Immediate Surgical Evacuation is Required
This 6-year-old child with confirmed extradural hematoma and left-sided weakness requires urgent neurosurgical intervention with craniotomy for hematoma evacuation (Option B). The presence of focal neurological deficits is an absolute indication for immediate surgery, as it indicates significant brain compression and mass effect 1.
Why Surgical Evacuation is Mandatory
- Focal neurological deficits (left-sided weakness) represent an absolute indication for urgent neurosurgical intervention in extradural hematoma, regardless of other factors 1
- Any extradural hematoma causing focal neurological signs necessitates immediate surgical treatment 1
- Delaying surgical intervention in symptomatic patients with extradural hematoma leads to neurological deterioration and worse outcomes 1
- The combination of vomiting, headache, and focal weakness indicates significant mass effect requiring decompression 1
The Surgical Procedure
The intervention involves 1:
- Craniotomy for hematoma evacuation
- Removal of bone fragments if present
- Control of the bleeding source (typically middle meningeal artery)
- Assessment and management of any dural tear
Why Other Options Are Inappropriate
Option A (MRI brain): Inappropriate because this child needs immediate intervention, not additional imaging. MRI would only delay life-saving surgery 1.
Option C (Intubation and airway): While airway management may be needed perioperatively, it is not the primary next step. The child is conscious enough to present with vomiting and headache, suggesting adequate airway protection currently. The priority is surgical decompression 1, 2.
Option D (Admission and repeat imaging): This conservative approach is contraindicated in the presence of focal neurological deficits. Conservative management is only appropriate for patients with 3, 4:
- Glasgow Coma Scale 13-15 without focal deficits
- Hematoma volume <40mm
- Midline shift <6mm
- No neurological deterioration
This patient fails the most critical criterion—they have focal neurological deficits (left-sided weakness), which absolutely excludes conservative management 1, 3.
Critical Timing Considerations
- Extradural hematomas can deteriorate rapidly due to ongoing arterial bleeding 5
- Even patients with initially mild symptoms can develop sudden respiratory arrest if surgical evacuation is delayed 5
- Early diagnosis and immediate treatment are essential for improving prognosis 6
- Never delay surgical intervention in a patient with focal neurological deficits from extradural hematoma 1
Post-Operative Management
After surgical evacuation, the patient will require 1:
- Monitoring for complications including rebleeding, infection, and intracranial hypertension
- Neurological assessment for recovery of left-sided weakness
- Consideration of intracranial pressure monitoring if severe brain injury is present 2