Technical Note
495
Endoscopic Removal of Neonatal Acute Epidural Hematoma via Strip-Bending Osteoplastic Craniotomy. Technical Note Tokutaro Tanaka1
Chikanori Inenaga1
1 Department of Neurosurgery, Seirei Hamamatsu General Hospital,
Hamamatsu, Shizuoka, Japan J Neurol Surg A 2015;76:495–498.
Abstract Keywords
► acute epidural hematoma ► neonate ► neuroendoscope ► delivery trauma ► strip-bending osteoplastic craniotomy
Ayataka Fujimoto1
Address for correspondence Hirokazu Nakatogawa, MD, Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi Naka-ku, Hamamatsu, Shizuoka 430-8558, Japan (e-mail: [email protected]).
We present a rare case of an acute epidural hematoma extending through a skull fracture into a cephalohematoma in a neonate. The epidural hematoma was caused by a fall after delivery. The neonate remained neurologically asymptomatic. A computed tomography scan 12 days after delivery showed the large-volume epidural hematoma with midline shift. We performed a strip-bending osteoplastic craniotomy and removed the epidural hematoma and external cephalohematoma under neuroendoscopic control. This is the first reported case of an acute epidural hematoma in a neonate treated successfully neuroendoscopically via a strip-bending craniotomy.
Background
Case Report
Acute epidural hematoma in neonates is very rare1–20 because the development of an acute epidural hematoma in neonates differs from adults. There are only a few reported cases of neonatal acute epidural hematoma related to delivery.4,6,9,21–24 In particular, the reports of epidural hematomas after falls following delivery are very rare.4,10,20,23 The meningeal artery is less developed in a neonate because of the shallow groove on the skull. This is why only 60 cases of epidural hematoma with detailed descriptions have been reported globally since 1922. The introduction of computerized tomography (CT) in the 1970s increased the numbers of reported cases. In Japan, acute epidural hematoma in neonates is usually treated by osteoclastic craniotomy plus evacuating the clot or by needle aspiration. We treated this acute epidural hematoma using a strip-bending craniotomy with a neuroendoscope and report our experience.
A female infant was born at 39 weeks of gestation by vaginal delivery. Pregnancy was uneventful. The infant’s birthweight was 2918 g and length was 50 cm. An Apgar score was 9 and 10 at 1 and 5 minutes, respectively. When the mother was being moved onto the delivery bed, a fall of the newborn occurred. Physical examination was normal except for a right temporoparietal cephalohematoma. The fontanelle was not tense. Because the newborn was asymptomatic except for the cephalohematoma, the obstetrician who delivered her observed her progress as bilirubin increased daily. He treated her with phototherapy. When she was 12 days old, total bilirubin was abnormally high, and she was referred to a pediatrician. A cranial CT showed a voluminous right temporoparietal epidural hematoma with midline shift (►Fig. 1). Therefore she was immediately sent to our pediatric neurosurgical team for surgery. We performed evacuation with a neuroendoscopy-assisted strip-bending craniotomy. Skin incision was of inverted U
received December 8, 2014 accepted January 19, 2015 published online June 19, 2015
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1551822. ISSN 2193-6315.
Downloaded by: Washington University. Copyrighted material.
Hirokazu Nakatogawa1 Takamichi Yamamoto1
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Nakatogawa et al.
Fig. 2 Skin incision. Skin incision was of inverted U shape across the fracture.
fracture communicating with an acute epidural hematoma. We made two small parallel skull bone cuts perpendicular to the fracture site to hinge the skull using the fracture site as the first opening. The neonate skull was so soft that it allowed us to perform a strip-bending craniotomy ( ►Fig. 3). Through the neuroendoscope we observed the clot and searched for the bleeding point. Using endoscopic tools we evacuated the acute epidural hematoma, which was both liquid and clotted. We decided to use the strip-bending craniotomy plus neuroendoscopic removal of the hematoma because aspiration with a needle can lead to excessive bleeding, infection, and hematoma calcification, all of which would be higher risk in a neonate. There was enough space for hemostasis. The dura mater rose spontaneously after clot removal; nonetheless we performed as many dural tenting sutures using absorbable material as possible and sutured the skin incision. At postoperative day 1, CT showed evacuated hematoma, normal position of the ipsilateral ventricle, and no midline shift (►Fig. 4). Magnetic resonance imaging obtained 7 days after the procedure showed no contusion and full evacuation
Fig. 1 Head computed tomography (CT) on admission. (A) Threedimensional CT shows right parietal bone fracture. (B, C) Axial CT shows right acute epidural hematoma and right cephalohematoma with the lateral ventricles shifted.
