Is Surgery Advocated in M1 Extradural Hematoma, or Is It Not?—A Case Report

Abstract

Pediatric EDH (extradural hematoma) following trauma is a well-known surgical entity with early diagnosis and treatment reducing morbidity and mortality. It is custom not to suggest surgery for a patient with traumatic EDH with a Glasgow Coma Scale (GCS) of E1M1Vt, with no cough or gauge reflux. Case history: a 5-year-old school-going girl presented with posttraumatic temporo-parietal EDH with GCS of E1M1Vt with fixed dilated right pupil. The patient denied surgery due to poor recovery and a high rate of morbidity and mortality. Hospital course: with the patient being young and just a ray of hope, surgery was performed. To a surprise, she completely recovered and was discharged with residual weakness in her left upper and lower limbs and was able to return to her daily work/school. At follow-up, she was able to perform all the daily routine work with residual weakness and required help from others to perform complex tasks. This rare case is being reported because the patient improved from M1 to M6 and returned to school, which was a rare event, and many had lost hope; even literature is scarce to justify this approach.

Keywords

complete recovery - computed tomography scan - extradural hematoma - residual weakness

Introduction

EDH (extradural hematoma) is the blood that is collected between the bone and outer dura, most common in the younger age groups and in road traffic accident (RTA).[1] The cause of the bleeding was mostly due to a rupture of the middle meningeal artery (MMA).[2] Early diagnosis and treatment will lead to good results and early recovery with minimal complications.[1] There is a clinical dilemma in treating these patients with poor Glasgow Coma Scale (GCS). Counseling these patient attendees with the outcomes post-surgery is very challenging. This is a case of a young schoolgirl with a history of injury who came with the GCS of E1M1V1; her right pupil is dilated and fixed, and her left eye is sluggish, reactive to light, absent cough, and gauge reflux. She was taken to surgery after considering all the adverse effects and complications after surgery. Post-surgery, she completely improved, and now she is going to school with minimal weakness, which is a miracle. I wanted to report this case as little is noted in the literature, and no clear-cut guidance exists to treat such patients. Hence, I reported this case, which will be an example to show that surgery on these kinds of patients with poor GCS and delayed presentation at the hospital can still save a patient's life. Young age and adequate surgery/evacuation of hematoma might cause complete recovery of this patient, giving a ray of hope.[3] [4]

Case Presentation

A 5-year-old girl was studying in the first standard and was playing in the garden then she met with an accident, where she was accidentally hit by a cricket bat while playing. She was taken to a local practitioner, and primary aid was given; she was fine, and after 1 to 1.5 hours, she became drowsy and was again taken to the same doctor; she was referred to another hospital due to lack of infrastructure and treating doctor, from there she was shifted to a local hospital. A computed tomography scan was done and found to have right parietal EDH with an underlying fractured bone. She was referred to our hospital ([Figs. 1] and [2]). By the time she came to our center, it was almost 9 hours late, and her GCS score was E1M1V1; she was immediately intubated, and on examination, her right pupil was dilated and fixed, and her left pupil was partially reactive to light. Lower cranial nerve reflexes were not present when checked during intubation. Other vitals were normal.

Fig. 1 Right temporo-polar EDH with linear fracture of temporal bone. EDH, extradural hematoma.

Fig. 2 Right temporo-parietal EDH with swirl sign with mass effect and midline shift toward left side. EDH, extradural hematoma.

Poor prognosis was explained to the caretakers, and they were told about the treatment options. They accepted surgery as a ray of hope, and she underwent surgery immediately.

Intra-op

Classic right question mark incision was made, primary burr hole was made, and clotted blood and hematoma found coming out. Right parietal craniotomy was done ([Fig. 3]), and on evacuating EDH, active bleed from ruptured MMA was seen, it was coagulated ([Fig. 4]), post-evacuation dura was lax, and no dural breach noted. Hence, bone flap was replaced.

Fig. 3 Specimen of removed right temporal bone with evacuated hematoma.

Fig. 4 Ruptured MMA artery in the pool of hematoma. MMA, middle meningeal artery.

Post-surgery

She was shifted to the intensive care unit, was provided elective ventilation, and was observed for any improvement in GCS. No signs of improvement were noted for the first 2 days; from the 3rd day, her pupils became equal but sluggish and reactive, her breathing parameters improved, and she started to move the right upper and lower limbs spontaneously. She got extubated on POD6 (postoperative day 6), and she had GCS of E3M5V3 before shifting to step-down ward. On POD11, she became E4M6V5 with response to verbal commands and was moving right upper and lower limbs without residual weakness; the left upper limb had the power of 1/5 with improved tone, and the lower limb had a power of 3/5. She was able to drink liquids and swallow food, and her speech was understandable and coherent.

Outcome and Follow-up

She was seen after 1 month, and she could go to school and perform her daily activities with minimal help. She had residual left upper limb weakness with left lower limb power of 4/5. No other complications were noted. The operative wound was healthy and healed.

Discussion

Traumatic EDH in young following assault/RTA is more common in young adults; early diagnosis and treatment are the factors predicting good prognosis. The reason for reporting this case is that there is no clear-cut guidance on whether to go on with surgery in a patient with GCS of E1M1V1 with dilated and fixed pupils and absent cough and gauge reflux. This case was presented to our center with a delay of more than 9 hours post-trauma/injury due to lack of a hospital near their residence; through history, it was evident that she had gone past the lucid interval following injury. Upon arrival, she was in poor GCS and had very little hope of recovery. After counseling the parents and other caretakers, she underwent EDH evacuation. She had an unexpectedly excellent recovery to such an extent that even the treating doctor was unaware of it. In searching the literature, I could not find any evidence of EDH patient improving from the E1M1Vt to the E4M6V5 state and being able to go to school again/return to daily activities. However, she had residual weakness, but it did not stop her from doing her routine work. This case opens a new window of opportunity to proceed with research and further formulate guidance for treating such patients. This case highlights the importance of surgery in the hope of reviving such patients. Early surgery, close monitoring, physical therapy, and rehabilitation could improve and provide early recovery and reduce morbidity and also mortality.

Conclusion

Doing surgery on a patient with GCS of E1M1Vt with high morbidity and mortality and seeing them improve completely and returning to daily activities with minimal residual weakness is a miracle, but whether it has to be followed in all cases is an unanswered question. This case is an example to show that surgery in EDH patients with M1 GCS can also improve their clinical status. Further research and guidelines are required to treat such patients. This is one such case where a timely surgery can provide a life that was thought to be lost.

Conflict of Interest

None declared.

Authors' Contribution

C.K.A. named the title, designed the study, provided critical reagents, and wrote the manuscript.

Patients' Consent

Informed consent for publication was obtained from the patient in this study.

• References

• 1 Gerlach R, Dittrich S, Schneider W, Ackermann H, Seifert V, Kieslich M. Traumatic epidural hematomas in children and adolescents: outcome analysis in 39 consecutive unselected cases. Pediatr Emerg Care 2009; 25 (03) 164-169
• 2 Rocchi G, Caroli E, Raco A, Salvati M, Delfini R. Traumatic epidural hematoma in children. J Child Neurol 2005; 20 (07) 569-572
• 3 Rosenthal AA, Solomon RJ, Eyerly-Webb SA. et al. Traumatic epidural hematoma: patient characteristics and management. Am Surg 2017; 83 (11) e438-e440
• 4 Irie F, Le Brocque R, Kenardy J, Bellamy N, Tetsworth K, Pollard C. Epidemiology of traumatic epidural hematoma in young age. J Trauma 2011; 71 (04) 847-853

Publication History

Article published online:
13 June 2025