronto-temporal 12 2
patients (18.4%). The relationship of the volume with lo- Bifrontal 7 1
Fronto-parietal 6 2
cation of hematoma was not significant (χ2 = 5.910, p = Posterior fossa 7 1
0.749; Table 3). Motor response (M)
M1–M2 2 12
M3–M4 6 12
Time between Trauma to Surgery M5–M6 178 18
Within 6–24 h after injury, 100 patients (43.8%) were Age, years
operated. About 90 patients were operated within 6 h ≤6 43 3
7–12 51 9
(39.5%) and only 38 patients had undergone surgery after 13–18 92 30
24 h (16.7%). Statistically significant association was pres- Time from injury to time of surgery, h
ent between volume and time between trauma and sur- <6 77 13
6–24 93 7
gery (χ2 = 8.469, p ≤ 0.05; Table 3). >24 16 22

Best Motor Score at Presentation

As depicted in Figure 2, majority of the patients pre-
sented to us in motor responses of M6 (n = 108, 47.4%) and
M5 (n = 88, 38.6%), whereas only 2 patients (0.9%) were
observed in M1 response and 12 patients in M2 response
(5.2%). The association was significant between volume of
hematoma and the motor response (χ2 = 93.468, p ≤ 0.001).
Pupillary Abnormalities
The size of pupil in majority of the patients at various
locations of hematoma was normal and showed normal
pupillary reaction to light (n = 196, 86.0%). In 18 patients
(8%), pupillary asymmetry was noted, and 6 patients (2.6%)
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Traumatic Pediatric EDH Pediatr Neurosurg 2019;54:237–244 239

DOI: 10.1159/000501043
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 Color version available online
120

108

100

88

80

Cases, n
60

40

20
10 12
8
2
0
Fig. 2. Patients with various motor re- M6 M5 M4 M3 M2 M1
sponses.

Table 4. Pupillary reaction at various location of hematoma

Pupillary reaction Site of hematoma Total

frontal parietal temporoparietal temporal frontotemporal bifrontal frontoparietal posteriorfossa

NSNR 57 46 34 26 12 8 7 6 196
Anisocoria 2 5 6 3 1 0 1 0 18
CNBT 7 1 0 0 0 0 0 0 8
Dilated and fixed 0 2 0 1 1 0 0 2 6
Total 66 54 40 30 14 8 8 8 228

NSNR, normal size and normal reaction; CNBT, could not be tested.

