J Neurosurg Pediatrics 12:181–186, 2013

©AANS, 2013

Postoperative epidural hematoma covering the galeal flap

in pediatric patients with moyamoya disease: clinical
manifestation, risk factors, and outcomes
Clinical article

Hyunho Choi, M.D.,1 Ji Yeoun Lee, M.D.,1 Ji Hoon Phi, M.D.,1

Seung-Ki Kim, M.D., Ph.D.,1 Byung-Kyu Cho, M.D., Ph.D., 2
and Kyu-Chang Wang, M.D., Ph.D.1
1
Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of
Medicine; and 2Department of Neurosurgery, The Armed Forces Capital Hospital, Seoul, Republic of Korea

Object. Postoperative epidural hematoma (EDH), a blood collection between the inserted galeal flap and the
overlying skull flap (epigaleal flap hematoma), is a frustrating complication of the surgical treatment of moyamoya
disease (MMD) in pediatric patients. The symptoms of postoperative EDH are often similar to those of postopera-
tive cerebral ischemia, and may cause confusion during clinical decision making. The authors designed this study to
evaluate the incidence, clinical presentation, risk factors, and treatment outcomes of postoperative EDH in pediatric
patients with MMD.
Methods. A retrospective review of 148 pediatric patients with 250 craniotomies who underwent indirect bypass
revascularization surgery between January 2002 and December 2006 was performed. This group consisted of 60 male
and 88 female patients, and the mean age at surgery was 7.5 years (range 1–18 years).
Results. Of the 250 craniotomies, postoperative EDH was detected in 32 cases. In 12 cases of EDH, surgical
treatment was necessary (4.8% of 250 craniotomies). During the same period, 743 non-MMD craniotomy operations
were performed. In 6 of these 743 operations, patients developed postoperative EDH that required surgical treatment,
significantly less than the percentage of EDH requiring postoperative treatment in patients with MMD (0.8%, p <
0.001). The average interval between craniotomy surgery and the detection of EDH was 1.8 days (range 0–5 days) in
patients with MMD and 0.5 days (range 0–2 days; p = 0.018) in the non-MMD craniotomy group.
Postoperative EDH was observed in significantly fewer cases (17 of 191) when a subcutaneous drain (SCD) was
inserted over the bone flap than in cases in which an SCD was not inserted (14 of 55; p = 0.001). The mean interna-
tional normalized ratio of prothrombin time in the immediate postoperative blood test was 1.27 ± 0.17 in the EDH
group and 1.20 ± 0.11 in the non-EDH group (values are expressed as the mean ± SD; p = 0.008). Central galeal flap
tenting suture and immediate postoperative platelet count were not related to the incidence of postoperative EDH
following pediatric MMD surgery.
Conclusions. Postoperative EDH is more likely to be found following craniotomy in patients with MMD than
in those without MMD, and may occur in a delayed fashion. Insertion of an SCD and immediate correction of an
abnormal value for international normalized ratio of prothrombin time can decrease the incidence of postoperative
EDH following surgery for pediatric MMD.
(http://thejns.org/doi/abs/10.3171/2013.4.PEDS12505)

Key Words      •      moyamoya disease      •      craniotomy      •      surgical treatment      •     

postoperative epidural hematoma      •      vascular disorders

T
he clinical features of pediatric MMD are mainly
ischemic symptoms, such as transient ischemic at-
tack and cerebral infarction, whereas half of adult
patients with MMD present with symptoms of intracra-
Abbreviations used in this paper: EDAS = encephaloduroarterio­
synangiosis; EDH = epidural hematoma; EGS = encephalogaleo-
synangiosis; MMD = moyamoya disease; OA = occipital artery;
PT INR = international normalized ratio of prothrombin time; SCD
= subcutaneous drain; STA = superficial temporal artery; STAp =
parietal branch of the STA.
nial hemorrhage.8,17 Moyamoya disease accounts for 14%
of all strokes in pediatric patients.18 The natural history
of MMD is not well understood; however, patients with
conservative management demonstrate poorer intellectual
development and proficiency in daily living activities than
the patients who undergo surgical treatment.9,11,16 There-
fore, surgical treatment is generally recommended for pe-
diatric patients with MMD.
Postoperative EDH, a blood collection between the
inserted galeal flap and the overlying skull flap (called the
“epigaleal flap hematoma” in this study), is a frustrating

