Clinical and tomographic criteria for neurosurgical approach in children diagnosed with acute traumatic epidural hematoma

Purpose: The criteria for selecting surgical versus nonsurgical treatment of pediatric traumatic epidural hematoma (EDH) remain poorly defined. This study describes the clinical and neuroimaging parameters guiding neurosurgical intervention in children and adolescents with EDH at a reference trauma center.Methods: A retrospective review was conducted of medical records from patients under 17 years who underwent neurosurgical treatment for traumatic EDH between January 2016 and December 2023. Clinical presentations and neuroimaging findings were analyzed to identify the criteria used for surgical decisions.Results: Fifty patients met the inclusion criteria. The cohort had a median age of 5.5 years (IQR 2–10.25) and was predominantly male. Falls (66%) were the most frequent trauma mechanism, followed by road traffic accidents (22%). Mild traumatic brain injury (TBI) was most common (60%). Frequent clinical findings included altered consciousness (50%), vomiting (36%), and nausea (12%). Pupillary changes and motor deficits were observed in 20% and 16%, respectively. In mild TBI, surgery was performed in children ≤ 2 years when EDH was ≥ 10 mm; in older children, EDH > 15 mm with midline shift (MLS) > 5 mm prompted intervention. In moderate TBI, EDH ≥ 15 mm with MLS ≥ 5 mm or EDH ≥ 10 mm with MLS plus pupillary/motor signs led to surgery. In severe TBI, surgery was indicated when EDH was ≥ 8 mm with MLS ≥ 5 mm.Conclusions: Surgical criteria for pediatric EDH vary by age, symptom persistence, and TBI severity. Younger age and neurological signs justify intervention at smaller hematoma sizes and lower MLS thresholds.