Brief Communication Acute Epidural Hematoma With Infarction of the Right Hemisphere in a 5-Month-Old Child: Case Report With a Long-Term Follow-Up and a Review of the Literature Journal of Child Neurology Volume 23 Number 9 September 2008 1066-1069 © 2008 Sage Publications 10.1177/0883073808315411 http://jcn.sagepub.com hosted at http://online.sagepub.com Peter T. Ulrich, MD, PhD, Helmut Fuessler, MD, and Elke Januschek, MD Two hours after a fall, a 5-month-old girl was admitted to our hospital because of an extended galea hematoma and restlessness. Five hours after the trauma, a left hemiparesis developed. The child became drowsy. The hematocrit had fallen to 7.1 g/dL. Cranial computerized tomography disclosed a huge frontoparietal epidural hematoma on the right side and a hypodensity in the territories of the middle and posterior cerebral arteries. Immediately before surgery, the right pupil dilated. After evacuation of the epidural hematoma and ligation of the middle meningeal artery, the girl recovered satisfactorily. Nevertheless, magnetic resonance imaging showed a vast defect zone in the territories of the right middle and posterior cerebral arteries. Six weeks after the injury, the visual-evoked potentials were unavailable on both sides. Four years after the accident, visual assessment revealed normal acuity and stereopsis. Cognitive and neuromotor development were undisturbed and appropriate to the age. E Case Report pidural hematomas occur in 1% to 5% of traumatic head injuries in infancy. The mortality in children younger than 4 years has been estimated to be up to 20%.1 Late diagnosis of a developing hematoma mostly contributes to the high mortality rate. The grade of injury itself seems to be less important. In infancy, a high intracranial pressure is compensated longer than in adults because of the high compliance of the cranial vault and brain, but may suddenly lead to midbrain compression syndrome. In 50% of infants with an epidural hematoma, hemorrhagic anemia is seen.2 Reports of secondary ischemic complications in the brain are rare. From the Department of Neurosurgery, Klinikum Offenbach GmbH, Offenbach, Germany. This work was not supported by a grant or otherwise. The authors contributed equally to this work. Address correspondence to: Peter T. Ulrich, MD, PhD, Department of Neurosurgery, Klinikum Offenbach GmbH, Starkenburgring 66, 63069 Offenbach, Germany; e-mail: peter.ulrich@klinikum-offenbach.de. Ulrich PT, Fuessler H, Januschek E. Acute epidural hematoma with infarction of the right hemisphere in a 5-month-old child: case report with a long-term follow-up and a review of the literature. J Child Neurol. 2008;23:1066-1069. Keywords: injury epidural hematoma; cerebral infarction; head A 5-month-old girl fell out of her bed (at about 80 cm height) onto the floor. Immediately after the fall, she was awake and cried. The parents observed a swelling of the right parietal scalp. Ninety minutes after the trauma, the child seemed drowsy. Thirty minutes later, the child was admitted to the hospital. On transport, the girl vomited once. In the hospital, the patient presented crying, inconsolable, irritable, and restless, opening her eyes to verbal stimuli. Her spontaneous movements were symmetrical, and her pupils were equal in size with prompt reaction to light. At that time, the Children’s Glasgow Coma Scale score (modified for children according to Hahn et al3) was 9. It was decided to refrain from cranial computerized tomography scan under sedation. A skull radiograph did not reveal any fracture of the skull. In the pediatric intensive care ward, the girl was initially calm and opened her eyes to verbal stimuli inconsistently, but showed a brisk flexion withdrawal to tactile stimuli. The laboratory examination of the venous blood yielded the following results: hemoglobin, 8.5 g/dL (normal value, 15-25 g/dL); red blood cells, 3.2 M/μL (normal value, 3.5-5.0 M/μL); hematocrit, 28% (normal value, 30%-42%); thrombin time, 23 seconds (normal value, 11-15 seconds). Four hours after the trauma, spontaneous movements of the right arm decreased and a progressive retardation was obvious. 1066 Downloaded from jcn.sagepub.com by guest on November 14, 2015 Acute Epidural Hematoma With Infarction / Ulrich et al 1067 Figure 1. Cranial computerized tomography before surgery: (A) with a midline shift of 1.7 cm and (B) hypodensity in the territory of the right middle cerebral artery. The Children’s Glasgow Coma Scale score dropped to 8 points. Five and a half hours posttrauma, dilation of the right pupil and a loss of light reaction were observed. At that time, the lab parameters were as follows: hemoglobin, 7.1 g/dL; red blood cells, 2.8 M/μL; hematocrit, 21%; thrombin time, 23 seconds; and serum glucose, 205 mg/dL (normal value, 70-110 mg/dL). Cranial computerized tomography revealed a vast epidural hematoma of 4 × 8.5 cm compressing the right hemisphere (Figure 1A) with partial hypodensity of the middle cerebral artery territory and in the entire territory of the posterior cerebral artery (Figure 1B). After immediate intubation, the infant was transferred to the surgical suite without delay. On arrival, the blood pressure was 85/60 mm Hg. Red blood cells and albumin were administered. Eight hours after the fall, the large epidural hematoma was evacuated by a right parieto-temporo-occipital craniotomy. Postoperatively, the pupils were equal in size again and showed prompt light reactions on both sides. On day 2 after the operation, cranial computerized tomography showed midline shift reversed (Figure 2A) and a partial infarction of the right hemisphere (Figure 2B). On day 6, normal blood flow and pulsatility in the middle and anterior cerebral arteries on both sides and in the left posterior cerebral artery was proved by transcranial Doppler examination. No flow signal could be detected in the posterior cerebral artery on the right side. Further development was favorable. The Munich Functional Developmental Diagnostic Battery (4th ed; Hogrefe, Goettingen, Germany) revealed in month 7 a crawling age of 9 months; a sitting, grip, perception, and