J Neurosurg: Pediatrics / Volume 12 / August 2013 181


complication of surgical treatment of MMD in pediatric
patients, sometimes causing disability, mental disturbance,
and death. Many neurosurgeons are concerned about
EDH and use various methods to prevent its occurrence.
However, the incidence and risk factors of postoperative
EDH are still unclear, and the effectiveness of preventive
methods previously used by neurosurgeons has not been
investigated in pediatric MMD revascularization surgery.
Collateral vascular channels formed through the skull and
dura mater in MMD can be sources of slow blood accu-
mulation in the operative field. In addition, the indication
for surgical treatment for EDH in patients with MMD has
not yet been established because it is not unusual for these
patients to show postoperative transient ischemic attack
or infarction, and these events may combine with and ob-
scure the occurrence of EDH. We designed a retrospec-
tive analysis to evaluate the incidence, clinical presenta-
tion, risk factors, and treatment outcomes of postoperative
EDH in pediatric patients with MMD.
Our experimental questions were as follows. 1) Is
postoperative EDH more common in MMD surgery than
in non-MMD craniotomy operations? 2) Do EDHs result-
ing from MMD surgery manifest more slowly than post-
operative EDHs resulting from non-MMD craniotomy
op­erations? 3) What are the risk factors of postoperative
EDH in MMD?
Methods
A retrospective review of medical records at Seoul
National University Children’s Hospital in Seoul, Korea,
was conducted for patients with MMD who were younger
than 18 years of age and who underwent indirect bypass
revascularization surgery including bifrontal EGS, STA
EDAS, and OA EDAS.
An STA EDAS was performed for the collateral for-
mation in the middle cerebral artery territory. The STA,
most commonly the STAp, was dissected along with a
strip of galea through a sigmoid skin incision. The dura
was opened without injury of the major meningeal artery
along the course of the STAp. Wide opening of arachnoid
was performed to promote the ingrowth of the neovascu-
lature. The STAp with the strip of galea overlying on the
exposed cortex was sutured to the edges of the dura mater.
Bifrontal EGS was performed for the collateral for-
mation in the anterior cerebral artery territory. A trans-
verse S-shaped skin incision was made anterior to the
coronal suture. The galea was freed from periosteum and
incised to make bilateral flaps that had bases on the lateral
side. After creation of a 4 × 8–cm rectangular craniotomy
crossing the superior sagittal sinus, the dura was opened
on both sides as for the galeal flaps, and wide opening of
arachnoid was performed. The galeal flap was sutured to
the dural margins.
An EDAS was performed using the OA for the col-
lateral formation in the posterior cerebral artery territory.
The OA was dissected along with a strip of galea through
a sigmoid skin incision. The arachnoid was opened. The
OA with the strip of galea was sutured to the edges of the
dura mater.
All records were reviewed, and data regarding patient
age, sex, name of the operation, occurrence, presentation,
182
H. Choi et al.
and amount of postoperative EDH, and the interval be-