shape 3 cm in length (►Fig. 2). A cephalohematoma, 7.2 cm in diameter, was noted over the right parietal skull Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
Fig. 3 Intraoperative view. We made use of the skull fracture itself as the entry point opposite the hinging plus two parallel cuts made three cuts in total instead of the usual circular bone removal method.
Downloaded by: Washington University. Copyrighted material.
496
Nakatogawa et al.
Fig. 4 Postoperative computed tomography (CT) finding. (A) Three-dimensional CT shows improved right parietal bone fracture. (B, C) Axial CT shows that the right acute epidural hematoma is reduced and bone is repaired.
of the epidural hematoma and cephalohematoma (►Fig. 5). She had no deficits and was discharged 8 days after the procedure.
Discussion In neonates, rupture of the middle meningeal artery is less involved in the formation of an acute epidural hematoma because of the shallow groove on the skull.6,22,23,25 Therefore, a large osteoclastic craniotomy often is not necessary.26 Accordingly, we failed to find an active arterial bleeding in the present case. An acute epidural hematoma compresses the brain parenchyma, and will calcify and may lead to seizures if left untreated. Thus, there was an indication for surgery. When clinical symptoms are mild and an acute epidural hematoma communicates with a cephalohematoma,
the liquid hematoma can be removed by cephalohematoma aspiration.16,17,21,24 However, a clotted hematoma cannot be removed by aspiration. Neonate skull strips can be bent manually. The created space is narrow, but spacious enough to insert an endoscope. Using the endoscope, the liquid hematoma could be aspirated and the clotted hematoma can be removed with forceps under visual control. If needed, coagulation of an active bleeding likewise would be possible with the endoscope. There are two previous reports of adult acute epidural hematoma treatment with a neuroendoscope.27,28 We were unable to find any reports regarding neonatal acute epidural hematoma removal using a neuroendoscope. Overall, we believe that endoscopic removal of an acute epidural hematoma is less invasive than standard osteoclastic craniotomy, because of smaller skin incisions, hinging bones, and less Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
497
Downloaded by: Washington University. Copyrighted material.
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Nakatogawa et al. 7 Merry GS, Stuart G. Extradural hematoma in the neonate. Case
report. J Neurosurg 1979;51(5):713–714 8 Akiyama Y, Moritake K, Maruyama N, Takamura M, Yamasaki T.
9
10
11
12 13
14
Fig. 5 Postoperative axial T2-weighted magnetic resonance image excluding a brain injury.
15 16
blood loss from the skin and bone. Osteoplastic craniotomy benefits are no gaps between the strips, faster bone reattachment, and bone stability after the procedure.
17
18
Conclusion We reported the first case of strip-bending craniotomy plus neuroendoscopic hematoma removal in a case of an acute epidural hematoma in a neonate. We demonstrated that the neuroendoscopic procedure is a minimally invasive and effective treatment and may provide an alternative to standard craniotomy.
