title: Surgical evacuation of acute subdural hematoma improves cerebral hemodynamics in children: a transcranial Doppler evaluation.
abstract: OBJECTIVE
  The objective was to evaluate cerebral hemodynamics in young children with acute subdural hematoma (SDH) and the impact of surgical treatment using transcranial Doppler (TCD).
  
  
  METHODS
  The design was a prospective study of infants with SDH requiring surgical evacuation.
  
  
  METHODS
  The setting was the neuro intensive care unit of a university hospital.
  
  
  METHODS
  Indications for surgical evacuation were based upon clinical and radiological arguments. Surgery included emergency needle aspiration followed by external or/and internal shunting as required. A TCD evaluation was performed before needle aspiration, and after each surgical drainage procedure. It included a pressure provocation test to assess cerebral compliance. Preoperative and postoperative middle cerebral artery (MCA) velocities, Gosling pulsatility (PI) and Pourcelot resistivity (RI) indexes and compliance were compared with Student's t-test, or Fisher's exact test as indicated.
  
  
  RESULTS
  Out of 26 infants, 23 (88%) had injuries that had possibly been inflicted, and 3 had accidental injuries. Initial TCD evaluation demonstrated intracranial hypertension with decreased diastolic velocity, increased PI and RI, and decreased compliance. Surgical evacuation resulted in statistically significant improvement in cerebral hemodynamics (diastolic velocity: 17.2+/-10 cm/s vs. 31.1+/-10 cm/s, p<0.0015, PI: 2.5+/-1.3 vs. 1.4+/-0.8, p<0.002, RI: 0.8+/-0.2 vs. 0.6+/-0.1, p<0.005) in all but 3 infants, who eventually died. Surgical drainage (primary shunting or external drainage) was needed in 23 infants and resulted in further improvement in cerebral hemodynamics. Finally, 73% of the infants made a good recovery.
  
  
  CONCLUSIONS
  Children with acute bilateral HSD have a high incidence of increased intracranial pressure as assessed by TCD. Surgical evacuation improves cerebral hemodynamics. TCD could be used for assessing the need for, and the efficiency of surgical drainage.
authors.affiliation: Department of Pediatric Anesthesiology and Neuro Intensive Care Unit, Hôpital Necker Enfants Malades, Université Paris 5, 149 Rue de Sèvres, 75743, Paris, France. philippe.meyer@nck.ap-hop-paris.fr
authors.forename: Philippe Gabriel
authors.initials: PG
authors.lastname: Meyer
authors.forename: Sarah
authors.initials: S
authors.lastname: Ducrocq
authors.forename: Thibault
authors.initials: T
authors.lastname: Rackelbom
authors.forename: Gilles
authors.initials: G
authors.lastname: Orliaguet
authors.forename: Dominique
authors.initials: D
authors.lastname: Renier
authors.forename: Pierre
authors.initials: P
authors.lastname: Carli
mesh_terms: D001783:Blood Flow Velocity; D002560:Cerebrovascular Circulation / Q000502:physiology; D005069:Evaluation Studies as Topic; D005260:Female; D020199:Hematoma, Subdural, Acute / Q000503:physiopathology* / Q000601:surgery*; D006439:Hemodynamics / Q000502:physiology*; D006801:Humans; D007223:Infant; D008297:Male; D020768:Middle Cerebral Artery / Q000503:physiopathology; D011673:Pulsatile Flow; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D014656:Vascular Surgical Procedures