tween the revascularization surgery and detection of EDH
were collected. To evaluate risk factors of postoperative
EDH, we reviewed the presence of presumed risk factors
including age, sex, insertion of an SCD over the bone flap,
central galeal flap tenting suture, immediate postoperative
PT INR, platelet level, type of surgery, and number of sur-
gery sites. Postoperative coagulation status was examined
by collecting peripheral blood within half an hour after
surgery.
Between January 2002 and December 2006, there
were 148 patients: 49 patients who underwent revascu-
larization craniotomy once; 96 patients who underwent
the surgery twice; and 3 patients who experienced the
surgery 3 times. Two hundred fifty revascularization cra-
niotomies were performed in all. The surgical treatment
is usually performed in 2–3 stages to obtain proper re-
vascularization. This group consisted of 60 male (40.5%)
and 88 female (59.5%) patients with a mean age at surgery
of 7.5 years (range 1–18 years). A brain CT scan without
enhancement was performed immediately after revas-
cularization surgery as a routine postoperative checkup
and when abnormal symptoms such as altered mentality,
significant headache and vomiting, or focal neurological
deficits were presented. The patients with an EDH larger
than 5 cm3 seen on the CT scan were included in the EDH
group.
To compare the incidence and time of diagnosis of
EDH in patients with MMD after revascularization sur-
gery with the same factors for non-MMD craniotomy sur-
geries, we also reviewed the information of patients who
underwent craniotomy surgery unrelated to MMD during
the same period. The risk and clinical manifestation of
EDH may vary according to the site of operation. There-
fore, we excluded sites of bifrontal EGS and OA EDAS
and focused on the “homogeneous” condition of STA
EDAS.
Patients with MMD often exhibit cerebral infarction
or ischemic symptoms such as transient focal neurological
deficit during the early postoperative period. For the man-
agement of postoperative EDH in patients with MMD, the
effects of an EDH versus possible postoperative cerebral
ischemia should be balanced in deciding on the treatment
plan, especially when the hematoma is not large. For this
reason, we reviewed the treatment outcome of patients
with postoperative EDH at the STA EDAS site only, where
both EDH and ischemia may similarly manifest as focal
neurological deficits. Surgical evacuation of EDH was de-
cided based on the symptoms, signs, and volume of the
hematoma.
The incidences of EDH in MMD surgery and in
non-MMD types of craniotomy and the frequency of risk
factors in EDH and non-EDH groups were compared us-
ing the Pearson chi-square test, Student t-test, and Mann-
Whitney U-test. Multivariate analysis using logistic re-
gression was performed for the risk factors related to the
EDH: age, sex, insertion of an SCD, central galeal flap
tenting suture, PT INR, platelet level, type of surgery, and
number of surgery sites. A 2-tailed p value < 0.05 was
considered statistically significant. All statistical analyses
were performed using the SPSS software package (version
12.0; SPSS, Inc.).
J Neurosurg: Pediatrics / Volume 12 / August 2013
Postoperative epidural hematoma in pediatric moyamoya disease