19
20
21 22
References
23
1 Campbell JB, Cohen J. Epidural hemorrhage and the skull of
children. Surg Gynecol Obstet 1951;92(3):257–280 2 Harwood-Nash DC, Hendrick EB, Hudson AR. The significance of
3
4
5
6
skull fractures in children. A study of 1,187 patients. Radiology 1971;101(1):151–156 Oatey PE, Dinning TA, Simpson DA. Extradural haematoma in children. Primary and secondary lucid intervals. Med J Aust 1983;2(4):176–180 Tada M, Echizenya K, Satoh M. Communication between epidural hematoma and cephalhematoma in a neonate. Hokkaido Igaku Zasshi 1986;61(2):244–248 Ballance AC, Ballance CA. Intracranial hemorrhage in the newborn, with observations on fracture of the skull of the infant. Lancet Neurol 1922;203:1109–1112 Takagi T, Nagai R, Wakabayashi S, Mizawa I, Hayashi K. Extradural hemorrhage in the newborn as a result of birth trauma. Childs Brain 1978;4(5):306–318
Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
24
25
26 27
28
Acute epidural hematoma related to cesarean section in a neonate with Chiari II malformation. Childs Nerv Syst 2001;17(4-5): 290–293 Andoh Y, Wakai S, Inoh S, Ochiai C, Nagai M. Extradural hematoma in neonates—report of two cases. Nerv Syst Child 1988; 13:177–182 Heyman R, Heckly A, Magagi J, Pladys P, Hamlat A. Intracranial epidural hematoma in newborn infants: clinical study of 15 cases. Neurosurgery 2005;57(5):924–929; discussion 924–929 Ishikawa S, Motohashi O, Kitahara M. A case of infant epidural hematoma treated by continuous drainage of cephalohematoma [in Japanese]. No Shinkei Geka 2007;35(2):175–179 Lieu AS, Sun ZM, Howng SL. Bilateral epidural hematoma in a neonate. Kaohsiung J Med Sci 1996;12(7):434–436 Makiyama Y, Nishimoto H, Hirota H, et al. Extradural hematoma in neonates: report of two cases and implications for treatment. Nerv Syst Child 1991;16:443–449 Noguchi M, Inamasu J, Kawai F, et al. Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuumassisted delivery. Childs Nerv Syst 2010;26(5):713–716 Scheibl A, Calderón EM, Borau MJ, Prieto RM, González PF, Galiana GG. Epidural hematoma. J Pediatr Surg 2012;47(2):e19–e21 Smets KJ, Vanhauwaert D. Treatment of cranial epidural hematoma in a neonate by needle aspiration of a communicating cephalhematoma. Eur J Pediatr 2010;169(5):617–619 Vachharajani A, Mathur A. Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: treating a rare complication of vacuum extraction. Am J Perinatol 2002;19(8):401–404 Wakai S, Andoh Y, Inoh S, Ochiai C, Nagai M. Characteristics of neonatal extradural hematoma. Report of two cases. Dokkyo J Med Sci 1990;17:57–61 Yamamoto T, Enomoto T, Nose T. Epidural hematoma associated with cephalohematoma in a neonate—case report. Neurol Med Chir (Tokyo) 1995;35(10):749–752 Yamanouchi Y, Tsukazaki Y, Inagaki T, et al. Acute epidural hematoma caused by precipitate neonate birth injury—case report. Nerv Syst Child 1999;24:298–301 Aoki N. Epidural hematoma communicating with cephalhematoma in a neonate. Neurosurgery 1983;13(1):55–57 Esparza J, Portillo JM, Mateos F, Lamas E. Extradural hemorrhage in the posterior fossa in neonates. Surg Neurol 1982;17(5):341–343 Hayashi T, Hashimoto T, Tsunosue M, Nakashima H. Three cases of epidural hematoma in newborns. Nerv Syst Child 1982; 7:167–172 Wakayama A, Morimoto K, Koga R, et al. Acute epidural hematoma in neonates—report of two cases. Nihon Kyukyu Igakukai Zasshi 1991;2:723–727 Zelson C, Lee SJ, Pearl M. The incidence of skull fractures underlying cephalhematomas in newborn infants. J Pediatr 1974;85(3): 371–373 Natelson SE, Sayers MP. The fate of children sustaining severe head trauma during birth. Pediatrics 1973;51(2):169–174 Huang AP, Huang SJ, Hong WC, et al. Minimally invasive surgery for acute noncomplicated epidural hematoma: an innovative endoscopic-assisted method. J Trauma Acute Care Surg 2012;73(3): 774–777 Ohshima T, Tajima H, Fujii K, et al. Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health. Neurol Med Chir (Tokyo) 2012;52(11):829–831
Downloaded by: Washington University. Copyrighted material.
498
495
Endoscopic Removal of Neonatal Acute Epidural Hematoma via Strip-Bending Osteoplastic Craniotomy. Technical Note Tokutaro Tanaka1
Chikanori Inenaga1
1 Department of Neurosurgery, Seirei Hamamatsu General Hospital,
Hamamatsu, Shizuoka, Japan J Neurol Surg A 2015;76:495–498.