had dilated and fixed pupil. The relationship between pu-
pillary abnormality and the site of hematoma was found to
be statistically significant (χ2 = 139.8, p = 0.003; Table 4).
Hospital Stay
Except for the 16 mortality, majority of the patients
(n = 181, 79.4%) were discharged in ≤7 days irrespective
of hematoma size and location, whereas only 31 patients
(13.6%) were discharged after 7 days (χ2 = 139.8, p ≤
0.0001). Similarly, majority of the patients in every seg-
ment of motor response had a hospital stay of ≤7 days
(n = 197, 86.4%) and it was found to be statistically sig-
nificant (χ2 = 18.484, p ≤ 0.001; Table 5).
Complications
Three patients were reexplored for the reaccumula-
tion of hematoma. Two of them with hematoma in tem-
poroparietal region had an arterial rebleed, whereas 1
patient of bifrontal EDH was reoperated as bleeding per-
sisted from the tear in superior sagittal sinus. One pa-
tient developed superficial wound infection which was
managed successfully with antibiotics and antiseptic
dressing, whereas another patient required removal of
the bone flap for which cranioplasty was done 6 months
later.
Mortality
• Based on Age
Out of 16 mortality, maximum was seen in the age
group of 13–18 years (n = 10, 8.3%) and least in the age
group of ≤6 years (n = 2, 4.2%; Fig. 3).
• Based on Pupillary Size and Reaction
All patients who presented to us with fixed and dilated
pupil had expired (n = 6, 100%), whereas least mortality
was observed in patients who had normal pupillary size
and reaction (n = 2, 1.0%; Fig. 4).
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Table 5. Hospital stay in relation to hematoma volume and motor Discussion
score
Up till now, only several small series of pediatric EDH
Hematoma site and volume, mL Hospital stay, days
exist in the literature [4–8]. We have done one of the larg-
≤7 (n = 197) >7 (n = 31) est series published till date. Although, EDH in pediatric
Frontal
age group constitutes only a small spectrum of traumatic
30–50 46 8 brain injury, yet it is an important cause of avoidable death
>50 7 5 in childhood. In our study, overall male preponderance
Parietal was reported which is consistent with other reported series
30–50 34 4
30–50 12 4 in the literature [8, 9]. Male preponderance may be attrib-
Parieto-temporal uted to early riding of unsupervised two-wheeler, more
30–50 32 4 physical, and outdoor sport activities as compared to girls.
30–50 2 2 Fall from a height was the commonest mode of injury
Temporal
30–50 26 0 in our study (50.9%), which is in line with the study done
30–50 4 0 by Zhong et al. [10] and Gerlach et al. [11]. It was mainly
Fronto-temporal attributed to unguarded rooftops while playing. RTA out-
30–50 12 0
30–50 2 0
weighs fall in a study by Umerani et al. [9], whereas we ob-
Bifrontal served RTA in only 40.4% of our patients. Unsupervised
30–50 7 0 driving at a younger age and playing in the vicinity of road
30–50 0 1 contributed to RTA. Duthie et al. [12] and Umerani et al.
Fronto-parietal
30–50 7 0 [9] reported assault as a cause of EDH in 9.0 and 6.9%, re-
30–50 0 1 spectively, which is comparable to our study (8.8%).
Posterior fossa As per our study, frontal region (28.9%) was the com-
30–50 5 1 monest location of hematoma, followed by parietal re-
30–50 1 1
gion (23.7%). Here, we differ from Gerlach et al. [11], Ben
Motor (M) score Hospital stay, days Abraham et al. [13], and Umerani et al. [9] who observed
≤7 >7 parietal region to be the commonest location of hema-
toma. There was overall right-sided preponderance in
M1–M2 8 6 our study, which is consistent with other reported series
M3–M4 11 7 in the literature [9]. As compared to 8.5% in the literature,
M5–M6 178 7
we reported only 3.5% of the posterior fossa EDH [11,
14]. The reason for this is attributed to the firm attach-
ment of dura to the posterior vault as compared to the
anterior half. EDH at multiple locations is rarely reported
• Based on the Location in the literature; however, we had 3.5% each in frontopa-
Maximum mortality was observed in patients who had rietal and bifrontal region [15].
a hematoma in posterior fossa (25.0%), followed by fron- We had operated maximum number of patients with-
totemporal region (14.3%) and least in patients having in 6–24 h (43.8%). Here we differ from the study done by
hematoma in parietotemporal region (5.0%). Gerlach et al. [11] who performed around 50% of their
• Based on Time between Trauma to Surgery surgery within 6 hours of injury. The delay in surgery may
Mortality was found to be maximum when operation be due to lack of transportation facilities during night and
was done after 24 h of injury (n = 8, 21%), whereas least availability of neurosurgical care only in large cities. Ma-
mortality was observed if operated within 6 h (n = 2, 2.2%; jority of the patients had a hospital stay of ≤7 days which
Fig. 5). was comparable to the other series [9, 12].
• Based on Best Motor Response Glasgow Coma Scale (GCS) plays an important role in
None of the patient expired, who had a preoperative categorizing injury severity, but it has also got numerous
motor response of M6, whereas 2 mortalities were ob- limitations such as:
served in M5 response. Preoperative motor response of 1 It does not take into account the pupillary size and
M2 had 50% mortality, and 100% mortality was noted in reaction, pulse rate, respiration, and blood pressure
patients who had a motor response of M1 (Fig. 6). [16].
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 Color version available online
<6 years, 2, 12%

7–12 years, 4, 25%

13–18 years, 10, 63%

Fig. 3. Mortality in different age groups.

