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EPIDURAL HAEMATOMA - keywords
epidural haematoma references to epidural haematoma r e f e r e n c e s n a v i g a t o r < Akiyama Y, Moritake K, Maruyama N, Takamura M, Yamasaki T (2001) Acute epidural hematoma related to cesarean section in a neonate with Chiari II malformation. Childs Nerv Syst, 17(4-5):290-3.  Aoki N (1990) ‘Epidural haematoma in the newborn infants: therapeutic consequences from the correlation between haematoma content and computed tomography features.’ Acta Neurochirurgica, 106, 65–67. Bergman, I., Bauer, R.E., Barmada, M.A., Latchaw, R.E., Taylor, H.G., David, R., Painter, M.J. (1985) ‘Intra­cerebral hemorrhage in the full-term neonatal infant.’ Pediatrics, 75, 488–496.Govaert P (1993) Cranial haemorrhage in the term newborn infant. Clinics in Developmental Medicine nr. 129, London: Mac Keith Press, ISBN 0 901260 98 3.Holden, KR, Titus, MO and Van Tassel, P (1999). 'Cranial magnetic resonance imaging examination of normal term neonates: a pilot study.' J Child Neurol, 14:708-10. King, SJ and Boothroyd, AE (1998). 'Cranial trauma following birth in term infants.' Br J Radiol, 71:233-8. Lam, A., Cruz, G.B., Johnson, I. (1991) ‘Extradural hematoma in neonates.’ Journal of Ultrasound Medicine, 10, 205–209. Noguchi M, Inamasu J, Kawai F, Kato E, Kuramae T, Oyanagi T, Takahashi T, Ihara M. Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuum-assisted delivery. Childs Nerv Syst. 2010 May;26(5):713-6. Okuno T, Miyamoto M, Itakura T, Ueno M, Shimizu M, Minamide A, Komai N. [A case of epidural hematoma caused by a vacuum extraction without any skull fractures and accompanied by cephalohematoma]. No Shinkei Geka. 1993 Dec;21(12):1137-41. Pierre-Kahn, A., Renier, D., Sainte-Rose, C., Flandin, C., Hirsch, J-F. (1985) ‘Les hématomes intracrâniens aigus du nouveau-né à terme. A propos de dix-sept cas.’ Annales de Pédiatrie, 32, 419–425.Smets KJ, Vanhauwaert D. Treatment of cranial epidural hematoma in a neonate by needle aspiration of a communicating cephalhematoma. Eur J Pediatr. 2010 May;169(5):617-9.  Tavani, F, Zimmerman, RA, Clancy, RR, Licht, DJ and Mahle, WT (2003). 'Incidental intracranial hemorrhage after uncomplicated birth: MRI before and after neonatal heart surgery.' Neuroradiology, 45:253-8. Tekkok, IH, Ventureyra, EC (1997). ‘Spontaneous intracranial hemorrhage of structural origin during the first year of life.’ Childs Nerv Syst, 13:154-65. Vachharajani A, Mathur A (2002) Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: treating a rare complication of vacuum extraction. Am J Perinatol, 19(8):401-4.  Vinchon M, Pierrat V, Tchofo PJ, Soto-Ares G, Dhellemmes P (2005) Traumatic intracranial hemorrhage in newborns. Childs Nerv Syst.   Wang, LW, Huang, CC and Yeh, TF (2004). ‘Major brain lesions detected on sonographic screening of apparently normal term neonates.’ Neuroradiology, 46:368-73. MR: epidural haematoma with some mass effect but no cortical ischaemia CT: limited epidural haematoma surgical options some events related to the mode of delivery: cephalhaematoma and subgaleal bleeding tend to be vacuum-specific Except in the rare instance of a primary disorder of haemostasis, neonatal epidural haemorrhage is an irrefutable sign of mechanical trauma. The lesion has been described following complicated breech delivery and after cephalic delivery with instrumental traction. The haemorrhage is nearly always located underneath a linear cranial fracture (not always: Nokuno et al. 1993). Very often a cephalhaematoma is found on top of the injured bone. Treatment of large haematomas can be done by puncture of the cephalhaematoma (Vachharjani and Matur 2002, Smets et al. 2010, Noguchi et al. 2010). Reports on ultrasound diagnosis are rare. If large enough it may be recognized with ultrasound. The haematoma may be hypo­dense due to liquefaction but remains a lentiform lesion. The diagnosis is best verified with MR. One will find an extracerebral density with biconvex contours, of variable thickness and spread. The inner margin is straight, blood is contained withing the periosteum. Early liquefaction of the clot (within 24–48 hours) is typical for this lesion, scans of which may indicate the relative fluid levels. Major haemorrhage may give rise to uncal herniation, intracranial hypertension and hypoperfusion of the ipsilateral middle cerebral artery or its branches. In case of a mass effect the ipsilateral ventricle may be compressed, with a shift of the interhemispheric fissure and third ventricle. There are infusion-related rare instances of epidural effusions with scalp or jugular vein occlusion from thrombophlebitis. > historical account cephalhaematoma externum et internum examples epidural haematoma s u m m a r y epidural haematoma: summary with plexus haemorrhage with contusion mitochondrial disorder Epidural  haematoma Synonyms : cephalhematoma internum, internal subperiosteal bleeding. Anatomical description : Epidural collections of blood are located between any calvarial bone and its inner periosteum or between the periosteal membrane and the underlying outer dural fibrous stratum. As with cephalhaematoma, some epidural haemorrhages are confined to one skull bone, either above (Takagi et al. 1978) or underneath (Esparza et al. 1982) the cerebellar tent. The frontal variant must be exceptionally rare in the neonatal period. If extravasation follows laceration of the middle meningeal artery or a large venous sinus the bleeding may rapidly attain life-threatening dimensions as space-occupying lesion and because of associated hypovolaemia (Choux et al. 1975, Gama and Fenichel 1985). Damage to small venous channels alone - emissary veins or dural vessels - will lead to moderate or mild bleeding, detectable only on CT or NMR scan against the appropriate anamnestic background. Venous haemorrhage could however become a major problem in case of associated haemostatic failure (Cooper and Lynch 1979).  