Intracranial subdural hematoma in children: Clinical features, evaluation, and management
- Mark R Proctor, MD
Mark R Proctor, MD
- Associate Professor of Neurosurgery
- Harvard Medical School
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Subdural hematoma (SDH) forms when there is hemorrhage into the potential space between the dura and the arachnoid membranes. SDH in children differs significantly from SDH in adults because abusive head injury is a common etiology, especially in pediatric patients <2 years of age . In contrast to epidural hematoma (EDH), indications for operative management of SDH are less clear, and surgery is less likely to prevent morbidity and mortality. (See "Intracranial epidural hematoma in children: Clinical features, diagnosis, and management".)
This review will discuss the clinical features, evaluation, and management of subdural hematoma in children. The epidemiology, anatomy, and pathophysiology of SDH in children and SDH in adults are discussed separately. (See "Intracranial subdural hematoma in children: Epidemiology, anatomy, and pathophysiology" and "Subdural hematoma in adults: Etiology, clinical features, and diagnosis" and "Subdural hematoma in adults: Prognosis and management".)
A rapid overview summarizes the important clinical features and initial management of SDH in children (table 1).
History — In the abused infant or young child, SDH is frequently discovered after physical examination and imaging. The history usually does not provide a plausible mechanism for the severity of injury and may be misleading. Frequently no mention of trauma of any kind is given. Common presenting complaints include altered mental status, seizures, apnea, breathing difficulty, or sudden cardiopulmonary arrest. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'History'.)
Historical features may suggest an increased risk of SDH in patients with unintentional injury, such as:
- Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363:846.
- Duffy GP. Lumbar puncture in the presence of raised intracranial pressure. Br Med J 1969; 1:407.
- Datta S, Stoodley N, Jayawant S, et al. Neuroradiological aspects of subdural haemorrhages. Arch Dis Child 2005; 90:947.
- Proctor MB. Neurosurgical aspects of nonaccidental trauma in children. In: Neurological Surgery Principles and Practice, Loftus B. (Ed), Lippincott Williams and Wilkins, Philadelphia 2003. p.1065.
- Young JY, Duhaime AC, Caruso PA, Rincon SP. Comparison of non-sedated brain MRI and CT for the detection of acute traumatic injury in children 6 years of age or less. Emerg Radiol 2016; 23:325.
- Cho DY, Wang YC, Chi CS. Decompressive craniotomy for acute shaken/impact baby syndrome. Pediatr Neurosurg 1995; 23:192.
- Tolias C, Sgouros S, Walsh AR, Hockley AD. Outcome of surgical treatment for subdural fluid collections in infants. Pediatr Neurosurg 2000; 33:194.
- Vinchon M, Noulé N, Soto-Ares G, Dhellemmes P. Subduroperitoneal drainage for subdural hematomas in infants: results in 244 cases. J Neurosurg 2001; 95:249.
- Sauter KL. Percutaneous subdural tapping and subdural peritoneal drainage for the treatment of subdural hematoma. Neurosurg Clin N Am 2000; 11:519.
- Meyer PG, Ducrocq S, Rackelbom T, et al. Surgical evacuation of acute subdural hematoma improves cerebral hemodynamics in children: a transcranial Doppler evaluation. Childs Nerv Syst 2005; 21:133.
- Proctor MB. Neurosurgical aspects of nonaccidental trauma in children. In: Neurological Surgery and Principles and Practice, Loftus B. (Ed), Lippincott Williams and Wilkins, Philadelphia 2003. p.1065.
- Duhaime AC, Gennarelli TA, Thibault LE, et al. The shaken baby syndrome. A clinical, pathological, and biomechanical study. J Neurosurg 1987; 66:409.
- Hollingworth W, Vavilala MS, Jarvik JG, et al. The use of repeated head computed tomography in pediatric blunt head trauma: factors predicting new and worsening brain injury. Pediatr Crit Care Med 2007; 8:348.
- Durham SR, Liu KC, Selden NR. Utility of serial computed tomography imaging in pediatric patients with head trauma. J Neurosurg 2006; 105:365.
- Vinchon M, Defoort-Dhellemmes S, Nzeyimana C, et al. Infantile traumatic subdural hematomas: outcome after five years. Pediatr Neurosurg 2003; 39:122.
- Jayawant S, Rawlinson A, Gibbon F, et al. Subdural haemorrhages in infants: population based study. BMJ 1998; 317:1558.
- CLINICAL FEATURES
- Physical examination
- - Abusive head injury (shaken baby syndrome)
- - Unintentional head injury
- PRIMARY EVALUATION AND MANAGEMENT
- Initial assessment and treatment
- Neurosurgical consultation
- Laboratory studies
- Radiographic imaging
- - Abusive head injury
- - Unintentional injury
- Child protection
- DEFINITIVE MANAGEMENT
- Operative decision
- Timing of surgery
- Surgical procedures
- Temporizing procedures
- Nonoperative management
- SUMMARY AND RECOMMENDATIONS
- Clinical features
- Primary evaluation and management
- Definitive management