What's the next step in management for a child with a confirmed extradural hematoma and symptoms of increased intracranial pressure, such as vomiting and left side weakness, after a CT (Computed Tomography) scan?

Surgical Evacuation is the Next Step in Management

This child with an extradural hematoma presenting with focal neurological deficits (left-sided weakness) and signs of increased intracranial pressure (vomiting, headache) requires immediate neurosurgical consultation and surgical evacuation. 1

Rationale for Immediate Surgical Intervention

The presence of left-sided weakness indicates a significant mass effect from the extradural hematoma causing compression of motor pathways, which represents a life-threatening brain lesion requiring urgent neurosurgical intervention. 1, 2 The combination of:

• Focal neurological deficit (left-sided weakness suggesting right hemisphere compression) 2
• Signs of increased intracranial pressure (vomiting, headache) 1
• Confirmed extradural hematoma on CT 3

This clinical triad mandates surgical decompression to prevent further neurological deterioration and potential herniation. 1, 4

Why Not Conservative Management?

While some small, asymptomatic extradural hematomas in neurologically intact children can be managed conservatively with serial imaging, this patient is NOT a candidate for observation because: 5

• Neurological deficits are already present (left-sided weakness), indicating the hematoma has exceeded the brain's compensatory capacity 5
• Symptomatic patients with focal deficits require immediate surgical evacuation to prevent progression to uncal herniation 4, 5
• Conservative management is only appropriate for neurologically normal children with small hematomas discovered incidentally 5

Why Not Other Options First?

Intubation and airway management (Option C) may be necessary if the patient deteriorates to coma or shows signs of herniation, but surgical evacuation takes priority as the definitive treatment. 1 Airway management should occur concurrently with preparation for surgery if needed, not as a delay to definitive intervention. 1

MRI (Option A) would cause dangerous delays when CT has already confirmed the diagnosis and the patient has focal deficits requiring immediate intervention. 3

Admission with repeat imaging in 12-24 hours (Option D) is inappropriate because the patient already demonstrates neurological compromise. 4, 5 This approach risks progression to herniation during the observation period, particularly since extradural hematomas can undergo an "expansile phase" even after initial diagnosis. 5

Critical Management Principles

• Extradural hematomas are potentially lethal lesions with 5% mortality when treated appropriately, but mortality increases dramatically with delayed intervention. 4
• Emergency surgical intervention should occur before further neurological deterioration appears, as outcomes worsen significantly once herniation develops. 4, 5
• In pediatric extradural hematomas, early CT detection combined with prompt surgical evacuation reduces mortality and morbidity. 3
• The favorable prognosis of extradural hematomas (compared to subdural hematomas) depends entirely on timely surgical decompression before irreversible brain injury occurs. 4, 3

Post-Operative Considerations

Following surgical evacuation, intracranial pressure monitoring should be instituted if there are concerns about ongoing intracranial hypertension or associated brain injury. 1 Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during the perioperative period to ensure adequate cerebral perfusion. 1