Incidence : The rarity of this event is illustrated by its absence from several classic reports on intracranial bleeding in perinatal autopsies : together they describe no such lesion against 186 tentorial injuries (Holland 1937, Craig 1938, Gröntoft 1953). Larroche mentioned one epidural haematoma with associated parietal fracture in a cohort of 700 perinatal autopsies (Larroche 1977). Valdes-Dapena and Arey 1970 recorded one epidural bleed in six cases of fatal cranial birth trauma coming from a population of 17,022 liveborn infants weighing over 2.5 kg. In a series of papers between 1980 and 1991 on 383 intracranial haemorrhagic lesions diagnosed in living term newborns only two epidurals were reported (Flodmark et al. 1980, Guekos-Thöni et al. 1980, Leblanc and O'Gorman 1980, Ludwig et al. 1980, Brockerhoff et al. 1981, Fenichel et al. 1984, Pierre-Kahn et al. 1985, Welch and Strand 1986, Romodanov and Brodsky 1987, Sachs et al. 1987, Oelberg et al. 1988) : 0.5 per cent were epidural bleeds, 4.4 cerebellar, 8.9 posterior fossa subdural, 9.1 cerebral parenchymal or in the basal ganglia, 15.1 intraventricular, 24.8 supratentorial subdural, 37.0 subarachnoid. Within a consecutive series between 1980 and 1990 of 31 term infants with cranial birth trauma autopsied at Hammersmith Hospital,  epidural haematoma was not on record. Aoki, reviewing the available literature from 1922 on, gathered 28 instances of neonatal epidural haemorrhage, the majority of Japanese origin (Aoki 1990). At least eight additional descriptions can be traced (Naujoks 1934, Saint-Anne-Dargassies 1957, Tank et al. 1971, Natelson and Sayers 1973). Whatever the exact number of reported cases, their scarcity is in slight contrast with personal observation of five cases in Gent between 1988 and 1991 (Table). This can probably be explained by our eagerness during the latter part of the eighties to undertake CT scanning of the cranium in neurologically distressed neonates following difficult vacuum extraction, resulting in recognition of an epidural haemorrhage in four infants over a three year period. Most reported cases have been ascribed to traumatic forceps traction (Saint-Anne-Dargassies 1957, Takagi et al. 1978, Gama and Fenichel 1985), but breech delivery was responsible in a few (Tank et al. 1971, Takagi et al. 1978) and vacuum extraction in one other (Aoki 1990). Spontaneous vaginal delivery preceded the event in a newborn with an early neonatal haemorrhagic diathesis (Merry and Stuart 1979). Pathogenesis : The rarity of epidural bleeding below the age of one year, even following events as predisposing to trauma as vaginal childbirth, is in part explained by skull pliability and by firm attachment of the dural membrane to neonatal sutures (Choux 1986). At least three different mechanisms can lead to it. The first was suspected by Lefkowitz and can be referred to as 'parieto-temporal osteodiastasis' : unusual separation between these bones could cause the upper temporal margin to act like a fracture and injure the dural vessels (Lefkowitz 1936). The second way has been recognized in over half the neonatal cases : irregular sharp bone edges along a genuine fracture lacerate the middle meningeal artery (Gama and Fenichel 1985) or one of its branches, or damage an important underlying sinus. Lack of a real groove for the meningeal vessels to rest in clarifies why skull fractures in the neonate are not often complicated by epidural haemorrhage (Takagi et al. 1978). The absence of a fracture in an important number of cases is explained by the third method, whereby bending of the moulded bone causes detachment of the dural membranes from its center. This dehiscence can disrupt fibrovascular connections between dura and bone (Takagi et al. 1978). An interesting observation, of practical importance in relation to treatment, is the early liquefaction of the blood collection sometimes within 24 hours after birth (personal observation). This phenomenon, attended to by Aoki, is comparable with early liquefaction of a cephalhaematoma and it is suggested that communication between an external and internal cephalhaematoma can on occasion lead to it (Aoki 1983, Aoki 1990). Clinical setting (Table) : Difficult delivery is nearly obligatory, only overruled by haemorrhagic diathesis, e.g. vitamin K deficiency, in exceptional situations (Cooper and Lynch 1979, Lam et al. 1991). Fetal and/or birth asphyxia are by no means impressive. As with other types of neonatal