Epidural hematoma in children
Introduction
Introduction to pediatric epidural hematoma Extradural hematoma (extradural hematoma) is the accumulation of blood between the inner plate of the skull and the dura mater. The reason is that the skull has a large deformation under the action of external force, and the dural arteriovenous vein peels or tears during this process. Produces epidural hemorrhage, and the hematoma reaches a certain volume and symptoms of increased intracranial pressure and/or brain pressure occur. basic knowledge The proportion of illness: 0.001% Susceptible people: children Mode of infection: non-infectious Complications: cerebral palsy, epilepsy
Cause
Pediatric epidural hematoma etiology
Causes:
Children can be seen in fall injuries and head violence injuries, and the hematoma is mostly located in the direct impact of violence.
Pathogenesis:
The typical case is frontotemporal trauma. The fracture line spans the meningeal middle artery passage area. The displacement of the bone piece tears the artery inside the bone tube, causing the formation of hematoma. In children, the skull is severely deformed by impact injury, which will make the dura mater and The removal of the skull, the internal vein of the stenosis, the small branch of the meningeal arteriovenous vein or the tear of the sinus can form a hematoma, usually without obvious fractures. The hematoma can be enlarged due to the continued bleeding of the ruptured blood vessels. The hematoma continues to peel off the dura mater, tearing the peripheral arterioles, leading to a progressive increase in hematoma. The acute epidural hematoma accounts for about 85%, showing a dark red clot in the epidural space, mixed with some bright red. Non-coagulation, subacute and chronic type are rare, visible hematoma enveloping, and adhesion to the dura mater.
Prevention
Prevention of epidural hematoma in children
Pay attention to perinatal work, prevent premature birth, dystocia, improve delivery technology, and prevent neonatal brain injury. Care for children of all ages to prevent brain trauma. Prevent violent damage.
Complication
Pediatric epidural hematoma complications Complications, cerebral epilepsy
When cerebral palsy, seizures, and cerebral palsy oppress the brainstem, blood pressure drops, heart rate, respiratory rhythm disorder, and finally brain stem failure, leading to death.
Symptom
Symptoms of epidural hematoma in children Common symptoms Inability to drop blood pressure, easy to provoke intracranial hypertension, irritability, restlessness, skull fracture, consciousness disorder, convulsions
1. Clinical manifestations:
Mainly the symptoms of acute brain compression, the severity and severity of symptoms are related to the speed of bleeding, the location and the compensatory ability of the child. In children, hematoma is mostly venous bleeding, blood flow pressure is low, and bleeding is slow. In addition, the intracranial compensatory ability is strong, so the symptoms of acute brain compression are mild, and the symptoms appear later. The hematoma of the frontotemporal lobe may increase the intracranial pressure due to the increase of the occupancy effect, and the cerebellar incision may occur in the late stage. Symptoms; and the posterior cranial fossa due to small volume, as long as a small amount of bleeding can lead to occipital foramen.
(1) disturbance of consciousness: elderly children may have a typical "primary coma - intermediate waking period - secondary coma" disease development process, while primary conscious disturbance in infants is often atypical, more performance For the crying, irritability and irritability after the injury, the progressive progression of the disturbance of consciousness will continue until the symptoms of cerebral palsy appear.
(2) increased intracranial pressure: with the increase of hematoma, intracranial pressure increased progressively, children may have headache, vomiting, increased anterior tendon tension, etc., but because of the infant's intracranial compensatory ability, Symptoms of increased intracranial pressure appear later than adults, but only manifest as mental weakness, lethargy or restlessness. Vomiting symptoms occur frequently in children and often occur early after trauma. It may be intraventricular pressure during trauma. Sudden changes stimulate the vomiting center of the fourth ventricle, and late vomiting may be associated with increased intracranial pressure.
(3) Changes in pupil: At the time of injury, some children developed enlargement of bilateral pupils, and then returned to normal. In the early stage of cerebral palsy, the pupil of the hematoma side was reduced, and the light reflection was slow. The oculomotor nerve is stimulated, but it is difficult to find in the clinic. After the cerebral palsy occurs, the pupil on the hematoma side is scattered, the light reflection disappears, and the eyeball is fixed. This is the performance of the oculomotor nerve palsy. There is a small cerebellum incision, the condition is critical, and urgent surgery is needed.
(4) Local neurological signs: children are prone to seizures after trauma, and the cortex compression and stimulation of the hematoma are related to the imperfect development of cortical inhibition function in children. Epilepsy can start from the convulsion of one limb and gradually develop into a major episode. If the hematoma is located near the exercise area, it may lead to a contralateral pyramidal tract sign, and there may be weakness or paralysis of the contralateral limb, and the degree of upper and lower limbs may vary. When the cerebral palsy causes the cerebral ankle to be compressed, the contralateral limb may also appear. Hemiplegia.