Color version available online

■ Survived ■ Expiry

Dilated and fixed 6

CNBT 8

Anisocoria 10 8

NSNR 194 2

0 10 20 30 40 50 60 70 80 90 100 %

Fig. 4. Figure depicting pupillary abnormality and mortality. CNBT, could not be tested; NSNR, normal size and normal reaction.

2 Inaccurate recording in patients with bilateral ecchy-
mosis of the eyelids.
3 Verbal scoring can be significantly affected by facial
injuries.
Gale et al. [17] observed that 50% of the patients could
not be assigned accurate GCS score because of these con-
founding variables. Among 3 components of GCS score,
motor response (M) is considered as the most reproduc-
ible and carries the best prognostic information [18]. So,
we have designed our study on the basis of motor com-
ponent (M) of GCS score to classify the severity of brain
injury and for the assessment of outcome.
Several factors were responsible for the outcome of pe-
diatric EDH, including initial motor response at presen-
tation, pupillary size and reaction, time between trauma
to surgery, and location of hematoma. Mortality rate var-
ies from 0 to 12% in various literatures [9, 19, 20]. Ac-
cording to our study, M1 and M2 responses had worst
outcome, and excellent outcome was seen in M5 and M6
responses. We had an overall mortality of 7.0%, which is
lower than Umerani et al. [9] and Molloy et al. [7], but
higher than Duthie et al. [12] who reported no death dur-
ing their study. We had observed maximum mortality in
the age group of 13–18 years (4.3%) and lowest in ≤6 years,
which was lower than Ben Abraham et al. [13] who re-
ported 7.4% death in the age group of 4–10 years and
16.7% in the age group of <4 years. Mortality was high in
patients who were operated 24 h after the injury and least
in patients if operated within 6 h after injury. We found
maximum mortality in patients who had posterior fossa
and frontotemporal hematoma along with fixed and di-
lated pupil at presentation. Here, our study is consistent
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 Color version available online
8 ■ Expiry ■ Survived
>24
30

6
Time, h

6–24
94

2
<6
88

0 10 20 30 40 50 60 70 80 90 100

Fig. 5. Figure showing relationship of time of surgery and mortality.

Color version available online

120

■ Patients, n ■ Expiry 108

100

88

80

60

40

20
12
10 8
6
4
2 2 2 2
0
0
M1 M2 M3 M4 M5 M6

Fig. 6. Mortality in various motor responses.

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Traumatic Pediatric EDH Pediatr Neurosurg 2019;54:237–244 243

DOI: 10.1159/000501043
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with Umerani et al. [9] but differ from Zhong et al. [10] Statement of Ethics
who did not find any relation of mortality with the loca-
Parents or guardians of all pediatric patients have given their
tion of hematoma. written informed consent.

Conclusion Disclosure Statement

Timely surgical intervention in patients with EDH im- The authors have no conflicts of interest to declare.
parts excellent outcome with low mortality. Best motor
response at presentation, pupillary abnormalities, time
between injury to surgery, and location of hematoma Funding Sources
have been identified as the important factors determining
outcome in patients of EDH. Funding source is nil.

Acknowledgments
This work was supported by the Department of Neurosurgery,
King George’s Medical University, Lucknow, UP, India and De-
partment of Neurosurgery, Uttar Pradesh University of Medical
Sciences, Etawah, Uttar Pradesh, India.
Author Contributions
Dr. Manish Jaiswal (corresponding author) conceived and de-
signed the research. Dr. Mohd Faheem, Prof. Bal Krishna Ojha,
Prof. Anil Chandra, Prof. Sunil Kumar Singh, and Prof. Chhitij
Srivastava contributed to the design and implementation of the
research, analysis of the results, and writing of the manuscript.

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