Is surgery the best option for epidural hematoma in an infant?

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Posted on Thu, 11 Jun 2015 in Child Health
Question: My 4 months old daughter is crying a lot by birth.
Doctors gave the medicines for meningitis but no improvement seen. only the tremble of her body has stopped. But she is still make curve structure of her legs, hand and neck and feeding problem. She used to vomits.Sir, I think she is losing her natural response ability. She is referred to the Neuro surgeon. He Suggested about the operation of the brain. Actually In CT Scan Image, He has founded the indication about Right Fronto Parietal Epidural Hematoma with Bilateral Focal Encephalomalacia and Mild hydrocephalus.
Sir, Can she not cure without operation? Sir, can she not be normal after Operation?
Please Sir, Suggest me and tell me clearly about her all risk in her treatment??
XXXXXXX XXXXXXX
doctor
Answered by Dr. Pradeep Kumar 35 minutes later
Brief Answer:
I am sorry to say this but the prognosis is poor

Detailed Answer:
Hello Mr XXXXXXX

Thanks for the query

After going through the prescription and report I have noticed that there is history of delayed cry and CT scan is suggestive of hypoxic damage(due to decreased O2 supply to the brain at birth) to the brain.Along with the hypoxic damage there is also large subdural hematoma.
I have also noticed that she has been advised to undergo surgery more than one and half month back(23/3/15).
The symptoms you have mentioned like feeding and arching problem along with excessive cry all are suggestive of intracranial abnormality leading to early cerebral palsy.
As already one and half month has been passed since the last evaluation I think there is a need of repeat CT to see the present status of hematoma.
I am very sorry to say that even after undergoing the neurosurgery the long term prognosis will not improve much and there may be residual weakness and persistence of seizure.
These babies are prone to gastroesophageal reflux causing frequent vomiting due to lack of proper development of swallowing reflex and muscle incoordination.
Adding prokinetic like domperidone helps.Giving antiepileptic medication like levetiracetam or phenobarbitone will help in arching and seizure,

Do ask freely if you have any more doubts.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 11 minutes later
Dear Doctor,
You are saying about Subdural hematoma but The CT Images are indicating about Epidural Hematoma.
According to you now operation must be required?
Which medicines are needed right now?
doctor
Answered by Dr. Pradeep Kumar 28 minutes later
Brief Answer:
M sorry for the mistake,was meant to say epidural hematoma

Detailed Answer:
I am sorry for the typing mistake.I was about to write epidural hematoma only.
I told you about the need of surgery according to the previous report (dated 23/3/2014).
I suggest you to consult a neurosurgeon regarding the need of repeat CT as it's already been one and half month of the previous CT done.
There may be the changes in the brain in past 1 month and the management will depend on the current finding.
Giving medication like domperidone will help in vomiting and phenobarbitone/levetiracetam for seizure/arching.
Both these are prescription medicine,please get it prescribed by a physician.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 21 hours later
Dear Doctor
As you have said to consult the neuro-surgeon, I have consulted and he confirmed me that the clotting of blood has scattered and also added that now there is no need of any surgery. He suggested that I should again consult the child specialist for her arching,vomiting and seizure condition. I want to add one more thing that yesterday she has been suffering from fever also.

Now Sir you suggest me that what should be to do in this regarding matter??
Kindly,Do the needful!
Thanks XXXXXXX XXXXXXX

Sir,
What should be done right now because my baby is very anxious. She is crying regularly. Her head is still warm and rest of body is cold. all symptoms are same as before.

Please reply me as soon as possible!
doctor
Answered by Dr. Pradeep Kumar 4 hours later
Brief Answer:
Give him paracetamol if temperature is more than 99 F

Detailed Answer:
Sorry for delayed response

If axillary temperature is more than 99 F give him paracetamol drops(dose is 10-15 mg/kg/dose).
Because of gastroesophageal reflux and vomiting these babies are prone to develop pneumonia.
I would like to know if there is any respiratory difficulty(in terms of rapid respiratory rate and chest wall retraction).

