Isolated Traumatic Basal Ganglia Hematoma in Children.

Dear Editor,

Basal ganglia (BG) hematoma following head injury in pediatric population is less discussed. Although initially included as a part of diffuse axonal injury, the distinctly different pathogenesis mandates it to be considered as a separate entity. Here, we describe three pediatric cases of isolated BG bleed managed conservatively with good outcome.

A 10-year-old male child presented with fall from tree in unconscious state. On presentation, he was in Glasgow coma scale (GCS) of E1VTM3. The computed tomography (CT) scan showed isolated right-sided BG bleed [Figure 1a]. He was managed conservatively with decongestants and improved gradually. At 6-month follow-up, CT showed complete resolution of hematoma and he improved completely without any focal motor power deficit [Figure 1b and C].

Figure 1

(a) Computed tomography scan showing right basal ganglia hematoma. (b) 6-month follow-up computed tomography showing complete resolution of hematoma. (c) Patient at 6-month follow-up

Another 4-year-old female child with isolated left BG bleed with GCS E1VTM4 and a 13-year-old male child with isolate right BG bleed in GCS E2VTM5 were managed conservatively [Figure 2a and b]. Both the patients had history of fall from stairs. Although these two patients improved with time, the female child remained aphasic with right-sided hemiparesis of Grade 3/5 at 6-month follow-up.

Figure 2

(a) Computed tomography showing isolated left-sided basal ganglia hematoma. (b) Computed tomography showing right-sided basal ganglia hematoma. Note that the size of hematoma is small without any mass effect

Isolated BG hematoma following closed head injury is unusual with incidence of <3%.[1] Sudden acceleration or deceleration forces that causes shearing of the lenticulostriate or the anterior choroidal artery will result in BG bleed.[2] Although rare bilateral BG hematoma following trauma has been reported,[3] the eloquent nature of this region is responsible for the severity of symptoms even with a small size hematoma. Moreover, the extent of involvement of the pyramidal or extrapyramidal pathway will determine the residual deficit.

Most of the cases described in literature were managed conservatively. Only those cases with a large hematoma producing mass effect need surgical evacuation. Ultrasound or CT-guided stereotactic aspiration of hematoma is an alternative to open surgery. In our cases, the hematoma sizes were small (<25 ml) and there was no mass effect so managed conservatively.

The mechanism of injury, size of hematoma and associated injuries, and age of patients are the most important prognostic factors.[4] All our three patients had history of fall from height. May be this low-velocity injury caused only rupture of lenticulostriate or the anterior choroidal artery and resulted in isolated BG bleed. However, cases of road traffic accidents with high-velocity injuries may have additional subarachnoid hemorrhage, diffuse axonal injuries, subdural hematoma, or intraventricular hemorrhage that will prolong the hospital stay and affect the overall outcome. Therefore, isolated BG bleed in a setting of closed head injury always has comparatively better outcome than associated multiple head injuries.

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