speech age of 8 months; and a walking age of 7 months. Six weeks after the trauma, visual-evoked potentials after unstructured light stimuli were not recordable. The distance vision was 0.06 on both sides and therefore substandard. The control after 4½ years revealed normal values of 1.0 on both eyes. The visual fields tested by finger perimetry seemed normal, and the eye motility, motor reaction of the pupils to light, and ocular movements were undisturbed. The flash-visual-evoked potentials testing binocular and monocular showed a prolonged latency of P2 on both sides, especially on the right. The magnetic resonance imaging scan 30 months after surgery showed a large parieto-occipital defect (Figure 3). Discussion Ischemic complications due to extracerebral, intracranial mass lesions are rarely reported in the literature. Only in a few cases are such coincidences described. Systematic analyses about their incidence and pathophysiology are lacking. Moros-Peña et al4 reported a 5-year-old child who was operated on due to traumatic brain injury after a 40-hour free interval. The preoperative cranial computerized tomography showed, in addition to an extradural hematoma, a subarachnoid hemorrhage. After evacuation of the hematoma, the cranial computerized tomography on day 5 after the injury detected ipsilateral infarctions in the thalamus, the internal capsule, and the cortical–subcortical area beneath the Downloaded from jcn.sagepub.com by guest on November 14, 2015 1068 Journal of Child Neurology / Vol. 23, No. 9, September 2008 Figure 2. Cranial computerized tomography on the second day after surgical evacuation of the extradural hematoma on the right side: (A) midline shift reversed and (B) infarct in the right hemisphere. Figure 3. Magnetic resonance imaging (T1 weighted) axial and coronar, 30 months after surgical evacuation of the extradural hematoma on the right side, infarctions in the middle and posterior cerebral arteries territories of the right hemisphere. Downloaded from jcn.sagepub.com by guest on November 14, 2015 Acute Epidural Hematoma With Infarction / Ulrich et al evacuated hematoma of the parietal lobe. Because of the slow growth of the epidural hematoma, the authors assumed bleeding into the epidural and subarachnoid space by rupture of a bridging vein close to a granulation of Pacchioni. They discussed a regional vasospasm as a partial cause of the middle cerebral artery infarct. The infarction in the basal ganglia could have been caused by the tilting of the small perforating branches of the middle cerebral artery due to the mass lesion. Similar findings with infarction of the rostral thalamoperforaters on both sides and the anterior chorioid artery have been reported in 5 adult cases of large epidural hematomas and transtentorial herniation by Endo et al5 and in 2 infant cases by Niikawa et al.6 In their series of 37 patients with a mortality of 0% and a permanent morbidity of 5%, Paterniti et al7 point out the importance of quick surgical pressure relief after loss of consciousness for the outcome. In our case, we assume the cause of the infarction in the territories of the middle and posterior cerebral arteries to be the vulnerability of the cerebral vessels of a 5-month-old infant. The elasticity of the arterial walls in childhood is certainly higher than in older ages, but the walls are thinner and more twistable than in adults due to the lack of collagen fibres.8,9 This leads to a minor stability of the vessel diameter and the vessel lumen in the case of biomechanical straining. The compression of the posterior cerebral artery at the tentorial edge with consequent infarction of the related vessel territory due to intracranial mass lesions by shifting into the tentorial notch is well described in the neuropediatric literature.10,11 Moreover, infarctions in the basal ganglia after brain injury are also described in the neuropediatric literature.4,11,12 However, infarctions in the territory of the middle cerebral artery caused by isolated traumatic extradural bleedings are uncommon and rarely reported in the literature. In addition to our report, the literature search retrieved only 2 other cases.4,13 Anemia with a hemoglobin level of 8.5 g/dL already observed 190 minutes after the injury was initially explained by the vast cephalohematoma alone. When computerized tomography proved a hypodensity in the vicinity of the epidural hematoma 230 minutes posttrauma, a further decrease of hemoglobin to 7.1 g/dL was registered. The acute drop of the hemoglobin concentration due to the massive subgaleal and epidural extravasations could have contributed to the rise of an extended supratententorial infarction. According to Gutierrez et al,14 hemoglobin concentrations less than 7 to 8 g/dL in critically ill young patients without any risks for hypoxia should be balanced by transfusions. Despite extensive ischemic deficits in the parieto-occipital areas of the right hemisphere, no functional impairment could be assessed at the age of 4 years. In particular, no deficit of the optical pathway was verifiable. This is in accordance with the results of Mercuri et al.15 In a series of 16 children who suffered from isolated or combined ischemic lesions of the optical pathways in infancy, proved by early visual assessment and by magnetic resonance imaging, 6 children (28%) had some visual impairment at their school 1069 age (between 5½ and 7 years of age), and 4 of the 6 showed abnormalities on only one of the 4 investigated fields. In accordance with the reported case, a good intellectual and functional motor outcome can be expected in children with isolated perinatal stroke.16 References 1. Mohanty A, Kolluri VR, Subbakrishna DK, Satish S, Mouli BA, Das BS. Prognosis of extradural haematomas in children. Pediatr Neurosurg. 1995;23:57-63. 2. Leggate JR, Lopez-Ramos N, Genitori L, Lena G, Choux M. Extradural haematoma in infants. Br J Neurosurg. 1989;3:553-539. 3. Hahn Y, Chyung C, Barthel M, Bailes J, Flannery AM, McLone DG. Head injuries in children under 36 months of age. 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