Clinical and tomographic criteria for neurosurgical approach in children diagnosed with acute traumatic epidural hematoma

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This study describes the clinical and neuroimaging parameters guiding neurosurgical intervention in children and adolescents with EDH at a reference trauma center. Methods: A retrospective review was conducted of medical records from patients under 17 years who underwent neurosurgical treatment for traumatic EDH between January 2016 and December 2023. Clinical presentations and neuroimaging findings were analyzed to identify the criteria used for surgical decisions. Results: Fifty patients met the inclusion criteria. The cohort had a median age of 5.5 years (IQR 2–10.25) and was predominantly male. Falls (66%) were the most frequent trauma mechanism, followed by road traffic accidents (22%). Mild traumatic brain injury (TBI) was most common (60%). Frequent clinical findings included altered consciousness (50%), vomiting (36%), and nausea (12%). Pupillary changes and motor deficits were observed in 20% and 16%, respectively. In mild TBI, surgery was performed in children ≤ 2 years when EDH was ≥ 10 mm; in older children, EDH > 15 mm with midline shift (MLS) > 5 mm prompted intervention. In moderate TBI, EDH ≥ 15 mm with MLS ≥ 5 mm or EDH ≥ 10 mm with MLS plus pupillary/motor signs led to surgery. In severe TBI, surgery was indicated when EDH was ≥ 8 mm with MLS ≥ 5 mm. Conclusions: Surgical criteria for pediatric EDH vary by age, symptom persistence, and TBI severity. Younger age and neurological signs justify intervention at smaller hematoma sizes and lower MLS thresholds. Cranial Epidural Hematoma Craniocerebral Trauma Traumatic Brain Injury Brain Edema and Trauma Care for Road Traffic Accidents Figures Figure 1 Introduction Acute epidural hematoma (EDH), most commonly caused by rupture of the middle meningeal artery [ 1 ], is know to be one of the bleeding events resulting from traumatic brain injury (TBI) with most urgent need for neurosurgical drainage due to the risk of sudden neurological deterioration and death, particularly in the cases of large-volume hematomas [ 2 – 5 ]. The treatment of EDH is better documented in the adult population, while few studies have established the criteria for surgical drainage in the pediatric population [ 6 , 7 ], making it difficult to develop guidelines [ 8 ]. To the best of our knowledge, no articles have hitherto defined specific protocols for indication of surgical treatment in cases of EDH in the pediatric population, hindering the standardization and guidelines for indication of neurosurgical drainage. Our assertion is based on a search for articles published in the last 10 years (2015–2024) providing guidelines for indication of surgery in cases of EDH in pediatric patients using the MeSH terms “extradural hematoma,” “epidural hematoma”, and “pediatrics” in the Google Scholar, LILACS (Latin American and Caribbean Health Science Literature), PubMed (National Library of Medicine; National Center for Biotechnology Information), and SciELO (Scientific Electronic Library Online) platforms [ 9 , 10 ]. The scope of this study was to identify the clinical and neuroimaging (cranial CT-scan) criteria used for indication of surgical treatment in pediatric patients diagnosed with traumatic EDH in a Brazilian reference trauma center. Method Ethical aspects The study was evaluated and approved by the Human Research Ethics Committee of the Irmandade da Santa Casa de Misericórdia de São Paulo (CAAE 79455824.4.0000.5479, opinion number 6.831.074). This is an exclusively retrospective study involving the analysis of medical records and therefore no individual use of informed consent forms was necessary. Considering the retrospective nature of the study, there were no new risks to the treatment or management of the selected cases. Regarding the precautions to avoid privacy breach and information leakage, the names, photos or images that could identify the patients included in the study were not exposed. Study Design and Sample This retrospective, cross-sectional, analytical study was conducted in the Neurosurgery Department of the Central Hospital of Santa Casa de Misericórdia de São Paulo (HCSCMSP) through a consecutive review of electronic medical records of pediatric patients under 17 years of age victims of TBI who underwent emergency treatment for EDH drainage and were hospitalized between January 2016 and December 2023. Children diagnosed with EDH who were treated non-surgically, patients whose indication of neurosurgical treatment did not include EDH drainage (associated or not with another surgery, according to the surgical description), as well as medical records with incomplete information either due to the absence of clinical data or absence of tomographic images that would allow the analysis of these exams through the review of electronic medical records were excluded from the analyses. Data Collected and Variables Analyzed Regarding the information collected, we analyzed demographic data (age and sex) and the mechanism of trauma (falls from standing height and falls from heights above the ground, road traffic accidents, and other mechanisms of trauma). Regarding the clinical criteria verified at admission to the pediatric emergency department (PED), the following data were reviewed: Glasgow Coma Scale (GCS) score, signs and symptoms (nausea and/or vomiting, headache, and seizures), assessment of pupillary diameter, and presence of motor deficits. Regarding the evaluation of imaging methods for the diagnosis of multiple trauma, we reviewed the results of whole-body CT-scans, radiographs or CT-scans of the suspected injury site, or abdominal ultrasounds. The CT-scan criteria that guided the indication of surgical treatment were reviewed and retrospectively evaluated by a senior neuroradiologist (a blinded evaluator who was unaware of the outcome of the cases included in the study) who verified the location and transverse diameter (measured in mm) of the EDH and the midline shift (MLS) (measured in mm) as well as the presence of other intracranial lesions associated with the EDH. Information regarding the neurosurgical treatment performed was obtained from the surgical descriptions recorded in the medical records. Statistical analyses Statistical analyses were performed using PSPP free software for data analysis/GNU General Public License. Some results are presented descriptively, without need of statistical analysis. Continuous variables with normal distribution were described through means ± standard deviation (SD); otherwise, they were presented as medians ± interquartile range (IQR). Fisher's exact test was used to investigate the presence of pairwise associations between categorical variables. We calculate the odds ratio (OR) when relevant. Results In total, 376 children with TBI were admitted to the PED during the study period. Among these, 50 children with traumatic EDH were treated surgically and included in the analyses of the present study (Fig. 1 ). The general characteristics of the sample included a median age of 5.5 years (IQR 2 -10.25), a similar proportion (50% for each group) of preschool and school-age children, and a predominance of boys (72%; 36/50). Regarding the trauma mechanism, falls prevailed (66%; 33/50) followed by road traffic accidents (22%; 11/50) (Table 1 ). Regarding the GCS score, there was a predominance of mild TBI (60%; 30/50) followed by moderate (22%; 11/50) and severe TBI (18%; 9/50). As for the clinical complaints that influenced the indication for neurosurgical treatment of EDH, most children presented two or more signs and symptoms (56%; 28/50), among which there was a predominance of altered level of consciousness (50%; 25/50) followed by vomiting (36%; 18/50). Regarding pupillary evaluation, abnormalities were recorded in 20% (10/50) of the cases; motor