Immediate Surgical Evacuation is Required
This 6-year-old child with confirmed extradural hematoma presenting with focal neurological deficit (left-sided weakness) requires urgent neurosurgical evacuation—this is an absolute indication for surgery and any delay will worsen outcomes. 1
Why Surgery is Mandatory
The presence of focal neurological deficits indicates significant brain compression and mass effect from the extradural hematoma. 1 This child has progressed beyond the criteria for conservative management and requires immediate intervention:
- Symptomatic extradural hematoma with focal neurological signs necessitates immediate surgical treatment, regardless of hematoma location or size 2, 1
- The left-sided weakness indicates the hematoma is causing sufficient mass effect to compress motor pathways, which will progress to herniation without intervention 1
- Delaying surgical intervention in symptomatic patients leads to neurological deterioration and significantly worse outcomes 1
Why Other Options Are Incorrect
Option A (MRI brain): Completely inappropriate—MRI adds no value when CT has already confirmed the diagnosis and the patient has focal deficits requiring urgent surgery. MRI would only delay definitive treatment. 2
Option C (Intubation and airway): While airway management may be needed perioperatively, it is not the "next step" in management. The priority is arranging immediate surgical evacuation. 2
Option D (Admission and repeat imaging): This is only appropriate for asymptomatic patients with small hematomas meeting specific conservative criteria (GCS 13-15, volume <40mm, midline shift <6mm, no focal deficits). 3, 4 This child has focal weakness, which excludes conservative management entirely.
Immediate Management Steps
While arranging urgent neurosurgery, concurrent measures should include:
- Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion—even brief hypotension worsens outcomes 5
- Consider osmotic therapy (mannitol 0.25-0.5 g/kg IV over 30-60 minutes or hypertonic saline 2.7-3% at 2-3 ml/kg) if signs of increased intracranial pressure develop 6, 2, 7
- Monitor for deterioration: pupillary changes, worsening weakness, decreased consciousness 2
- Transfer to neurosurgical center immediately if not already at one—do not delay for "stabilization" 2, 5
Critical Pitfall to Avoid
The most dangerous error would be choosing conservative management (Option D) based on the child's relatively preserved consciousness. The presence of focal neurological deficit (left-sided weakness) is an absolute contraindication to conservative management, regardless of GCS score. 1 Studies of conservative management explicitly exclude patients with focal deficits. 3, 4
Surgical Approach
The neurosurgical team will perform craniotomy for hematoma evacuation, control the bleeding source (typically middle meningeal artery), remove any bone fragments, and assess for dural tears. 1 In pediatric traumatic EDH, early surgical intervention produces excellent results, with mortality significantly reduced when surgery occurs within 24 hours of injury. 8