(5) Changes in vital signs: As the intracranial pressure continues to increase, the child may experience a decrease in pulse rate, an increase in blood pressure, and a compensatory change in slowing of breathing (Cushing response), but usually blood pressure and heart rate in infants and young children. The change is not obvious, it can cover up the early signs of cerebral palsy. When the intracranial pressure continues to rise and the cerebral palsy oppresses the brainstem, blood pressure drops, heart rate, respiratory rhythm disorder, and finally brain stem failure, leading to death.
2. Characteristics of children with epidural hematoma:
(1) usually venous hemorrhage, no combined with skull fracture: in adults, epidural hematoma is mostly arterial hemorrhage, and more combined with skull fracture. In children and infants, epidural hematoma is usually venous bleeding, and 30% to 40% of children do not have a skull fracture.
(2) No abnormalities of the nervous system before the occurrence of secondary coma: after the adult brain traumatic coma, before the epidural hematomas occupy a secondary coma, there is usually an intermediate waking period; but in the early stage of childhood trauma It was only a moment of cyanosis, followed by crying and irritability, and there was often no abnormal nervous system found within 36 to 48 hours before the occurrence of secondary coma.
(3) can lead to hemorrhagic shock: children's immature skull is very extended, sometimes more than 100ml of blood accumulated in the epidural space, in children will cause hemorrhagic shock.
(4) characteristics of neonates: neonatal epidural hematoma and skull fracture usually occur after the application of forceps, and the hematoma can also enter the aponeurotic sub-cavity through a separate suture or fracture line.
(5) Conscious changes with the development of hematoma: children with epidural hematoma can occur after extremely mild injuries, about 50% of children and 85% of babies have no loss of consciousness, just as the hematoma develops There is a change in consciousness.
(6) common posterior cranial epidural hematoma: posterior cranial fossa epidural hematoma is more common in childhood, mainly caused by children falling and falling head, accounting for 25% to 38% of children with posterior cranial fossa trauma, bleeding is the most common The source is the dural sinus or the plate vein.
Examine
Examination of pediatric epidural hematoma
Epidural hematoma with intracranial space-occupying effect Lumbar puncture is more manifested as increased intracranial pressure, cerebrospinal fluid cell number and protein content can be normal, but in the acute phase contraindications lumbar puncture examination, so as not to induce cerebral palsy.
1. Skull X-ray film: Skull fractures can be seen in older children, and the fracture line is often passed through the dura mater or the sinus. In infants and young children, there are few skull fractures.
2. CT scan: typical performance is the high-density shadow of the lower part of the skull. The edge is smooth and sharp. The brain tissue and ventricular system are under pressure. The midline structure is offset. The bone window image can show the skull fracture. CT is hard. The preferred auxiliary examination for extramembranous hematoma.
Diagnosis
Diagnosis and diagnosis of pediatric epidural hematoma
Usually the consciousness may be preserved in the early stage of the injury, and then signs of nervous system damage may appear soon, which may be manifested as progressive headache, vomiting, coma or signs of damage to the cerebellum and brain stem, and 65% of the skull X-ray films There is a occipital bone fracture. Once diagnosed, a craniotomy should be performed after drilling.
The clinical manifestations of acute epidural hematoma in children are atypical. It is necessary to carefully observe the changes in the condition in order to make a correct diagnosis. Sleepiness, restlessness, irritability, vomiting, seizures, or weakening of one limb's muscle strength should be considered in children after trauma. The possibility of intracranial hematoma should be further examined by head CT. If the disturbance of consciousness is progressively deepened and there is a disturbance of pupillary changes and vital signs, it means that it has entered the early stage of cerebral palsy and needs urgent surgical treatment. The discovery of epidural hematoma, delayed hematoma refers to the first CT scan without abnormal images, but after a few hours or days after the re-examination, only to find hematoma, delayed hematoma accounted for the total number of epidural hematoma 5 %22%, the pathogenesis may be due to the presence of dural hemorrhage in the head trauma of the child, but the filling effect caused by factors such as edema of the brain tissue or increased intracranial pressure after injury, oppresses the bleeding point; Take measures such as excessive ventilation, strong dehydration, or a sharp decrease in intracranial hypertension caused by a decrease in systemic blood pressure, which causes the original bleeding point to lose its packing effect. To peel off the dura, causing delayed epidural hematoma, clinical, such children often have a sudden deterioration of the disease, once diagnosed, surgery to remove the hematoma as soon as possible.
Different from primary brain stem injury, CT examination can confirm the diagnosis.