Results TABLE 1: Revascularization surgery for MMD in 148 patients with

250 craniotomies
General Assessments
In this study we examined 60 cases of left STA EDAS Op No. of Cases (%)
with bifrontal EGS, 15 cases of left STA EDAS with left lt STA EDAS w/ bifrontal EGS 60 (24.0)
OA EDAS, 44 cases of left STA EDAS, 58 cases of right
lt STA EDAS w/ lt OA EDAS 15 (6.0)
STA EDAS with bifrontal EGS, 7 cases of right STA
EDAS with right OA EDAS, 62 cases of right STA EDAS, lt STA EDAS 44 (17.6)
2 cases of bifrontal EGS, and 1 case each of left OA EDAS rt STA EDAS w/ bifrontal EGS 58 (23.2)
and right OA EDAS (Table 1). Of the 250 craniotomies, rt STA EDAS w/ rt OA EDAS 7 (2.8)
EDH was detected in 32 cases. Altered mentality was the rt STA EDAS 62 (24.8)
most common clinical manifestation of EDH (9 cases), bifrontal EGS 2 (0.8)
followed by nausea with vomiting (6 cases), dysarthria (3
cases), weakness and headache (2 cases each), and facial lt OA EDAS 1 (0.4)
palsy, tingling sense, wound swelling, and seizure (1 case rt OA EDAS 1 (0.4)
each). The EDH was detected during routine postopera- total 250 (100)
tive CT scanning in 5 cases and by intraoperative detec-
tion in 1 case (Table 2).
mean PT INR of the postoperative blood test was 1.27 ±
Incidence and Time to Diagnosis of EDH After Craniotomy 0.17 in the EDH group and 1.20 ± 0.11 in the non-EDH
group (Student t-test, p = 0.008). The mean platelet level
Postoperative EDHs were found in 32 cases (12.8% of of postoperative blood test was 231.23 ± 69.42 × 103/mm3
craniotomies). Of the 250 craniotomies, STA EDAS op- in the EDH group and 252.26 ± 75.55 × 103/mm3 in the
erations were performed in 246 cases, bifrontal EGS op- non-EDH group (Student t-test, p = 0.145) (Table 8). The
erations were performed in 120 cases, and OA EDAS op- foregoing values are expressed as the mean ± SD. Age (p
erations were performed in 24 cases. Postoperative EDHs = 0.311), sex (p = 0.409), type of surgery (p = 0.606), and
were detected in 26 cases in the STA EDAS sites (10.6%), number of surgery sites (p = 0.890) were not related with
in 5 cases in the bifrontal EGS sites (4.2%), and in a single the occurrence of EDH.
case in the OA EDAS sites (4.2%) (Table 3). We compared Multivariate analyses revealed that SCD insertion
the incidence of EDH between the “STA EDAS alone” (OR 0.236, 95% CI 0.098–0.569; p = 0.001) and postoper-
group and the “STA EDAS with bifrontal EGS” group. ative PT INR levels (OR 0.038, 95% CI 0.002–0.905; p =
Postoperative EDH occurred in 14 of 106 cases in the 0.043) were associated with the incidence of postoperative
STA EDAS alone group, and in 13 of 118 cases in the STA EDH in pediatric patients who underwent MMD surgery.
EDAS with bifrontal EGS group (Pearson chi-square, p =
0.615) (Table 4). Twelve of the EDH cases (4.8% of crani- Treatment Decisions Regarding Postoperative EDHs at the
otomies) had operative management to control postopera- Site of STA EDAS
tive symptoms and to prevent the progression of adverse
neurological symptoms. During the same period, 743 non- Of 32 postoperative EDH cases, 26 cases of patients
MMD craniotomy operations were performed (Table 5). with postoperative EDH only at the STA EDAS site were
In 6 (0.8%) of the 743 cases, EDHs received postoperative
surgical treatment (Table 6). That rate was significantly TABLE 2: Presentation of postoperative EDH*
less than the percentage of EDHs in patients with MMD
that required postoperative treatment (Pearson chi-square, Presentation No. of Cases
p < 0.001) (Table 7). asymptomatic
The average interval between the initial craniotomy   routine postoperative CT  5
surgery and detection of an EDH was 1.8 days (range 0–5
days) in patients with MMD and 0.5 days (range 0–2 days;   intraoperative finding  1
Mann-Whitney U-test, p = 0.018) in the non-MMD crani- symptomatic
otomy group.   altered mentality  9
  nausea w/ vomiting  6
Comparison of Risk Factors   dysarthria  3
We compared the following risk factors in the EDH  weakness  2
and non-EDH groups: 1) age; 2) sex; 3) the insertion of an   headache  2
SCD; 4) central galeal flap tenting suture; 5) postoperative   facial palsy  1
PT INR value; 6) postoperative platelet level; 7) type of
surgery; and 8) number of surgery sites.   tingling sense  1
Postoperative EDH occurred in 17 of 191 cases of   wound swelling  1
SCD insertion, and EDH occurred in 14 of 55 cases with-  seizure  1
out an SCD (Pearson chi-square test, p = 0.001). An EDH total 32
was observed in 7 of 64 cases with central galeal flap tent-
ing suture, and in 24 of 182 cases without central galeal *  For this study, EDH means “epigaleal flap hematoma” in a strict
flap tenting suture (Pearson chi-square, p = 0.641). The sense.