Increased intracranial pressure due to bleed may cause arching,seizure and vomiting but as you have consulted the neurosurgeon and surgery is not required it is only the medications that will help.

Give him lansoprazole/esomeprazole(nexpro junior/lanzol junior) along with domperidone(domstal) drops for vomiting. Injectable antiemetic may be needed if vomiting persists.

For seizure as I have mentioned already giving levetiracetam/phenobarbitone will help.If seizure is uncontrolled then dose should be increased till the maximum limit and even another antiseizure medication may need to be added.
For increased arching baclofen(liofen) should be given.All these are prescription medicines so please get it prescribed by a physician.
If vomiting is persistent he may need to be put on IV fluid or nasogastric tube feed.
Most of the time fever in this age is due to viral infection.But here in this case as baby comes under high risk category I would like to get him evaluated by a pediatrician for clinical examination and for the need of investigation if any.
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 6 days later
Dear Doctor,
Sorry to delay in my response due to some urgency of my job.
Sir,
some pathological examination reports are uploaded by me for your re-investigation and ofcourse for your kind suggestion.
CT Image will be also uploaded tomorrow.

Do the needful please!
Thanking You XXXXXXX
doctor
Answered by Dr. Pradeep Kumar 30 minutes later
Brief Answer:
Details below

Detailed Answer:
Thanks for the follow up
I feel privileged to follow you up.
I have gone through all the prescriptions and reports.
I would like to make you understand in detail
The biochemical report is absolutely normal.This means that there is no electrolyte disturbances.Low calcium level is notorious to cause seizure and increased tone in babies but this too is normal.The kidney function test as shown by urea and creatinine is also normal.CRP is normal which rules out any serious infection.You mentined that he had fever but now after getting the CRP report I won't get worried and it appears to be due to viral infection as I assumed it earlier.
The hematological report is also normal except for the hemoglobin and RBC indices like MCV,MCH.This suggests that there is iron deficiency anemia.Although this test is enough to suggest iron deficiency anemia but I would like to get iron studies done( if you can afford) for better documentation and follow up.
The iron deficiency is common and it is mostly due to nutritional deficiency.Supplementation of oral iron drops helps in improving the level.
I would like to supplement Vit D (in drops form)also as it is recommended for all babies by XXXXXXX and XXXXXXX academy of pediatrics till one year of age.
Now coming to the CSF report it is also normal and thus rules out any brain infection.
Neurosurgeon also cleared your baby by saying that no surgical intervention is needed.
Now what you need to do is that consult a pediatrician for clinical evaluation.
Also learn from the pediatrician about physiotherapy and how to meet adequate nutrition and calorie for better growth.
Get her hearing and visual assessment done if not done earlier.It will be rude but I want to say you that the long term neurological outcome can not be very good in your baby.
Let me no about further proceedings.
I shall be more than glad to serve you.
Wish you baby better health.
Warm regards

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Pradeep Kumar 19 hours later
Dear Doctor,
I want an appointment with you for my the clinical evaluation of my baby before you.I hope you will never mind to give your appointment.If you don't mind, can we meet on 27th May 2015?
Please, confirm me about the appointment with the clinic address!

with warm regard! XXXXXXX

Sir,
Please, confirm me also about all requirements for clinical evaluation and whatever you understand to suggest me, You are most welcome.
I am awaiting for your reply!
With warm Regards XXXXXXX
doctor
Answered by Dr. Pradeep Kumar 1 hour later
Brief Answer:
Sure Sir, it's my pleasure

Detailed Answer:
It's my pleasure sir that you have chosen me for follow up of your baby.
But I think you are in XXXXXXX right now.I live in XXXXXXX and my clinic is here only.
It is too far from your place.I suggest you to visit any nearby pediatrician and let me know about the proceedings.
If you come to my clinic then I would suggest you to go through my profile of healthcare magic where you can get my clinic's address.
There you can also get my XXXXXXX number.
I will be available on 27/05/15.
Please ring me once you decided to visit XXXXXXX
Regards
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
Answered by
Dr.
Dr. Pradeep Kumar

Pediatrician, Cardiology

Practicing since :2006

Answered : 1988 Questions

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