deficit was described in the records of 16% (8/50) (Table 2 ). Table 1 General characteristics of children with traumatic brain injury (TBI) and tomographic diagnosis of acute epidural hematoma (EDH) admitted for neurosurgical treatment in a Brazilian reference trauma center, São Paulo, Brazil (2016–2023). General characteristics Age, n (%) Total < 5 ≥5 n (%) n = 25 (50%) n = 25 (50%) n = 50 (100%) Sex Male 15 (60%) 21 (84%) 36 (72%) Female 10 (40%) 4 (16%) 14 (28%) Mechanism of trauma Fall from own height 7 (28%) 6 (24%) 13 (26%) Falls from heights above the ground* 10 (40%) 10 (40%) 20 (40%) Road traffic accidents ** 4 (16%) 7 (28%) 11 (22%) Others *** 4 (16%) 2 (8%) 6 (12%) * Fall from a slab, stairs, bed and parents' and/or caregivers' lap. **Run over and collision between vehicles. *** Non-motorized means of transport such as skateboarding, rollerblades, scooter and the like, burial (as in landslides), obstetrical trauma and runover by a train. Table 2 Clinical information of children with traumatic brain injury (TBI) and tomographic diagnosis of acute epidural hematoma (EDH) admitted for neurosurgical treatment in a Brazilian reference trauma center, São Paulo, Brazil (2016–2023). Clinical criteria n(%) GCS Score Mild TBI (14–15) 30 (60%) Moderate TBI (9–13) 11 (22%) Severe TBI (≤ 8) 9 (18%) Signs or symptoms Altered level of consciousness 25 (50%) Vomiting 18 (36%) Nausea 12 (24%) Headache 7 (14%) Others* 10 (20%) Pupillary evaluation Isocoria 40 (80%) Anisocoria 8 (16%) Mydriasis 2 (4%) Motor neurological deficit No deficit 33 (66%) Plegia or paresis 8 (16%) Impossibility to evaluate** 9 (18%) GCS: Glasgow Coma Scale. * Blunt-force injuries, otorrhea, irritability and seizures. ** Need for orthopedic immobilization due to multitrauma treatment. The results of whole-body CT-scans, radiographs or CT-scans of the suspected injury site or abdominal ultrasounds revealed the diagnosis of multiple trauma in 26% (13/50) of the children. Regarding the data related to brain CT-scans, other TBI-related intracranial injuries were identified in 19% (8/41) of mild and moderate TBI cases (GCS > 8) and in 67% (6/9) of children with severe TBI (19% vs. 67%; OR 8.2, 95% CI 1.6881–40.3200; p = 0.009). The EDH was predominantly located in the parietal region (30%; 15/50), followed by the temporal (22%; 11/50), frontal (14%; 7/50), temporoparietal (12%; 6/50) region and other less frequent regions (frontotemporoparietal, fronto-parietal, fronto-temporal and occipital) (22%; 11/50). In cases of mild TBI, in children ≤ 2 years of age, surgical drainage was indicated when persistent signs and symptoms were associated with EDH with a transverse diameter ≥ 10 mm; in older age groups, surgical drainage was indicated in the presence of EDH > 15 mm associated with MLS > 5 mm and persistent clinical complaints and/or neurological symptoms. In cases of moderate TBI, regardless of age, surgical drainage was indicated when the children presented EDH ≥ 15 mm and/or MLS ≥ 5 mm, or EDH ≥ 10 mm associated with MLS ≥ 2 mm in the cases in which pupillary alteration or motor deficit was detected. In the group of children with severe TBI, surgery was indicated when EDH ≥ 8 mm and MLS ≥ 5 mm; in cases of pupillary alteration and/or motor deficit, decompressive craniectomy combined with hematoma drainage was chosen due to the frequent association with other intracranial injuries (Table 3 ). The median length of hospital stay was 5 days (IQR 4–9) and the overall death rate was 6% (3/50). Death occurred exclusively in patients with severe TBI and pupillary abnormalities (33%; 3/9). Table 3 Proposed protocol for surgical drainage of traumatic acute epidural hematoma (EDH) in children admitted to a Brazilian reference trauma center, São Paulo, Brazil (2016–2023). GCS Clinical presentation CT-scan Surgical proposal 14–15 Children ≤ 2 years old with persistent clinical manifestations and/or motor deficit. EDH ≥ 10 mm MLS ≥ 2 mm Drainage of EDH only Children > 2 years old with persistent clinical manifestations and/or motor deficit. EDH > 15 mm MLS > 5 mm Drainage of EDH only 9–13 Absence of pupillary alteration and/or motor deficit. EDH ≥ 15 mm MLS ≥ 5 mm Drainage of EDH only Presence of pupillary alteration and/or motor deficit. EDH ≥ 10 mm MLS ≥ 2 mm Drainage of EDH only ≤ 8 Absence of pupillary alteration and/or motor deficit. EDH ≥ 8 MLS ≥ 5 Drainage of EDH only Presence of pupillary alteration and/or motor deficit. EDH ≥ 8 MLS ≥ 5 Drainage of EDH + decompressive craniectomy GCS: Glasgow Coma Scale; EDH: Acute epidural hematoma; MLS: Midline shift. Discussion The median age of the patients analyzed is close to the values ​​described in the literature, ranging from 5.5 to 5.7 years [ 11 , 12 ]. The equal representation of the preschool and school age groups associated with the predominance of males, especially of school age, agrees with previous findings that indicate a higher incidence of TBI in boys, possibly due to behavioral and cultural factors that expose this group to higher-risk activities [ 13 – 16 ]. Regarding the trauma mechanism, EDHs result from direct impacts of the skull against hard surfaces [ 17 ], usually involving falls from different heights and various intensities. In preschool children, there is a prevalence of falls from small heights (< 1 m) such as from beds, the caregiver's lap, low steps, and one's own height, and the trauma usually occurs in domestic environments. One possible explanation for this pattern is the immature walking skills, anatomical characteristics (relatively larger head, displaced center of gravity, and immature cervical muscles), and curiosity inherent to children in this age [ 18 – 22 ]. In school-age children, in turn, there is a prevalence of falls from greater heights, such as those from first floor or higher floor slabs. Slabs, that is, continuous reinforced concrete structures that form upper floors or ceilings, generally lack structures to ensure the safety of people walking on them, what may result in falls with high kinetic energy [ 23 ]. Furthermore, these places are often used for games, with kite flying being the most common game in the region covered by the reference hospital where this study was developed [ 24 ]. The GCS, the gold standard scale for assessing the level of consciousness in TBI victims, proved to be essential in the current study to identify children with traumatic EDH who received an indication for surgical treatment. The predominance of mild TBI identified in this study is in agreement with previous publications that describe prevalence rates between 49.7–65% [ 11 , 21 , 25 , 26 ]. The high percentage of mild trauma can be explained by the fact that most falls are from small heights, usually from one's own height or from heights below one meter, such as from a few steps, beds, and the caregiver's lap. Furthermore, young children have greater cranioencephalic plasticity compared to adults and, therefore, their skull absorbs better the initial impact [ 27 , 28 ]. Regarding signs and symptoms following TBI, we noticed that altered consciousness was the most common symptom, similarly to previous studies in which prevalence rates between 22–56% are reported [ 1 , 2 , 29 – 33 ]. Regarding pupillary abnormalities, we found results that are in line with other authors who indicate a prevalence between 20% and 30% [ 1 , 2 , 30 , 34 , 35 ]. The appearance of motor deficits and pupillary abnormalities in patients with EDH can both be attributed to the direct compression of the motor cortex by the overlying hematoma, as well as to compression of the cerebral peduncle due to displacement of the brain and uncal herniation. In younger children, there is greater compaction of the petrous bone in relation to the other bones of the skull base, which results in a biomechanical difference in how the impact of trauma and compression caused by hematomas can affect the region of the cerebral