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Discussion

Subdural hematoma

A subdural hematoma is an intracranial injury, which can be associated with abusive head trauma (AHT). Other injuries detected with AHT include epidural hematoma, diffuse axonal injury, parenchymal injury, and others.

Data on AHT is more robust in Europe and the U.S. than in other geographic regions, with an incidence of 17 per 100,000 children. However, the incidence of subdural hematoma occurring in children under the age of 2 is about 13 per 100,000 children. The risk of developing a subdural hematoma is highest for those under the age of 1 (1-to-4,761) according to a study in South Wales, England, with an incidence of up to 21 per 100,000 children in this age group. No sex difference has been reported for early-stage subdural hematoma. However, symptomatic subdural hematoma arising from trauma in the teenage years tends to affect males.

Treatment

The immediate treatment of a subdural hematoma initially includes airway and breathing management and circulatory stabilization. After the patient is stabilized and monitored, a secondary care plan should be followed.

Nonsurgical conservative management of a subacute and chronic subdural hematoma is appropriate if the accumulation does not extend so far into the dome that it causes impingement of the brain or brainstem. In contrast, a subdural hematoma that is rapidly increasing or causing any signs of increased intracranial pressure, e.g., hypertension and bradycardia with irregular breathing should prompt surgical evacuation, which is critical for preserving vital functions.

In the meantime, the doctor should begin immediate medical treatment. These measures include anesthesia, a neuromuscular blockade when appropriate, moderate hyperventilation, adequate oxygen, head elevation, and avoidance of hyperthermia. Infusion of hypertonic saline or mannitol reduces intracranial pressure by enhancing osmotic changes in the brain and transiently affecting the rheological properties of cerebral blood flow, respectively.

Prognosis

The prognosis for children with subdural hematoma is highly variable and depends on the extent of the intracranial injury. Many children present with severe neurological deficiencies, including seizures and neurodevelopmental delays, with persistent encephalopathy due to severe and devastating neurological injuries.

References

  1. Cheshire EC, Malcomson RDG, Sun P, Mirkes EM, Amoroso JM, Rutty GN. A systematic autopsy survey of human infant bridging veins. Int J Legal Med. 2018 Mar;132(2):449-461.
  2. Bode-Jänisch S, Bültmann E, Hartmann H, Schroeder G, Zajaczek JE, Debertin AS. Serious head injury in young children: Birth trauma versus non-accidental head injury. Forensic Sci Int. 2012 Jan 10;214(1-3):e34-38.
  3. Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatr Radiol. 2018 Aug;48(8):1048-1065.
  4. Joyce T, Gossman W, Huecker MR. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 9, 2022. Pediatric Abusive Head Trauma.
  5. Rao MG, Singh D, Vashista RK, Sharma SK. Dating of acute and subacute subdural haemorrhage: A histo-pathological study. J Clin Diagn Res. 2016 Jul;10(7):HC01-7.

Note: The author would like to thank Drs. Ajay Prashanth Dsouza, Muhammad Anwar, Elham Ahmed Elgabaly, as well as Jukha Shater Ali Al Badawi of Al Jalila Children's Specialty Hospital, Dubai, UAE, for their kind assistance with this case.

Our appreciation is extended to Dr. Abdelaziz Ibrahim Gbril, Al Jalila Children's Specialty Hospital, Dubai, United Arab Emirates, for contributing this case.