Management of Subdural Hematoma in a 2-Year-Old Boy
For a 2-year-old boy with subdural hematoma, immediate non-contrast head CT should be performed to assess for mass effect and neurological compromise, followed by surgical evacuation if symptomatic with significant mass effect or neurological deterioration, while stable patients without significant deficits can be managed conservatively with close monitoring. 1
Initial Assessment and Imaging
Perform immediate non-contrast CT scan of the head to evaluate hematoma characteristics, including maximal thickness, degree of midline shift, and presence of mass effect 2, 1. The neurological examination must document:
- Glasgow Coma Scale (GCS) score 1, 3
- Pupillary examination (abnormal pupils indicate herniation risk) 1
- Focal neurological deficits including motor weakness 1, 3
- Level of consciousness (altered consciousness, drowsiness, stupor) 4, 3
- Seizure activity (most common presentation in infants) 5, 3
Funduscopic examination is mandatory - retinal and preretinal hemorrhages are characteristic findings in infantile subdural hematoma and should not be missed 5, 3. This is particularly important as subdural hematoma is the most commonly seen intracranial abnormality in abusive head trauma, which has case fatality rates above 20% in children under 2 years 2.
Surgical Indications
Immediate surgical evacuation is indicated for: 1
- Symptomatic subdural hematoma with significant mass effect
- Neurological deterioration after admission
- Decreased level of consciousness
- Increased intracranial pressure refractory to medical management
For acute subdural hematomas requiring surgery, craniotomy with evacuation is the preferred approach 5. In the pediatric series, 63% of patients undergoing craniotomy for acute subdural hematoma had good outcomes 5. Importantly, none of the patients who underwent early craniotomy developed chronic subdural hematoma, whereas 85% (11/13) of conservatively managed cases progressed to chronic subdural hematoma requiring subsequent burr hole drainage 5.
Conservative Management Protocol
Conservative management with close monitoring is appropriate for stable patients without significant neurological deficits 1, 4. This requires:
- Regular neurological assessments (at least every 4 hours initially) 1
- Maintain euvolemia to optimize cerebral perfusion 1
- Serial imaging to monitor for progression 1
- Close follow-up in pediatric intensive care unit 4
In pediatric patients with favorable neurological and radiological findings, spontaneous resolution can occur 4. One series showed dramatic regression of hematoma within 4 hours in a 3-year-old with initially 11.2 mm thick hematoma and 8.3 mm midline shift 4.
Critical Pitfall: Chronic Subdural Hematoma Development
A major pitfall is that infantile acute subdural hematoma, if treated conservatively or neglected, is an important cause of chronic subdural hematoma 5. In one series, 85% of conservatively managed acute subdural hematomas developed chronic subdural hematomas 15-80 days (mean 28 days) after the acute event 5. Early recognition and suitable treatment may improve outcome and prevent this progression 5.
Additional Considerations for This Age Group
Consider child abuse evaluation - at 2 years of age, this falls into the high-risk category where clinicians should have a low threshold for comprehensive evaluation 2. If abuse is suspected:
- Skeletal survey to evaluate for multiple fractures 2
- MRI of the brain should be considered after initial CT to detect additional injuries (provides 25% more diagnostic information than CT alone) 2
- MRI of cervical spine should be strongly considered, as intracranial injury is associated with spinal trauma 2
Outcome Expectations
Based on GCS on admission, good recovery rates are: 5
- 100% for mild head injury (GCS 13-15)
- 75% for moderate head injury (GCS 9-12)
- 50% for severe head injury (GCS ≤8)
Do not delay surgical intervention when neurological deterioration occurs, as this leads to poorer outcomes 1. The key is distinguishing patients who can be safely monitored from those requiring immediate intervention, with readiness to proceed to surgery if the clinical status changes.