peduncle [ 27 , 28 ]. Regarding the occurrence of motor deficits, the percentage observed in the current study is greater than that observed in other studies [ 36 , 37 ]. This dissonance can be attributed to the higher incidence, in this study, of moderate and severe trauma resulting from falls of more than 1 m and from road traffic accidents in a population with a median age lower than that described in the aforementioned studies. Regarding the results of whole-body CT scans, radiographs or CT scans of the suspected injury site, and abdominal ultrasounds, the diagnosis of multiple trauma was established in a proportion similar to that reported in the literature, which cites a prevalence of 25.6% which is particularly evident in the proportion of multiple trauma cases associated with road traffic accidents [ 38 ] Considering the CT-scan analyzed, EDH showed a higher prevalence in the parietal region followed by the temporal region. These results are in agreement with the reviewed literature, which indicates these areas as the most frequently affected [ 1 , 25 , 27 , 28 ]. This distribution is explained by the extension of the parietal and temporal bones, which form a large part of the lateral and superior walls of the skull, making these regions more susceptible to trauma. Regarding the radiological criteria for indication of surgical treatment, the literature focuses mainly on the adult population and indicates surgical management for patients with hematoma volume > 30 cm³ or thickness > 15 mm and midline shift (MLS) > 5 mm [ 1 , 39 ]. When available in pediatric cases, the tomographic criteria differ. Some studies propose other cutoff values ​​for surgical indication, such as volume > 20 cm³ [ 40 ] or thickness > 18 mm with MLS > 4 mm [ 41 ]. Other authors still advocate that EDHs with thickness > 12 mm [ 42 ] or even thickness > 10 mm and MLS > 5 mm should undergo surgical drainage [ 43 ]. In mild TBI (GCS 14–15), isolated EDH drainage was observed in the present study in children ≤ 2 years of age with EDH ≥ 10 mm or MLS ≥ 2 mm and persistent clinical manifestations or motor deficit, and in cases of patients > 2 years of age, when EDH > 15 mm and/or MLS > 5 mm. A possible explanation for this decisions is the limitation of the GCS in pre-verbal children, as highlighted by other authors [ 44 – 46 ]. In children ≤ 2 years of age, speech criteria cannot be assessed with the same accuracy as in older children, adolescents, and adults, resulting in lower reliability of the scale as a predictor of prognosis. Regarding children > 2 years of age, management occurs as in adults [ 1 , 39 ], which may be justified by the greater cranial plasticity in childhood [ 27 , 28 , 47 ]. In cases of moderate TBI (GCS 9–13) in our sample, exclusive drainage of the EDH was indicated in children without pupillary alterations or motor deficits whose tomographic criteria were borderline to those adopted in the protocol considered for the treatment of adult patients (EDH ≥ 15 mm and/or MLS ≥ 5 mm) [ 1 , 39 ]. In the presence of focal neurological deficits, surgical intervention was indicated with lower thresholds (EDH ≥ 10 mm, MLS ≥ 2 mm), as suggested by pediatric protocols [ 42 , 43 ]. This difference indicates that, in the presence of neurological motor deficit or pupillary abnormalities, these parameters tend to override the isolated criterion of hematoma volume in the therapeutic decision. Considering the children with severe TBI (GCS ≤ 8) included in the present study, surgical treatment was mainly indicated in cases of MLS ≥ 5 mm, regardless of the diameter of the hematoma. We can infer, thus, that in more severe cases the signs and symptoms are mainly caused by secondary compression of brain structures (multiple brain injuries) after the primary injury [ 21 , 48 ]. Regarding the length of hospital stay, the findings of this study are consistent with the mean described in the literature, which varies between 4.8 and 8.6 days [ 11 , 21 , 25 , 38 , 41 , 49 , 50 ]. This short hospital stay can be attributed to the predominance of mild and moderate TBI cases, the absence of associated traumatic brain injuries in most cases, and early neurosurgical intervention, factors that favor discharge in a shorter time [ 41 ]. The mortality rate observed in the present study is among the data verified in the literature, ranging from 4–12.5% ​​ [ 1 , 11 , 18 , 38 ], and is frequently associated with the presence of pupillary alterations in patients with severe TBI [ 11 ]. Limitations and Merits Until the completion of this article, we did not find any established guidelines for the surgical treatment of pediatric patients with traumatic EDH in the literature consulted, which has also been observed by other authors [ 47 ], demonstrating the difficulty in establishing criteria for indication of surgical treatment in this age group. Our study evaluated only one reference trauma center, which does not necessarily represent the reality of other centers, especially in regions with different resources and standards for medical care provision. Additionally, due to systemic limitations in the current hospital infrastructure at HCSCMSP, it was not possible to access or evaluate the clinical progression of patients with EDH who did not undergo surgical intervention, preventing inclusion of this population as a comparative or control group in the study. There are no surgical guidelines aimed at the pediatric population with traumatic EDH. This hinders standardization and leads neurosurgeons to rely on individual clinical experience and protocols established for adult patients to make decisions regarding a surgical approach. Further research is needed to corroborate or refute the findings presented here. We recognize that a thorough clinical evaluation and case-by-case definition are essential to appropriately design the treatment for children with traumatic EDH. However, we believe that based on the criteria established for the neurosurgical treatment of children with traumatic EDH in a Brazilian trauma center, our study can help in the decision-making process of neurosurgeons who treat these patients in different situations and conditions. Conclusion The criteria for the surgical approach to traumatic EDH in children and adolescents vary according to age group, persistence of signs and symptoms, and severity of TBI. In children ≤ 2 years of age with persistent complaints or clinical changes, EDH ≥ 10 mm are treated surgically. In older age groups, surgical treatment was usually established in cases of EDH ≥ 15 mm associated with MLS ≥ 5 mm. In cases of severe TBI associated with pupillary abnormalities and/or motor neurological deficit with multiple brain injuries and MLS, surgical drainage of the EDH was associated with decompressive craniectomy. Declarations Author Contribution Conceptualization: Caio VA Chaves, José RT Melo and Luiza M Montagna.Data curation: Caio VA Chaves, José RT Melo and Luiza M Montagna.Formal analysis: Caio VA Chaves, José RT Melo and Luiza M Montagna.Investigation: Caio VA Chaves, José RT Melo, Luiza M Montagna and Max YO Salazar.Methodology: Caio VA Chaves and José RT Melo.Project administration: Jean G de Oliveira, Antônio J da Rocha and José CE Veiga.Supervision: Jean G de Oliveira, Antônio J da Rocha and José CE Veiga.Writing – original draft: Caio VA Chaves and José RT Melo.Writing – review and editing: Caio VA Chaves and José RT Melo. References Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute epidural hematomas. Neurosurgery. 2006 Mar;58(3 Suppl):S7-15; discussion Si-iv. PMID: 16710967. Bricolo A, Pasut L: Extradural hematoma: toward zero mortality. 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CJT 19: 75-78. https://dx.doi.org/10.1016/j.cjtee.2015.10.004. Chen TY, Wong CW, Chang CN, et al. The expectant treatment of asymptomatic supratentorial epidural hematomas. Neurosurgery 1993;32: 176-179. Gok H, Celik SE, Yangi K, Yavuz AY, Percinoglu G, Unlu NU, Goksu K. Management of Epidural Hematomas in Pediatric and Adult Population: A Hospital-Based Retrospective Study. World Neurosurg. 