J Neurosurg: Pediatrics / Volume 12 / August 2013 183

 H. Choi et al.
TABLE 3: Incidence of EDH after MMD revascularization surgery TABLE 5: Diagnosis in 743 non-MMD craniotomy cases

Op Site No. of Ops No. of Postop EDH Cases (%) Diagnosis No. of Cases (%)
STA EDAS 246 26 (10.6) benign brain tumor 312 (41.9)
bifrontal EGS 120 5 (4.2) malignant brain tumor 151 (20.3)
OA EDAS  24 1 (4.2) epilepsy 84 (11.3)
craniofacial anomaly 67 (9.0)
wound revision 25 (3.4)
reviewed. Of the 26 cases, 10 underwent surgical treat-
skull defect 22 (3.0)
ment due to EDH volume and remarkable symptoms, such
as altered mentality or focal neurological deficit, and 16 intracerebral hematoma 16 (2.2)
were managed conservatively. In 25 cases, patients were arteriovenous malformation 13 (1.8)
discharged from the hospital without additional neurologi- CSF disorder 12 (1.6)
cal deterioration. However, 1 patient who was treated with benign cyst 10 (1.3)
conservative management had fine motor dysfunction of miscellaneous 31 (4.2)
the hand.
total 743 (100)

Discussion
The incidence of MMD is relatively low; however, it
is a common cause of pediatric cerebral infarction. The
early diagnosis and appropriate treatment of MMD is cru-
cial in preventing cerebral infarction.13
The optimal treatment for MMD is not yet clearly es-
tablished. The effectiveness of various medical treatments
has not been proven in MMD, but surgical treatment has
been an excellent option providing a favorable outcome.3
We previously reported a comparison between STA EDAS
and STA EDAS with bifrontal EGS. An STA EDAS with
bifrontal EGS could reperfuse regions of the brain requir-
ing blood flow from the middle cerebral and anterior cere-
bral arteries. Thus, this surgical approach may be a more
effective modality for the treatment of MMD.12,14,15
Postoperative EDH is a common complication of re-
vascularization surgery for MMD. Palmer et al.19 reported
an overall incidence rate of 1.1% for postoperative hema-
tomas requiring surgical evacuation after craniotomies in
general, and EDH accounted for 33% of these hematomas.
Other prior studies have reported the incidence of postop-
erative EDHs as 0.9%–1.3%.5,22 In our study, the incidence
of postoperative EDH requiring surgical treatment was
4.8% of craniotomies in patients with MMD and 0.8%
of craniotomies unrelated to MMD. Although postopera-
tive ischemia causing focal neurological deficits may have
led to more frequent neuroimaging studies with increased
incidence of postoperative EDH, the higher incidence of
postoperative EDH in MMD surgery may be due to pa-
tient and disease characteristics rather than to technical
reasons. Patients with MMD have characteristic collateral
vessels at the cranial vault and the base of the brain that
TABLE 4: Incidence of EDH after MMD revascularization surgery
(by craniotomy)
No. of Postop EDH
Op No. of Ops Cases (%)
STA EDAS alone 106 14 (13.2)
STA EDAS + bifrontal EGS 118 13 (11.0)*
provide an alternative route for cerebral perfusion. We
frequently found that these collateral vessels bled during
the surgical procedure. We assumed that these epidural
fine vessels also exist on the periphery of the craniotomy
site. We also hypothesized that slow blood leakage from
injured fine collateral vessels in the cranial vault causes
the hematoma. The difference in intervals between the
surgery and detection of postoperative EDH in MMD and
non-MMD craniotomies (1.8 days vs 0.5 day, respectively)
supports our hypothesis.
Early recognition and diagnosis of postoperative EDH
are essential in preventing devastating results because of
frequent rapid progression during the first several hours.
In our study, frequent postoperative symptoms of an EDH
were altered mentality and nausea with vomiting. Howev-
er, these are nonspecific postoperative symptoms. Weak-
ness, dysarthria, and tingling are common symptoms in
both postoperative EDH and postoperative cerebral isch-
emia. Thus, similarity of symptoms may cause confusion
in clinical decision making. Because of the difficulty in
differentiating the symptoms of EDH from those of ce-
rebral ischemia, brain imaging is a crucial tool to verify
the occurrence of an EDH. Sometimes, however, when the
hematoma is small or medium sized it is not clear whether
the symptoms are caused by EDH, even after imaging
studies.
Guangming et al.7 evaluated the efficacy of the epi-
dural drain in preventing EDH following supratentorial
craniotomy in epileptic patients. These authors concluded
TABLE 6: Sites of 6 EDHs in non-MMD cases*
Case No. Disease Site of EDH
1 pilocytic astrocytoma bifrontal
2 medulloblastoma rt parietal
3 medulloblastoma posterior fossa
p Value 4 medulloblastoma posterior fossa
0.615 5 PNET lt parietal
6 glioblastoma lt parietal

*  Bifrontal EGS site in 4 cases, STA EDAS site in 9 cases. *  PNET = primitive neuroectodermal tumor.

184 J Neurosurg: Pediatrics / Volume 12 / August 2013

Postoperative epidural hematoma in pediatric moyamoya disease
TABLE 7: Incidence of postoperative EDH after craniotomy that TABLE 8: Comparison of the risk factors for EDH after STA EDAS
needed surgical evacuation (by craniotomies) in 246 cases*

