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CHAPTER 3
SURGICAL MANAGEMENT OF ACUTE
EPIDURAL HEMATOMASM. Ross Bullock, M.D., Ph.D.Department of Neurological Surgery,Virginia Commonwealth UniversityMedical Center,Richmond, Virginia
Randall Chesnut, M.D.Department of Neurological Surgery,University of WashingtonSchool of Medicine,Harborview Medical Center,Seattle, Washington
Jamshid Ghajar, M.D., Ph.D.Department of Neurological Surgery,Weil Cornell Medical College ofCornell University,New York, New York
David Gordon, M.D.Department of Neurological Surgery,Montefiore Medical Center,Bronx, New York
Roger Hartl, M.D.Department of Neurological Surgery,Weil Cornell Medical College ofCornell University,New York, New York
David W. Newell, M.D.Department of Neurological Surgery,Swedish Medical Center,Seattle, Washington
Franco Servadei, M.D.Department of Neurological Surgery,M. Bufalini Hospital,Cesena, Italy
Beverly C. Walters, M.D., M.Sc.Department of Neurological Surgery,New York UniversitySchool of Medicine,New York, New York
Jack E. Wilberger, M.D.Department of Neurological Surgery,Allegheny General Hospital,Pittsburgh, Pennsylvania
Reprints requests:Jamshid Ghajar, M.D., Ph.D.,Brain Trauma Foundation,523 East 72nd Street,New York, NY 10021.Email: ghajar@braintrauma.org
RECOMMENDATIONS(see Methodology)
Indications for Surgery● An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated
regardless of the patient’s Glasgow Coma Scale (GCS) score.● An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than
a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focaldeficit can be managed nonoperatively with serial computed tomographic (CT)scanning and close neurological observation in a neurosurgical center.
Timing● It is strongly recommended that patients with an acute EDH in coma (GCS score �
9) with anisocoria undergo surgical evacuation as soon as possible.Methods● There are insufficient data to support one surgical treatment method. However,
craniotomy provides a more complete evacuation of the hematoma.
KEY WORDS: Coma, Computed tomographic parameters, Craniotomy, Epidural, Head injury, Hematoma,Surgical technique, Timing of surgery, Traumatic brain injury
Neurosurgery 58:S2-7-S2-15, 2006 DOI: 10.1227/01.NEU.0000210363.91172.A8 www.neurosurgery-online.com
OVERVIEW
Incidence
Since the introduction of CT scanning as theimaging study of choice to detect intracraniallesions after trauma, the incidence of surgicaland nonsurgical EDH among traumatic braininjury (TBI) patients has been reported to be inthe range of 2.7 to 4% (8, 11, 25, 41). Amongpatients in coma, up to 9% harbored an EDHrequiring craniotomy (10, 35). The peak inci-dence of EDH is in the second decade, and themean age of patients with EDH is between 20and 30 years of age ( 3, 8, 9, 13, 16–18, 20, 22,26, 29, 32, 37, 39). EDH are a rare entity inpatients older than 50 to 60 years of age. Inpediatric patients, the mean age of patientsharboring EDH is between 6 and 10 years (21,34), and EDH is less frequent in very youngchildren and neonates (27, 30).
Pathogenesis
Traffic-related accidents, falls, and assaultsaccount for 53% (range, 30–73%), 30% (range,
7–52%), and 8% (range, 1–19%), respectively,of all EDH (3, 8, 20, 22, 26, 27, 36, 40). Inpediatric patients, falls are the leading causeof EDH in 49% of cases (range, 25–59%) andtraffic-related accidents are responsible for34% (range, 25–41%) of all EDH (21, 25–27, 30,34). EDH can result from injury to the middlemeningeal artery, the middle meningeal vein,the diploic veins, or the venous sinuses. His-torically, bleeding from the middle meningealartery has been considered the main sourcefor EDH. In a recent report on EDH in 102pediatric patients and 387 adults, arterialbleeding was identified as the source of theEDH in 36% of the adults and only in 18% ofthe children (27). In 31% of the pediatric pa-tients, a bleeding source could not be identi-fied and venous bleeding accounted for ap-proximately 32% of EDH in both age groups.