2023 Jul 3:S1878-8750(23)00906-3. doi: 10.1016/j.wneu.2023.06.123. Epub ahead of print. PMID: 37406801. Bejjani GK, Donahue DJ, Rusin J, et al. Radiological and clinical criteria for the management of epidural hematomas in children. Pediatr Neurosurg 1996;25:302-308. Cucciniello B, Martellotta N, Nigro D, Citro E: Conservative management of extradural haematomas. Acta Neurochir (Wien) 120:47–52, 1993. Paiva, W. S., Andrade, A. F. de, Mathias Júnior, L., Guirado, V. M. de P., Amorim, R. L., Magrini, N. N., & Teixeira, M. J. (2010). Management of supratentorial epidural hematoma in children: report on 49 patients. Arquivos de Neuro-Psiquiatria, 68(6), 888–892. doi:10.1590/s0004-282x2010000600011. Borgialli DA, Mahajan P, Hoyle JD Jr, Powell EC, Nadel FM, Tunik MG, Foerster A, Dong L, Miskin M, Dayan PS, Holmes JF, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma. Acad Emerg Med. 2016 Aug;23(8):878-84. doi: 10.1111/acem.13014. Epub 2016 Aug 1. PMID: 27197686. Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9. doi: 10.1197/j.aem.2005.04.019. PMID: 16141014. Melo JRT, Lobo IAS, Montagna LM, Totaro S, Vasques VP, Chicuto LAD, de Oliveira JG, Veiga JCE. Performance of the necker cranial injury scale as a predictor of prognosis in children with severe traumatic brain injury: A retrospective cohort study. Neurochirurgie, v. 71, p. 101657, 2025. Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J. Epidural Hematoma Treated Conservatively: When to Expect the Worst. Can J Neurol Sci. 2016 Jan;43(1):74-81. doi: 10.1017/cjn.2015.232. PMID: 26786639. Uzan M, Yentür E, Hanci M, Kaynar MY, Kafadar A, Sarioglu AC, Bahar M, Kuday C. Is it possible to recover from uncal herniation? Analysis of 71 head injured cases. J Neurosurg Sci. 1998 Jun;42(2):89-94. PMID: 9826793. Silva JAV, Padula MPC, Waters C. Epidemiological and clinical profile and outcome of patients with traumatic brain injury. Arq Med Hosp Fac Cienc Med Santa Casa São Paulo 2021;66:e017. Doi: 10.26432/1809-3019.2021.66.017. Chaoguo Y, Xiu L, Liuxun H, Hansong S, Nu Z. Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature. J Korean Neurosurg Soc. 2019 Mar;62(2):225-231. doi: 10.3340/jkns.2016.0506.007. Epub 2019 Feb 27. PMID: 30840978; PMCID: PMC6411576. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7356997","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":530855575,"identity":"73c69567-a3a8-491d-8843-434c84a18e78","order_by":0,"name":"Caio Vinícius de Almeida Chaves","email":"data:image/png;base64,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","orcid":"","institution":"School of Medical Sciences, Santa Casa of São Paulo","correspondingAuthor":true,"prefix":"","firstName":"Caio","middleName":"Vinícius de Almeida","lastName":"Chaves","suffix":""},{"id":530855576,"identity":"480cb859-688e-4d03-abd8-e1a7919321d3","order_by":1,"name":"José Roberto Tude Melo","email":"","orcid":"","institution":"School of Medical Sciences, Santa Casa of São 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12:42:14","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118086,"visible":true,"origin":"","legend":"","description":"","filename":"63567d1f24a84f848d5f593ac6ebde2e1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7356997/v1/cb1e56fd72a79c3840c1f106.xml"},{"id":93778900,"identity":"b86afa9f-c8ef-4c57-a3b9-16f6b9a84057","added_by":"auto","created_at":"2025-10-17 12:50:14","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":130695,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7356997/v1/e2e93a5d0dfddf94e7647844.html"},{"id":93777611,"identity":"72e3354c-b22e-4ad5-990d-63ec909e9cfb","added_by":"auto","created_at":"2025-10-17 12:42:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":267141,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of hospitalization of pediatric patients victims of traumatic brain injury (TBI) in a Brazilian reference trauma center, São Paulo, Brazil (2016-2023).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7356997/v1/29afa2a277ff305a1ab33ce7.png"},{"id":99799534,"identity":"ba911782-3d73-48d6-9f2a-73a728d7f303","added_by":"auto","created_at":"2026-01-08 13:49:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":848572,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7356997/v1/e60e8f24-d503-43cc-bb44-1a7f6fe32770.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical and tomographic criteria for neurosurgical approach in children diagnosed with acute traumatic epidural hematoma","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute epidural hematoma (EDH), most commonly caused by rupture of the middle meningeal artery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], is know to be one of the bleeding events resulting from traumatic brain injury (TBI) with most urgent need for neurosurgical drainage due to the risk of sudden neurological deterioration and death, particularly in the cases of large-volume hematomas [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The treatment of EDH is better documented in the adult population, while few studies have established the criteria for surgical drainage in the pediatric population [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], making it difficult to develop guidelines [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e To the best of our knowledge, no articles have hitherto defined specific protocols for indication of surgical treatment in cases of EDH in the pediatric population, hindering the standardization and guidelines for indication of neurosurgical drainage. Our assertion is based on a search for articles published in the last 10 years (2015\u0026ndash;2024) providing guidelines for indication of surgery in cases of EDH in pediatric patients using the MeSH terms \u0026ldquo;extradural hematoma,\u0026rdquo; \u0026ldquo;epidural hematoma\u0026rdquo;, and \u0026ldquo;pediatrics\u0026rdquo; in the Google Scholar, LILACS (Latin American and Caribbean Health Science Literature), PubMed (National Library of Medicine; National Center for Biotechnology Information), and SciELO (Scientific Electronic Library Online) platforms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The scope of this study was to identify the clinical and neuroimaging (cranial CT-scan) criteria used for indication of surgical treatment in pediatric patients diagnosed with traumatic EDH in a Brazilian reference trauma center.\u003c/p\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthical aspects\u003c/h2\u003e\u003cp\u003e The study was evaluated and approved by the Human Research Ethics Committee of the Irmandade da Santa Casa de Miseric\u0026oacute;rdia de S\u0026atilde;o Paulo (CAAE 79455824.4.0000.5479, opinion number 6.831.074). This is an exclusively retrospective study involving the analysis of medical records and therefore no individual use of informed consent forms was necessary. Considering the retrospective nature of the study, there were no new risks to the treatment or management of the selected cases. Regarding the precautions to avoid privacy breach and information leakage, the names, photos or images that could identify the patients included in the study were not exposed.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy Design and Sample\u003c/h3\u003e\n\u003cp\u003e This retrospective, cross-sectional, analytical study was conducted in the Neurosurgery Department of the Central Hospital of Santa Casa de Miseric\u0026oacute;rdia de S\u0026atilde;o Paulo (HCSCMSP) through a consecutive review of electronic medical records of pediatric patients under 17 years of age victims of TBI who underwent emergency treatment for EDH drainage and were hospitalized between January 2016 and December 2023. Children diagnosed with EDH who were treated non-surgically, patients whose indication of neurosurgical treatment did not include EDH drainage (associated or not with another surgery, according to the surgical description), as well as medical records with incomplete information either due to the absence of clinical data or absence of tomographic images that would allow the analysis of these exams through the review of electronic medical records were excluded from the analyses.