No. of Postop EDH Non-EDH Group EDH Group

Op No. of Ops Cases (%) p Value
MMD surgery 250 12 (4.8) <0.001
non-MMD craniotomy 743 6 (0.8)
that the epidural drain did not decrease the incidence or
volume of EDH and CSF collection. Conversely, in our
study, the insertion of an SCD had a significant impact on
the prevention of postoperative EDH. In years past, we did
not insert an SCD to avoid CSF leakage because the nega-
tive pressure of the SCD was feared to facilitate leakage
of CSF though the dural defect, which is unavoidable in
indirect revascularization surgery. More recently we have
inserted an SCD to prevent postoperative EDH, and the
rate of postoperative CSF leakage has not increased.
Zhao et al.25 reported the efficacy of central dural
tenting suture and epigaleal (over the bone flap, in non-
MMD cases) drainage in craniotomy. Both procedures
were effective in preventing postoperative EDH. However,
other prior reports concluded that central dural tenting su-
ture has no significant impact on preventing EDH after
craniotomy.20,23,24 In our study, the frequency of central
galeal flap tenting suture was not significantly different in
EDH and non-EDH groups. In pediatric MMD revascu-
larization surgery such as EDAS and EGS, the bone flap is
relatively small and could decrease the efficacy of central
galeal flap tenting suture.
Gerlach et al.6 reported that patients with postopera-
tive hemorrhage displayed significant abnormalities in
prothrombin time and in fibrinogen and platelet counts
immediately after surgery. In addition, patients with a
hemorrhage had a lower platelet count 1 day after surgery
for intracranial meningioma. Chan et al.2 also reported an
acute, significant drop in platelet count from normal to be-
tween 100,000 and 124,000/ml in the immediate postoper-
ative period in patients with hemorrhage. In our study, the
level of PT INR was significantly different between EDH
and non-EDH groups. Although 0.07 is a small differ-
ence with major overlap in standard deviation, the statisti-
cal analysis shows a significant difference between EDH
and non-EDH groups. We think that although this small
difference is not clinically significant in the usual condi-
tion, it could make a difference between EDH and non-
EDH groups in a special circumstance like the immediate
postoperative state of craniotomy. There is a possibility
that the level of INR could be related to the occurrence of
EDH, and we would like to pay attention and correct the
INR level.
Many previous authors have reported on the inci-
dence of and treatments for traumatic EDH,4,21 but reports
on postoperative EDH have been rare. Some authors have
recommended rather conservative management of acute
EDH in children. For example, in some patients with a
Glasgow Coma Scale score of 14 or 15 the lesions were
successfully managed without surgical intervention, al-
though the EDHs were caused by mild trauma unrelated
to craniotomy.1,10 In our study, surgery was determined by
Risk Factor (n = 215) (n = 31) p Value
SCD 0.001
  yes (n = 191) 174 17
  no (n = 55)  41 14
central galeal flap tenting 0.641
  yes (n = 64)  57  7
  no (n = 182) 158 24
PT INR 1.20 ± 0.11 1.27 ± 0.17 0.008
platelet count (103/mm3) 252.26 ± 75.55 231.23 ± 69.42 0.145
*  Data for the last 2 entries are expressed as the mean ± SD.
the symptoms, signs, and volume of the hematoma. Al-
though in 15 of 16 cases in which conservative manage-
ment was chosen, the individuals recovered fully without
any neurological deterioration, 1 had fine motor dysfunc-
tion of the hand. It is not clear whether this deficit was
caused by EDH or by postoperative ischemia. Therefore, it
is difficult to know whether surgery could have prevented
the fine motor dysfunction. However, in cases in which it
is difficult to differentiate signs or symptoms of ischemia
versus EDH, we think that surgery would be a viable op-
tion.
Conclusions
Postoperative EDH was significantly more common
in MMD craniotomies than in craniotomies unrelated to
MMD. Diagnosis of postoperative EDH is more delayed
following MMD surgery than after non-MMD cranioto-
my. Insertion of an SCD and immediate correction of an
abnormal PT INR value seemed to be associated with less
incidence of postoperative EDH in pediatric patients un-
dergoing surgery for MMD.
Disclosure
This study was supported by a grant from the Korean Healthcare
Technology R&D Project, Ministry for Health, Welfare & Family
Affairs, Republic of Korea (A120099). The authors report no con­flict
of interest concerning the materials or methods used in this study or
the findings specified in this paper.
Author contributions to the study and manuscript prepara-
tion include the following. Conception and design: Wang, Choi.
Acquisition of data: Choi. Analysis and interpretation of data: Wang,
Choi. Drafting the article: Choi. Critically revising the article: all
au­thors. Reviewed submitted version of manuscript: all authors. Ap­­
proved the final version of the manuscript on behalf of all authors:
Wang. Statistical analysis: Choi. Administrative/technical/ma­te­rial
support: Choi, Kim. Study supervision: Wang.
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Manuscript submitted October 13, 2012.
Accepted April 29, 2013.
Please include this information when citing this paper: published
online June 7, 2013; DOI: 10.3171/2013.4.PEDS12505.
Address correspondence to: Kyu-Chang Wang, M.D., Ph.D.,
Di­vision of Pediatric Neurosurgery, Seoul National University Chil-
dren’s Hospital, 101 Daehakro, Jongno-gu, Seoul 110-769, Re­pub­lic
of Korea. email: kcwang@snu.ac.kr.
J Neurosurg: Pediatrics / Volume 12 / August 2013