Abstract Keywords
► acute epidural hematoma ► neonate ► neuroendoscope ► delivery trauma ► strip-bending osteoplastic craniotomy
Ayataka Fujimoto1
Address for correspondence Hirokazu Nakatogawa, MD, Department of Neurosurgery, Seirei Hamamatsu General Hospital, 2-12-12 Sumiyoshi Naka-ku, Hamamatsu, Shizuoka 430-8558, Japan (e-mail: [email protected]).
We present a rare case of an acute epidural hematoma extending through a skull fracture into a cephalohematoma in a neonate. The epidural hematoma was caused by a fall after delivery. The neonate remained neurologically asymptomatic. A computed tomography scan 12 days after delivery showed the large-volume epidural hematoma with midline shift. We performed a strip-bending osteoplastic craniotomy and removed the epidural hematoma and external cephalohematoma under neuroendoscopic control. This is the first reported case of an acute epidural hematoma in a neonate treated successfully neuroendoscopically via a strip-bending craniotomy.
Background
Case Report
Acute epidural hematoma in neonates is very rare1–20 because the development of an acute epidural hematoma in neonates differs from adults. There are only a few reported cases of neonatal acute epidural hematoma related to delivery.4,6,9,21–24 In particular, the reports of epidural hematomas after falls following delivery are very rare.4,10,20,23 The meningeal artery is less developed in a neonate because of the shallow groove on the skull. This is why only 60 cases of epidural hematoma with detailed descriptions have been reported globally since 1922. The introduction of computerized tomography (CT) in the 1970s increased the numbers of reported cases. In Japan, acute epidural hematoma in neonates is usually treated by osteoclastic craniotomy plus evacuating the clot or by needle aspiration. We treated this acute epidural hematoma using a strip-bending craniotomy with a neuroendoscope and report our experience.
A female infant was born at 39 weeks of gestation by vaginal delivery. Pregnancy was uneventful. The infant’s birthweight was 2918 g and length was 50 cm. An Apgar score was 9 and 10 at 1 and 5 minutes, respectively. When the mother was being moved onto the delivery bed, a fall of the newborn occurred. Physical examination was normal except for a right temporoparietal cephalohematoma. The fontanelle was not tense. Because the newborn was asymptomatic except for the cephalohematoma, the obstetrician who delivered her observed her progress as bilirubin increased daily. He treated her with phototherapy. When she was 12 days old, total bilirubin was abnormally high, and she was referred to a pediatrician. A cranial CT showed a voluminous right temporoparietal epidural hematoma with midline shift (►Fig. 1). Therefore she was immediately sent to our pediatric neurosurgical team for surgery. We performed evacuation with a neuroendoscopy-assisted strip-bending craniotomy. Skin incision was of inverted U
received December 8, 2014 accepted January 19, 2015 published online June 19, 2015
© 2015 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1551822. ISSN 2193-6315.
Downloaded by: Washington University. Copyrighted material.
Hirokazu Nakatogawa1 Takamichi Yamamoto1
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Nakatogawa et al.
Fig. 2 Skin incision. Skin incision was of inverted U shape across the fracture.
fracture communicating with an acute epidural hematoma. We made two small parallel skull bone cuts perpendicular to the fracture site to hinge the skull using the fracture site as the first opening. The neonate skull was so soft that it allowed us to perform a strip-bending craniotomy ( ►Fig. 3). Through the neuroendoscope we observed the clot and searched for the bleeding point. Using endoscopic tools we evacuated the acute epidural hematoma, which was both liquid and clotted. We decided to use the strip-bending craniotomy plus neuroendoscopic removal of the hematoma because aspiration with a needle can lead to excessive bleeding, infection, and hematoma calcification, all of which would be higher risk in a neonate. There was enough space for hemostasis. The dura mater rose spontaneously after clot removal; nonetheless we performed as many dural tenting sutures using absorbable material as possible and sutured the skin incision. At postoperative day 1, CT showed evacuated hematoma, normal position of the ipsilateral ventricle, and no midline shift (►Fig. 4). Magnetic resonance imaging obtained 7 days after the procedure showed no contusion and full evacuation
Fig. 1 Head computed tomography (CT) on admission. (A) Threedimensional CT shows right parietal bone fracture. (B, C) Axial CT shows right acute epidural hematoma and right cephalohematoma with the lateral ventricles shifted.