intracranial bleeding male sex clearly dominates in the cases reviewed, as does nulliparity. Major neurological disturbances - rarely following a lucid interval - such as coma or stupor, severe hypotonia, apnoea, fixed bradycardia and a tense fontanelle, are one possible presenting symptom-complex. Life-threatening intracranial hypertension in those cases with extensive bleeding, warrants neurosurgical intervention especially if uncal herniation is suggested by unilateral mydriasis. Because the neonatal skull is able to bear with important distention, some important bleedings may only present with anaemia and obstructive hydrocephalus (Merry and Stuart 1979). We believe the majority of epidural haemorrhages to hide within the population of more or less unremarkable newborns presenting with cephalhaematoma or mild subgaleal bleeding, having less striking signs such as grunting, paleness, painful grimacing on handling or showing opisthotonic posturing. Other neurological features like fever (Gama and Fenichel 1985), seizures or hemiparesis are exceptional. Floppiness, due to Prader-Willi syndrome in one of our patients, is a well-known cause of breech presentation and subsequent birth trauma. Some epidural haematomas are a chance finding during CT scanning e.g. for the investigation of cephalhaematoma with skull fracture (Aoki 1983, Gouyon et al. 1985). The latter was present in all our cases, though several authors suggest its absence in up to 50 per cent of patients (Takagi et al. 1978, Choux 1986). All epidurals we could trace to be associated with vacuum delivery were covered by a bone fracture. Radiological assessment : Conventional skull X-rays usually illustrate a linear fracture of the parietal or occipital bone or, less common, a depressed one (Aoki 1983). Temporo-parietal osteodiastasis is indirectly suggested by obvious parietal bone lifting. Even though ultrasound examination will not detect a small haematoma located within the concave curve of a skull bone, obvious haemorrhages are readily demonstrated mainly because of hypodensity due to partial liquefaction (Lam et al. 1991).  CT - and probably NMR - scans are the only reliable diagnostic tools. Typically the haematoma is biconcave like a lens and has very neat margins. As stipulated in the  definition, some of them do cross suture lines because they are situated between periosteum and outer dural layer. Bone window setting on CT scan helps to document associated osseous lesions. The most intruiging phenomenon is a tendency to liquefy fast - in about one third of the cases - leading to a differential density within the collection (Aoki 1990). Uncal herniation can sometimes be suspected because of hypodensity of the brain parenchyma perfused by the ipsilateral posterior or middle cerebral artery (see chapter on arterial cerebral occlusion following birth trauma). The only haematoma associated with severe neurological problems and arterial cerebral hypoperfusion in our series had a depth above 10 mm, a width above 50 mm, was situated below the level of Reill's insula and shifted the midline. Comparable measurements from other reports are not available, but we suggest they should be interpreted for differentiation between surgical and conservative situations. Case history (AT,  male, outborn, 39/40, 2350 g): This boy was firstborn at 39 weeks of gestation. He was delivered by the breech, fundal pressure being exerted to pass the aftercoming head. His Apgar scores were one and four at one and five minutes respectively; birthweight was 2350 g. Paleness, hypotonia and lethargy developed on the first day. He was referred with a tense fontanelle and because an extracerebral haemorrhage had been suspected on CT scan. Neither seizures nor inequality of the pupils had been observed. His heart rate was fixed around 120 bpm. The lentiform extraparenchymal density on CT and US scan was pathognomonic of epidural haemotoma with partial liquefaction. Plain X rays and CT scan with bone window setting documented an underlying parietal bone fracture on the right. Hypodensity of the ipsilateral occipito-temporal brain parenchyma suggested impending arterial ischaemia and prompted neurosurgical intervention on day three. The haematoma was aspirated under local anaesthesia through a dural incision via the lateral lambdoid suture. In the immediate postsurgical period the fontanelle lost its tension and the shifted midline on US returned to the original position. A residual epidural hygroma resorbed over the ensuing weeks. Slow neurological recovery, with profound floppiness and distinct facial dysmorphic features, was shown to be due to underlying Prader-Willi syndrome with characteristic karyotypic abnormalities.  