Pediatric vs. adult extradural hematoma outcomes in LMICs: mortality, surgical timing, and age-specific hematoma volume cutoffs.

BACKGROUND

Extradural hematoma (EDH) is a neurosurgical emergency that, although uncommon, contributes significantly to morbidity and mortality following traumatic brain injury (TBI). Differences in anatomical, physiological, and injury-related factors may influence the clinical course and surgical outcomes of EDH in pediatric versus adult populations. Yet, comparative data remain limited, particularly in low- and middle-income countries (LMICs).

OBJECTIVE

To compare clinical characteristics, surgical outcomes, and predictors of mortality in pediatric and adult patients undergoing surgical evacuation of traumatic EDH at a tertiary care center in Pakistan.

MATERIAL AND

METHODS

This retrospective cohort study included 289 patients (158 adults; 131 pediatric) who underwent surgical evacuation of traumatic EDH over a 24-month period at Lady Reading Hospital. Data on demographics, clinical presentation, hematoma characteristics, associated injuries, surgical timing, and outcomes were analyzed. Multivariable logistic regression was used to identify independent predictors of mortality, and receiver operating characteristic (ROC) curve analysis was used to determine optimal hematoma volume thresholds.

RESULTS

Pediatric patients had significantly lower in-hospital mortality (3.1% vs. 14%, p = 0.001), smaller hematoma volumes (30 mL vs. 34 mL, p = 0.032), and higher admission Glasgow coma scale (GCS) scores (median 12 vs. 10, p < 0.001). Midline shift and associated intracranial injuries like acute subdural hematoma (ASDH) and traumatic subarachnoid hemorrhage (TSAH) were strong predictors of mortality across both cohorts. In adults, mortality followed a U-shaped trend with respect to surgical timing, while in pediatrics, earlier surgery showed a linear reduction in risk (OR = 0.78/hour, p = 0.047). ROC analysis identified a pediatric-specific hematoma volume threshold of ≥ 33.5 mL predictive of mortality (AUC = 0.763, NPV = 99.2%).

CONCLUSION

Pediatric EDH patients demonstrated more favorable surgical outcomes compared to adults, with lower mortality and milder presentations. Hematoma volume and surgical timing emerged as key predictors of outcome. These findings highlight the need for age-specific triage protocols and underscore the importance of timely intervention, particularly in resource-limited neurosurgical settings.