\u003c/p\u003e\n\u003ch3\u003eData Collected and Variables Analyzed\u003c/h3\u003e\n\u003cp\u003eRegarding the information collected, we analyzed demographic data (age and sex) and the mechanism of trauma (falls from standing height and falls from heights above the ground, road traffic accidents, and other mechanisms of trauma). Regarding the clinical criteria verified at admission to the pediatric emergency department (PED), the following data were reviewed: Glasgow Coma Scale (GCS) score, signs and symptoms (nausea and/or vomiting, headache, and seizures), assessment of pupillary diameter, and presence of motor deficits. Regarding the evaluation of imaging methods for the diagnosis of multiple trauma, we reviewed the results of whole-body CT-scans, radiographs or CT-scans of the suspected injury site, or abdominal ultrasounds. The CT-scan criteria that guided the indication of surgical treatment were reviewed and retrospectively evaluated by a senior neuroradiologist (a blinded evaluator who was unaware of the outcome of the cases included in the study) who verified the location and transverse diameter (measured in mm) of the EDH and the midline shift (MLS) (measured in mm) as well as the presence of other intracranial lesions associated with the EDH. Information regarding the neurosurgical treatment performed was obtained from the surgical descriptions recorded in the medical records.\u003c/p\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eStatistical analyses were performed using PSPP free software for data analysis/GNU General Public License. Some results are presented descriptively, without need of statistical analysis. Continuous variables with normal distribution were described through means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD); otherwise, they were presented as medians\u0026thinsp;\u0026plusmn;\u0026thinsp;interquartile range (IQR). Fisher's exact test was used to investigate the presence of pairwise associations between categorical variables. We calculate the odds ratio (OR) when relevant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn total, 376 children with TBI were admitted to the PED during the study period. Among these, 50 children with traumatic EDH were treated surgically and included in the analyses of the present study (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The general characteristics of the sample included a median age of 5.5 years (IQR 2 -10.25), a similar proportion (50% for each group) of preschool and school-age children, and a predominance of boys (72%; 36/50). Regarding the trauma mechanism, falls prevailed (66%; 33/50) followed by road traffic accidents (22%; 11/50) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding the GCS score, there was a predominance of mild TBI (60%; 30/50) followed by moderate (22%; 11/50) and severe TBI (18%; 9/50). As for the clinical complaints that influenced the indication for neurosurgical treatment of EDH, most children presented two or more signs and symptoms (56%; 28/50), among which there was a predominance of altered level of consciousness (50%; 25/50) followed by vomiting (36%; 18/50). Regarding pupillary evaluation, abnormalities were recorded in 20% (10/50) of the cases; motor deficit was described in the records of 16% (8/50) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eGeneral characteristics of children with traumatic brain injury (TBI) and tomographic diagnosis of acute epidural hematoma (EDH) admitted for neurosurgical treatment in a Brazilian reference trauma center, S\u0026atilde;o Paulo, Brazil (2016\u0026ndash;2023).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneral characteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge, n (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ge;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;25 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;25 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u0026thinsp;=\u0026thinsp;50 (100%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (60%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (84%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36 (72%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14 (28%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMechanism of trauma\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFall from own height\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (24%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13 (26%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFalls from heights above the ground*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (40%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 (40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRoad traffic accidents **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (28%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOthers ***\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (16%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (12%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Fall from a slab, stairs, bed and parents' and/or caregivers' lap.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e**Run over and collision between vehicles.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e*** Non-motorized means of transport such as skateboarding, rollerblades, scooter and the like, burial (as in landslides), obstetrical trauma and runover by a train.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical information of children with traumatic brain injury (TBI) and tomographic diagnosis of acute epidural hematoma (EDH) admitted for neurosurgical treatment in a Brazilian reference trauma center, S\u0026atilde;o Paulo, Brazil (2016\u0026ndash;2023).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClinical criteria\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGCS Score\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild TBI (14\u0026ndash;15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (60%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate TBI (9\u0026ndash;13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (22%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSevere TBI (\u0026le;\u0026thinsp;8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSigns or symptoms\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAltered level of consciousness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25 (50%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVomiting\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (36%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNausea\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (24%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeadache\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (14%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (20%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePupillary evaluation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsocoria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (80%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnisocoria\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (16%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMydriasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotor neurological deficit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo deficit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33 (66%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePlegia or paresis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (16%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImpossibility to evaluate**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (18%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003eGCS: Glasgow Coma Scale.