shape 3 cm in length (►Fig. 2). A cephalohematoma, 7.2 cm in diameter, was noted over the right parietal skull Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
Fig. 3 Intraoperative view. We made use of the skull fracture itself as the entry point opposite the hinging plus two parallel cuts made three cuts in total instead of the usual circular bone removal method.
Downloaded by: Washington University. Copyrighted material.
496
Nakatogawa et al.
Fig. 4 Postoperative computed tomography (CT) finding. (A) Three-dimensional CT shows improved right parietal bone fracture. (B, C) Axial CT shows that the right acute epidural hematoma is reduced and bone is repaired.
of the epidural hematoma and cephalohematoma (►Fig. 5). She had no deficits and was discharged 8 days after the procedure.
Discussion In neonates, rupture of the middle meningeal artery is less involved in the formation of an acute epidural hematoma because of the shallow groove on the skull.6,22,23,25 Therefore, a large osteoclastic craniotomy often is not necessary.26 Accordingly, we failed to find an active arterial bleeding in the present case. An acute epidural hematoma compresses the brain parenchyma, and will calcify and may lead to seizures if left untreated. Thus, there was an indication for surgery. When clinical symptoms are mild and an acute epidural hematoma communicates with a cephalohematoma,
the liquid hematoma can be removed by cephalohematoma aspiration.16,17,21,24 However, a clotted hematoma cannot be removed by aspiration. Neonate skull strips can be bent manually. The created space is narrow, but spacious enough to insert an endoscope. Using the endoscope, the liquid hematoma could be aspirated and the clotted hematoma can be removed with forceps under visual control. If needed, coagulation of an active bleeding likewise would be possible with the endoscope. There are two previous reports of adult acute epidural hematoma treatment with a neuroendoscope.27,28 We were unable to find any reports regarding neonatal acute epidural hematoma removal using a neuroendoscope. Overall, we believe that endoscopic removal of an acute epidural hematoma is less invasive than standard osteoclastic craniotomy, because of smaller skin incisions, hinging bones, and less Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
497
Downloaded by: Washington University. Copyrighted material.
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Endoscopic Removal of Neonatal Acute Epidural Hematoma
Nakatogawa et al. 7 Merry GS, Stuart G. Extradural hematoma in the neonate. Case
report. J Neurosurg 1979;51(5):713–714 8 Akiyama Y, Moritake K, Maruyama N, Takamura M, Yamasaki T.
9
10
11
12 13
14
Fig. 5 Postoperative axial T2-weighted magnetic resonance image excluding a brain injury.
15 16
blood loss from the skin and bone. Osteoplastic craniotomy benefits are no gaps between the strips, faster bone reattachment, and bone stability after the procedure.
17
18
Conclusion We reported the first case of strip-bending craniotomy plus neuroendoscopic hematoma removal in a case of an acute epidural hematoma in a neonate. We demonstrated that the neuroendoscopic procedure is a minimally invasive and effective treatment and may provide an alternative to standard craniotomy.