Management and prognosis : Most epidural bleedings do not present with intracranial hypertension and heal spontaneously. Three major indications for surgical intervention are : (i) impression of a bone fragment into the cerebral parenchyma; (ii) growing skull fracture; (iii) life-threatening acute intracranial hypertension (Choux 1986). Some lesions, especially those with associated fracture, can only be approached safely with craniotomy (Gama and Fenichel 1985). In the same intervention a cephalhaematoma can be surgically drained. Tapping through a suture - either coronal or lambdoid - under local anaesthesia (as in our case four) or through a burr hole is the alternative method (Aoki 1990). Irrespective of the density-aspects on CT, this percutaneous approach has been advocated as the warranted first treatment method. Within this small series, neurological sequelae related to the intracranial injury were not recognized. Table                           Neonatal epidural haemorrhage (UZ Gent 1988-1991, N = 5) Number                           1        2         3         4         5         Sex                                 M        F         M         M        M  Inborn                             +        +         -         -         -  GA (w)                            39       38      40.      39      40 Parity                              2         1        ?         1        1   Birthweight (g)              2950     3300     3100     2350     3550            OFC (cm)                   34       36       33       35       33   Delivery  . stage I (h)                    5        25        ?        ?         21      stage II (min)               22       55       40      30       60    . decelerations on CTG   +         -         +        +        -    . fundal pressure.           -         +        +        +         ?   . breech                         -         -        -         +         -     . vacuum                        +        +        +        -         +       number                      3        5       15        0         6        detachments.             -        +        +         -         +       elective                     +        -         -         -         -       Apgar 1/5 min               2/8      8/10     4/6      1/4      4/6  pH umb art                   7.16     7.27  Pericranial trauma  . cephalhaematoma        +        -        -        -        +     . subgaleal haem.           -        +        +        -        -  . fracture      bone                       par     occip     par      par      par       side                         R        R        L        R        R Haemoglobin (g/dL)       18       16       13       17      17.6  Tense fontanelle             -        -        -        +       -    Seizures                         -        -        -        -       +    Intracranial lesions  . subarachnoid haem.    +        +        +        +       +  . epidural haem.      side                          R        R        R        R       R       location                   par  par-occ  par    par     par        above insula.             +        -         +        -       -      depth mm                  8        6        2      13       5      length mm                 32     28       8       66      25       diff. density               -        +        -        -       -    . midline shift                -        -        -        +       -   . arterial ischaemiaa      -        -        -        +       -                                                         Treatmentb                     -        -        -        +       -                                                                             Development c  . normal                        +        +        +        -       ?  . cerebral palsy              -        -         -        -       ?                                                         a : region of the right posterior cerebral artery b : tapping through the lambdoid suture c : case 4 was diagnosed, including typical karyotype, as having Prader-Willi syndrome  historical account of epidural haematoma: references from Govaert 1993 one of the intentions of neurosurgery is to stop a mass effect that may lead to several types of tissue herniation, best known is uncal herniation surgical intervention for neonatal intracranial haemorrhage Supratentorial lobar, epidural, subdural or subarachnoid haematoma may cause mass effect and compress the temporal uncus into the tentorial notch (Govaert et al. 1993). This compresses the arterial fork of PCA and superior cerebellar artery, that holds the oculomotor nerve, which results in unilateral mydriasis and ptosis together with anaemia and a tense fontanelle. In advanced cases consciousness may be influenced and a Cushing reflex may follow. This situation requires emergency subdural puncture. The consequence of this lesion is hemianopsia with or without epilepsy of temporal type (Deonna and Prod’hom 1978). uncal herniation The Cushing reflex is manifested clinically in Cushing's triad: (i) when mean arterial pressure is lower than intracranial pressure: hypothalamus increases sympathetic stimulation of the heart, resulting in vasoconstriction, increased contractility, and increased cardiac output; (ii) increase in blood pressure is detected by baroreceptors in the carotid arteries, triggering a parasympathetic response via vagal stimulation inducing bradycardia; (iii) bradycardia may also be stimulated by impinging on the vagal nerve due to increased intracranial pressure causing a stimulate parasympathetic response. Mac OS X  2Û ATTR Ü1Ücom.apple.TextEncodingë com.apple.provenanceöcom.apple.quarantineutf-8;134217984Â.Im0ÖWq/0082;6ad60fd3;Hype4;