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e* Blunt-force injuries, otorrhea, irritability and seizures.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"2\"\u003e** Need for orthopedic immobilization due to multitrauma treatment.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe results of whole-body CT-scans, radiographs or CT-scans of the suspected injury site or abdominal ultrasounds revealed the diagnosis of multiple trauma in 26% (13/50) of the children. Regarding the data related to brain CT-scans, other TBI-related intracranial injuries were identified in 19% (8/41) of mild and moderate TBI cases (GCS\u0026thinsp;\u0026gt;\u0026thinsp;8) and in 67% (6/9) of children with severe TBI (19% vs. 67%; OR 8.2, 95% CI 1.6881\u0026ndash;40.3200; p\u0026thinsp;=\u0026thinsp;0.009). The EDH was predominantly located in the parietal region (30%; 15/50), followed by the temporal (22%; 11/50), frontal (14%; 7/50), temporoparietal (12%; 6/50) region and other less frequent regions (frontotemporoparietal, fronto-parietal, fronto-temporal and occipital) (22%; 11/50).\u003c/p\u003e\u003cp\u003eIn cases of mild TBI, in children\u0026thinsp;\u0026le;\u0026thinsp;2 years of age, surgical drainage was indicated when persistent signs and symptoms were associated with EDH with a transverse diameter\u0026thinsp;\u0026ge;\u0026thinsp;10 mm; in older age groups, surgical drainage was indicated in the presence of EDH\u0026thinsp;\u0026gt;\u0026thinsp;15 mm associated with MLS\u0026thinsp;\u0026gt;\u0026thinsp;5 mm and persistent clinical complaints and/or neurological symptoms. In cases of moderate TBI, regardless of age, surgical drainage was indicated when the children presented EDH\u0026thinsp;\u0026ge;\u0026thinsp;15 mm and/or MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm, or EDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm associated with MLS\u0026thinsp;\u0026ge;\u0026thinsp;2 mm in the cases in which pupillary alteration or motor deficit was detected. In the group of children with severe TBI, surgery was indicated when EDH\u0026thinsp;\u0026ge;\u0026thinsp;8 mm and MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm; in cases of pupillary alteration and/or motor deficit, decompressive craniectomy combined with hematoma drainage was chosen due to the frequent association with other intracranial injuries (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The median length of hospital stay was 5 days (IQR 4\u0026ndash;9) and the overall death rate was 6% (3/50). Death occurred exclusively in patients with severe TBI and pupillary abnormalities (33%; 3/9).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eProposed protocol for surgical drainage of traumatic acute epidural hematoma (EDH) in children admitted to a Brazilian reference trauma center, S\u0026atilde;o Paulo, Brazil (2016\u0026ndash;2023).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGCS\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eClinical presentation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCT-scan\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSurgical proposal\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u0026ndash;15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChildren\u0026thinsp;\u0026le;\u0026thinsp;2 years old with persistent clinical manifestations and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026ge;\u0026thinsp;2 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH only\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChildren\u0026thinsp;\u0026gt;\u0026thinsp;2 years old with persistent clinical manifestations and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026gt;\u0026thinsp;15 mm\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026gt;\u0026thinsp;5 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH only\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u0026ndash;13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsence of pupillary alteration and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026ge;\u0026thinsp;15 mm\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH only\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresence of pupillary alteration and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026ge;\u0026thinsp;2 mm\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH only\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAbsence of pupillary alteration and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026ge;\u0026thinsp;8\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH only\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePresence of pupillary alteration and/or motor deficit.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEDH\u0026thinsp;\u0026ge;\u0026thinsp;8\u003c/p\u003e\u003cp\u003eMLS\u0026thinsp;\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDrainage of EDH\u0026thinsp;+\u0026thinsp;decompressive craniectomy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eGCS: Glasgow Coma Scale; EDH: Acute epidural hematoma; MLS: Midline shift.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe median age of the patients analyzed is close to the values ​​described in the literature, ranging from 5.5 to 5.7 years [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The equal representation of the preschool and school age groups associated with the predominance of males, especially of school age, agrees with previous findings that indicate a higher incidence of TBI in boys, possibly due to behavioral and cultural factors that expose this group to higher-risk activities [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Regarding the trauma mechanism, EDHs result from direct impacts of the skull against hard surfaces [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], usually involving falls from different heights and various intensities. In preschool children, there is a prevalence of falls from small heights (\u0026lt;\u0026thinsp;1 m) such as from beds, the caregiver's lap, low steps, and one's own height, and the trauma usually occurs in domestic environments. One possible explanation for this pattern is the immature walking skills, anatomical characteristics (relatively larger head, displaced center of gravity, and immature cervical muscles), and curiosity inherent to children in this age [\u003cspan additionalcitationids=\"CR19 CR20 CR21\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. In school-age children, in turn, there is a prevalence of falls from greater heights, such as those from first floor or higher floor slabs. Slabs, that is, continuous reinforced concrete structures that form upper floors or ceilings, generally lack structures to ensure the safety of people walking on them, what may result in falls with high kinetic energy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Furthermore, these places are often used for games, with kite flying being the most common game in the region covered by the reference hospital where this study was developed [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe GCS, the gold standard scale for assessing the level of consciousness in TBI victims, proved to be essential in the current study to identify children with traumatic EDH who received an indication for surgical treatment. The predominance of mild TBI identified in this study is in agreement with previous publications that describe prevalence rates between 49.7\u0026ndash;65% [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The high percentage of mild trauma can be explained by the fact that most falls are from small heights, usually from one's own height or