19
20
21 22
References
23
1 Campbell JB, Cohen J. Epidural hemorrhage and the skull of
children. Surg Gynecol Obstet 1951;92(3):257–280 2 Harwood-Nash DC, Hendrick EB, Hudson AR. The significance of
3
4
5
6
skull fractures in children. A study of 1,187 patients. Radiology 1971;101(1):151–156 Oatey PE, Dinning TA, Simpson DA. Extradural haematoma in children. Primary and secondary lucid intervals. Med J Aust 1983;2(4):176–180 Tada M, Echizenya K, Satoh M. Communication between epidural hematoma and cephalhematoma in a neonate. Hokkaido Igaku Zasshi 1986;61(2):244–248 Ballance AC, Ballance CA. Intracranial hemorrhage in the newborn, with observations on fracture of the skull of the infant. Lancet Neurol 1922;203:1109–1112 Takagi T, Nagai R, Wakabayashi S, Mizawa I, Hayashi K. Extradural hemorrhage in the newborn as a result of birth trauma. Childs Brain 1978;4(5):306–318
Journal of Neurological Surgery—Part A
Vol. 76
No. A6/2015
24
25
26 27
28
Acute epidural hematoma related to cesarean section in a neonate with Chiari II malformation. Childs Nerv Syst 2001;17(4-5): 290–293 Andoh Y, Wakai S, Inoh S, Ochiai C, Nagai M. Extradural hematoma in neonates—report of two cases. Nerv Syst Child 1988; 13:177–182 Heyman R, Heckly A, Magagi J, Pladys P, Hamlat A. Intracranial epidural hematoma in newborn infants: clinical study of 15 cases. Neurosurgery 2005;57(5):924–929; discussion 924–929 Ishikawa S, Motohashi O, Kitahara M. A case of infant epidural hematoma treated by continuous drainage of cephalohematoma [in Japanese]. No Shinkei Geka 2007;35(2):175–179 Lieu AS, Sun ZM, Howng SL. Bilateral epidural hematoma in a neonate. Kaohsiung J Med Sci 1996;12(7):434–436 Makiyama Y, Nishimoto H, Hirota H, et al. Extradural hematoma in neonates: report of two cases and implications for treatment. Nerv Syst Child 1991;16:443–449 Noguchi M, Inamasu J, Kawai F, et al. Ultrasound-guided needle aspiration of epidural hematoma in a neonate after vacuumassisted delivery. Childs Nerv Syst 2010;26(5):713–716 Scheibl A, Calderón EM, Borau MJ, Prieto RM, González PF, Galiana GG. Epidural hematoma. J Pediatr Surg 2012;47(2):e19–e21 Smets KJ, Vanhauwaert D. Treatment of cranial epidural hematoma in a neonate by needle aspiration of a communicating cephalhematoma. Eur J Pediatr 2010;169(5):617–619 Vachharajani A, Mathur A. Ultrasound-guided needle aspiration of cranial epidural hematoma in a neonate: treating a rare complication of vacuum extraction. Am J Perinatol 2002;19(8):401–404 Wakai S, Andoh Y, Inoh S, Ochiai C, Nagai M. Characteristics of neonatal extradural hematoma. Report of two cases. Dokkyo J Med Sci 1990;17:57–61 Yamamoto T, Enomoto T, Nose T. Epidural hematoma associated with cephalohematoma in a neonate—case report. Neurol Med Chir (Tokyo) 1995;35(10):749–752 Yamanouchi Y, Tsukazaki Y, Inagaki T, et al. Acute epidural hematoma caused by precipitate neonate birth injury—case report. Nerv Syst Child 1999;24:298–301 Aoki N. Epidural hematoma communicating with cephalhematoma in a neonate. Neurosurgery 1983;13(1):55–57 Esparza J, Portillo JM, Mateos F, Lamas E. Extradural hemorrhage in the posterior fossa in neonates. Surg Neurol 1982;17(5):341–343 Hayashi T, Hashimoto T, Tsunosue M, Nakashima H. Three cases of epidural hematoma in newborns. Nerv Syst Child 1982; 7:167–172 Wakayama A, Morimoto K, Koga R, et al. Acute epidural hematoma in neonates—report of two cases. Nihon Kyukyu Igakukai Zasshi 1991;2:723–727 Zelson C, Lee SJ, Pearl M. The incidence of skull fractures underlying cephalhematomas in newborn infants. J Pediatr 1974;85(3): 371–373 Natelson SE, Sayers MP. The fate of children sustaining severe head trauma during birth. Pediatrics 1973;51(2):169–174 Huang AP, Huang SJ, Hong WC, et al. Minimally invasive surgery for acute noncomplicated epidural hematoma: an innovative endoscopic-assisted method. J Trauma Acute Care Surg 2012;73(3): 774–777 Ohshima T, Tajima H, Fujii K, et al. Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health. Neurol Med Chir (Tokyo) 2012;52(11):829–831
Downloaded by: Washington University. Copyrighted material.
498
