Management of Extradural Hematoma in a 6-Year-Old with Focal Neurological Deficit
This child requires immediate surgical evacuation of the extradural hematoma. The presence of left-sided weakness represents a focal neurological deficit indicating mass effect and brain compression, which is an absolute indication for urgent neurosurgical intervention regardless of the child's overall clinical status 1, 2, 3.
Why Surgical Evacuation is Mandatory
The focal neurological deficit (left-sided weakness) is the critical decision point that mandates surgery. This indicates the hematoma is causing significant brain compression and mass effect 1, 2. The guidelines are unequivocal:
- Closed displaced skull fracture with brain compression requires surgical intervention 1
- Symptomatic extradural hematoma regardless of location is an indication for surgical evacuation 2
- Any extradural hematoma causing focal neurological signs necessitates immediate surgical treatment 3
The vomiting and headache further support significant intracranial pathology, but the focal weakness alone is sufficient to mandate surgery 2, 3.
Why Conservative Management is NOT Appropriate Here
Conservative management of extradural hematoma is only appropriate when ALL of the following strict criteria are met 4, 5, 6:
- Glasgow Coma Scale 13-15 with no focal neurological deficits
- Hematoma volume <40mm
- Midline shift <5-6mm
- Patient neurologically stable or improving
This patient fails the most critical criterion: absence of focal neurological signs. The left-sided weakness automatically excludes conservative management 4, 5, 6.
Why Other Options are Incorrect
MRI Brain (Option A)
MRI has no role in the acute management of confirmed extradural hematoma with neurological deficits 7. The diagnosis is already established by CT, and MRI would only delay definitive surgical treatment, risking further neurological deterioration and potential herniation 7.
Intubation First (Option C)
While airway management is important in severe traumatic brain injury, this child does not present with airway compromise or severe altered consciousness requiring immediate intubation 2, 3. The priority is surgical decompression. Intubation would be performed as part of the surgical preparation, not as an isolated intervention 3.
Admission with Repeat Imaging (Option D)
This "watch and wait" approach is dangerous in the presence of focal neurological deficits 1, 2. Delaying surgical intervention in symptomatic patients leads to neurological deterioration and worse outcomes 2. The 12-24 hour observation period is only appropriate for patients meeting strict conservative management criteria, which this child does not 4, 5.
Critical Pitfalls to Avoid
Never delay surgical intervention in a patient with focal neurological deficits from extradural hematoma 2. Even if the child appears relatively stable, the presence of weakness indicates the hematoma has already caused significant mass effect, and further expansion or deterioration can occur rapidly 8, 6.
Do not be falsely reassured by the child's ability to communicate or relatively preserved consciousness 6. Approximately 40% of extradural hematomas present with vomiting but minimal initial neurological signs, yet can deteriorate rapidly 6. This child has already progressed beyond that stage by developing focal weakness.
Posterior fossa extradural hematomas require particular urgency, as they can cause sudden respiratory arrest before surgery 8. While the location is not specified here, any extradural hematoma with focal signs requires prompt surgical evacuation 8.
Surgical Approach
The surgical intervention involves 1, 2:
- Craniotomy for hematoma evacuation
- Removal of bone fragments if present
- Control of bleeding source (typically middle meningeal artery)
- Assessment and management of any dural tear
Post-operatively, the child will require monitoring for complications including rebleeding, infection, and intracranial hypertension 1, 2.