from heights below one meter, such as from a few steps, beds, and the caregiver's lap. Furthermore, young children have greater cranioencephalic plasticity compared to adults and, therefore, their skull absorbs better the initial impact [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Regarding signs and symptoms following TBI, we noticed that altered consciousness was the most common symptom, similarly to previous studies in which prevalence rates between 22\u0026ndash;56% are reported [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Regarding pupillary abnormalities, we found results that are in line with other authors who indicate a prevalence between 20% and 30% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The appearance of motor deficits and pupillary abnormalities in patients with EDH can both be attributed to the direct compression of the motor cortex by the overlying hematoma, as well as to compression of the cerebral peduncle due to displacement of the brain and uncal herniation. In younger children, there is greater compaction of the petrous bone in relation to the other bones of the skull base, which results in a biomechanical difference in how the impact of trauma and compression caused by hematomas can affect the region of the cerebral peduncle [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Regarding the occurrence of motor deficits, the percentage observed in the current study is greater than that observed in other studies [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. This dissonance can be attributed to the higher incidence, in this study, of moderate and severe trauma resulting from falls of more than 1 m and from road traffic accidents in a population with a median age lower than that described in the aforementioned studies.\u003c/p\u003e\u003cp\u003eRegarding the results of whole-body CT scans, radiographs or CT scans of the suspected injury site, and abdominal ultrasounds, the diagnosis of multiple trauma was established in a proportion similar to that reported in the literature, which cites a prevalence of 25.6% which is particularly evident in the proportion of multiple trauma cases associated with road traffic accidents [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] Considering the CT-scan analyzed, EDH showed a higher prevalence in the parietal region followed by the temporal region. These results are in agreement with the reviewed literature, which indicates these areas as the most frequently affected [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. This distribution is explained by the extension of the parietal and temporal bones, which form a large part of the lateral and superior walls of the skull, making these regions more susceptible to trauma. Regarding the radiological criteria for indication of surgical treatment, the literature focuses mainly on the adult population and indicates surgical management for patients with hematoma volume\u0026thinsp;\u0026gt;\u0026thinsp;30 cm\u0026sup3; or thickness\u0026thinsp;\u0026gt;\u0026thinsp;15 mm and midline shift (MLS)\u0026thinsp;\u0026gt;\u0026thinsp;5 mm [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. When available in pediatric cases, the tomographic criteria differ. Some studies propose other cutoff values ​​for surgical indication, such as volume\u0026thinsp;\u0026gt;\u0026thinsp;20 cm\u0026sup3; [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] or thickness\u0026thinsp;\u0026gt;\u0026thinsp;18 mm with MLS\u0026thinsp;\u0026gt;\u0026thinsp;4 mm [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Other authors still advocate that EDHs with thickness\u0026thinsp;\u0026gt;\u0026thinsp;12 mm [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] or even thickness\u0026thinsp;\u0026gt;\u0026thinsp;10 mm and MLS\u0026thinsp;\u0026gt;\u0026thinsp;5 mm should undergo surgical drainage [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn mild TBI (GCS 14\u0026ndash;15), isolated EDH drainage was observed in the present study in children\u0026thinsp;\u0026le;\u0026thinsp;2 years of age with EDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm or MLS\u0026thinsp;\u0026ge;\u0026thinsp;2 mm and persistent clinical manifestations or motor deficit, and in cases of patients\u0026thinsp;\u0026gt;\u0026thinsp;2 years of age, when EDH\u0026thinsp;\u0026gt;\u0026thinsp;15 mm and/or MLS\u0026thinsp;\u0026gt;\u0026thinsp;5 mm. A possible explanation for this decisions is the limitation of the GCS in pre-verbal children, as highlighted by other authors [\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. In children\u0026thinsp;\u0026le;\u0026thinsp;2 years of age, speech criteria cannot be assessed with the same accuracy as in older children, adolescents, and adults, resulting in lower reliability of the scale as a predictor of prognosis. Regarding children\u0026thinsp;\u0026gt;\u0026thinsp;2 years of age, management occurs as in adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], which may be justified by the greater cranial plasticity in childhood [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. In cases of moderate TBI (GCS 9\u0026ndash;13) in our sample, exclusive drainage of the EDH was indicated in children without pupillary alterations or motor deficits whose tomographic criteria were borderline to those adopted in the protocol considered for the treatment of adult patients (EDH\u0026thinsp;\u0026ge;\u0026thinsp;15 mm and/or MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In the presence of focal neurological deficits, surgical intervention was indicated with lower thresholds (EDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm, MLS\u0026thinsp;\u0026ge;\u0026thinsp;2 mm), as suggested by pediatric protocols [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. This difference indicates that, in the presence of neurological motor deficit or pupillary abnormalities, these parameters tend to override the isolated criterion of hematoma volume in the therapeutic decision. Considering the children with severe TBI (GCS\u0026thinsp;\u0026le;\u0026thinsp;8) included in the present study, surgical treatment was mainly indicated in cases of MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm, regardless of the diameter of the hematoma. We can infer, thus, that in more severe cases the signs and symptoms are mainly caused by secondary compression of brain structures (multiple brain injuries) after the primary injury [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eRegarding the length of hospital stay, the findings of this study are consistent with the mean described in the literature, which varies between 4.8 and 8.6 days [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. This short hospital stay can be attributed to the predominance of mild and moderate TBI cases, the absence of associated traumatic brain injuries in most cases, and early neurosurgical intervention, factors that favor discharge in a shorter time [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The mortality rate observed in the present study is among the data verified in the literature, ranging from 4\u0026ndash;12.5% \u003cb\u003e​​\u003c/b\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], and is frequently associated with the presence of pupillary alterations in patients with severe TBI [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e"},{"header":"Limitations and Merits","content":"\u003cp\u003eUntil the completion of this article, we did not find any established guidelines for the surgical treatment of pediatric patients with traumatic EDH in the literature consulted, which has also been observed by other authors [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e], demonstrating the difficulty in establishing criteria for indication of surgical treatment in this age group. Our study evaluated only one reference trauma center, which does not necessarily represent the reality of other centers, especially in regions with different resources and standards for medical care provision. Additionally, due to systemic limitations in the current hospital infrastructure at HCSCMSP, it was not possible to access or evaluate the clinical progression of patients with EDH who did not undergo surgical intervention, preventing inclusion of this population as a comparative or control group in the study. There are no surgical guidelines aimed at the pediatric population with traumatic EDH. This hinders standardization and leads neurosurgeons to rely on individual clinical experience and protocols established for adult patients to make decisions regarding a surgical approach. Further research is needed to corroborate or refute the findings presented here. We recognize that a thorough clinical evaluation and case-by-case definition are essential to appropriately design the treatment for children with traumatic EDH. However, we believe that based on the criteria established for the neurosurgical treatment of children with traumatic EDH in a Brazilian trauma center, our study can help in the decision-making process of neurosurgeons who treat these patients in different situations and conditions.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe criteria for the surgical approach to traumatic EDH in children and adolescents vary according to age group, persistence of signs and symptoms, and severity of TBI. In children\u0026thinsp;\u0026le;\u0026thinsp;2 years of age with persistent complaints or clinical changes, EDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm are treated surgically. In older age groups, surgical treatment was usually established in cases of EDH\u0026thinsp;\u0026ge;\u0026thinsp;15 mm associated with MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm. In cases of severe TBI associated with pupillary abnormalities and/or motor neurological deficit with multiple brain injuries and MLS, surgical drainage of the EDH was associated with decompressive craniectomy.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eConceptualization: Caio VA Chaves, Jos\u0026eacute; RT Melo and Luiza M Montagna.Data curation: Caio VA Chaves, Jos\u0026eacute; RT Melo and Luiza M Montagna.Formal analysis: Caio VA Chaves, Jos\u0026eacute; RT Melo and Luiza M Montagna.Investigation: Caio VA Chaves, Jos\u0026eacute; RT Melo, Luiza M Montagna and Max YO Salazar.Methodology: Caio VA Chaves and Jos\u0026eacute; RT Melo.Project administration: Jean G de Oliveira, Ant\u0026ocirc;nio J da Rocha and Jos\u0026eacute; CE Veiga.Supervision: Jean G de Oliveira, Ant\u0026ocirc;nio J da Rocha and Jos\u0026eacute; CE Veiga.Writing \u0026ndash; original draft: Caio VA Chaves and Jos\u0026eacute; RT Melo.Writing \u0026ndash; review and editing: Caio VA Chaves and Jos\u0026eacute; RT Melo.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, Servadei F, Walters BC, Wilberger JE; Surgical Management of Traumatic Brain Injury Author Group. 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J Neuroimaging. 2012 Apr;22(2):e1-e17. doi: 10.1111/j.1552-6569.2011.00688.x. Epub 2012 Jan 24. PMID: 22273264.\u003c/li\u003e\n\u003cli\u003eJamjoom A: The difference in the outcome of surgery for traumatic extra- dural hematoma between patients who are admitted directly to the neuro- surgical unit and those referred from another hospital. Neurosurg Rev 20:227\u0026ndash;230, 1997.\u003c/li\u003e\n\u003cli\u003eKuday C, Uzan M, Hanci M: Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases. Acta Neurochir (Wien) 131: 203\u0026ndash;206, 1994.\u003c/li\u003e\n\u003cli\u003eLee E, Hung Y, Wang L, Chung K, Chen H: Factors influencing the func- tional outcome of patients with acute epidural hematomas: Analysis of 200 patients undergoing surgery. J Trauma 45:946\u0026ndash;952, 1998.\u003c/li\u003e\n\u003cli\u003eMaggi G, Aliberti F, Petrone G, Ruggiero C. Extradural hematomas in children. 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PMID: 26786639.\u003c/li\u003e\n\u003cli\u003eUzan M, Yent\u0026uuml;r E, Hanci M, Kaynar MY, Kafadar A, Sarioglu AC, Bahar M, Kuday C. Is it possible to recover from uncal herniation? Analysis of 71 head injured cases. J Neurosurg Sci. 1998 Jun;42(2):89-94. PMID: 9826793.\u003c/li\u003e\n\u003cli\u003eSilva JAV, Padula MPC, Waters C. Epidemiological and clinical profile and outcome of patients with traumatic brain injury. Arq Med Hosp Fac Cienc Med Santa Casa S\u0026atilde;o Paulo 2021;66:e017. Doi: 10.26432/1809-3019.2021.66.017.\u003c/li\u003e\n\u003cli\u003eChaoguo Y, Xiu L, Liuxun H, Hansong S, Nu Z. Traumatic Posterior Fossa Epidural Hematomas in Children : Experience with 48 Cases and a Review of the Literature. J Korean Neurosurg Soc. 2019 Mar;62(2):225-231. doi: 10.3340/jkns.2016.0506.007. Epub 2019 Feb 27. PMID: 30840978; PMCID: PMC6411576.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cranial Epidural Hematoma, Craniocerebral Trauma, Traumatic Brain Injury, Brain Edema, and Trauma Care for Road Traffic Accidents","lastPublishedDoi":"10.21203/rs.3.rs-7356997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7356997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003ePurpose: The criteria for selecting surgical versus nonsurgical treatment of pediatric traumatic epidural hematoma (EDH) remain poorly defined. This study describes the clinical and neuroimaging parameters guiding neurosurgical intervention in children and adolescents with EDH at a reference trauma center.\u003c/p\u003e\u003cp\u003eMethods: A retrospective review was conducted of medical records from patients under 17 years who underwent neurosurgical treatment for traumatic EDH between January 2016 and December 2023. Clinical presentations and neuroimaging findings were analyzed to identify the criteria used for surgical decisions.\u003c/p\u003e\u003cp\u003eResults: Fifty patients met the inclusion criteria. The cohort had a median age of 5.5 years (IQR 2\u0026ndash;10.25) and was predominantly male. Falls (66%) were the most frequent trauma mechanism, followed by road traffic accidents (22%). Mild traumatic brain injury (TBI) was most common (60%). Frequent clinical findings included altered consciousness (50%), vomiting (36%), and nausea (12%). Pupillary changes and motor deficits were observed in 20% and 16%, respectively. In mild TBI, surgery was performed in children\u0026thinsp;\u0026le;\u0026thinsp;2 years when EDH was \u0026ge;\u0026thinsp;10 mm; in older children, EDH\u0026thinsp;\u0026gt;\u0026thinsp;15 mm with midline shift (MLS)\u0026thinsp;\u0026gt;\u0026thinsp;5 mm prompted intervention. In moderate TBI, EDH\u0026thinsp;\u0026ge;\u0026thinsp;15 mm with MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm or EDH\u0026thinsp;\u0026ge;\u0026thinsp;10 mm with MLS plus pupillary/motor signs led to surgery. In severe TBI, surgery was indicated when EDH was \u0026ge;\u0026thinsp;8 mm with MLS\u0026thinsp;\u0026ge;\u0026thinsp;5 mm.\u003c/p\u003e\u003cp\u003eConclusions: Surgical criteria for pediatric EDH vary by age, symptom persistence, and TBI severity. Younger age and neurological signs justify intervention at smaller hematoma sizes and lower MLS thresholds.\u003c/p\u003e","manuscriptTitle":"Clinical and tomographic criteria for neurosurgical approach in children diagnosed with acute traumatic epidural hematoma","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-17 12:42:09","doi":"10.21203/rs.3.rs-7356997/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d05b581-e5fa-4cad-9636-bc78379df55b","owner":[],"postedDate":"October 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-01-08T07:40:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-17 12:42:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7356997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7356997","identity":"rs-7356997","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}