Location
In surgical series, EDH are more frequentlylocated in the temporoparietal and temporal re-gions as compared with other locations (3, 6, 25,
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27, 29, 32). In 2 to 5% of patients, bilateral EDH are found (11, 18,40), and there seems to be a slight predominance of right-sidedEDH over left-sided lesions (6, 40).
Clinical Presentation
In patients with EDH, 22 to 56% are comatose on admissionor immediately before surgery (3, 17, 20, 22, 25, 32). Theclassically described “lucid interval,” i.e., a patient who isinitially unconscious, then wakes up and secondarily deterio-rates, was observed in a total of 456 of 963 patients (47%)undergoing surgery for EDH in seven studies (3, 8, 18, 22, 28,31, 39). Between 12 and 42% of patients remained consciousthroughout the time between trauma and surgery (3, 8, 17, 22).Pupillary abnormalities are observed in between 18 and 44%of patients, and up to 27% (3–27%) of patients are neurologi-cally intact. Other presenting symptoms include focal deficits,such as hemiparesis, decerebration, and seizures. Early sei-zures are noted in 8% of pediatric patients presenting withEDH (21).
Mortality
The mortality in patients in all age groups and GCS scoresundergoing surgery for evacuation of EDH is approximately10% (range, 7–12.5%) (7, 8, 14, 17, 18, 20, 22, 28, 31, 32).Mortality in comparable pediatric case series is approximately5% (25, 30).
Determinants of Outcome in Patients UndergoingSurgical Evacuation of an EDH
GCS, age, pupillary abnormalities, associated intracraniallesions, time between neurological deterioration and surgery,and intracranial pressure (ICP) have been identified as impor-tant factors determining outcome from EDH.
Age and GCS
The influence of age on outcome in the subgroup of patientswith EDH is not as pronounced as it is in TBI patients overall.Three studies using multiple regression analysis found thatGCS was a better predictor of outcome than age in patientsundergoing surgery for EDH (20, 22, 38). In a retrospectiveanalysis of 98 patients of all age groups with EDH undergoingcraniotomy, van den Brink et al. (39) investigated determi-nants of outcome at 6 months. They identified GCS, age, andthe CT diagnosis of subarachnoid hemorrhage as significantfactors correlated with outcome, using multivariate analysis.Admission GCS or GCS before surgery is the single mostimportant predictor of outcome in patients with EDH under-going surgery (3, 10, 20, 22, 24, 38, 39). In three studies usingmultivariate analysis in a total of 284 patients, the admissionGCS score was identified as the most significant factor deter-mining outcome at 6 months (20, 38, 39). In one study with 200patients undergoing craniotomy, admission and preoperativeGCS both correlated with functional outcome at 1 year (22).Gennarelli et al. (10) analyzed the relationship between type oflesion, GCS score on admission, and 3-months outcome in
1107 comatose patients with TBI. The highest mortality wasfound in patients with a subdural hemorrhage and a GCSbetween 3 and 5 (74%). Patients with an EDH and a GCS of 3to 5 had a mortality of 36%, and patients with an EDH and aGCS of 6 to 8 had a mortality of only 9%.
Pupils
Pupillary abnormalities, such as pupillary asymmetry orfixed and dilated pupils occur in approximately 20 to 30% ofpatients with EDH undergoing surgery (3, 16, 20, 40) and in62% of patients who are comatose on admission (32). Onestudy showed that ipsilateral mydriasis was not associatedwith adverse outcome and was reversible when operated onwithin 70 minutes after pupillary dilation (6). Bilateral mydri-asis, however, is associated with a high mortality (3, 6, 8, 24,32, 39). Mydriasis contralateral to the hematoma is also asso-ciated with high mortality (24, 32). Van den Brink et al. (39), ina multivariate model evaluating the relative prognostic valueof predictive parameters, found that, in patients in all agegroups and GCS scores, pupillary abnormalities were signifi-cantly related to unfavorable outcome. Adverse outcome wasobserved in 30% of normal pupillary responses, in 35% ofunilateral fixed pupils, and in 50% of bilateral fixed pupils.Bricolo and Pasut (3) achieved a good outcome in 100% ofpatients who presented with anisocoria and in 90% of patientswho presented with anisocoria and hemiparesis. The onlypatient with bilateral mydriasis in their case series died.
Associated Lesions
Associated intracranial lesions are found in between 30 and50% of adult patients with surgically evacuated EDH (3, 8, 13,16, 20, 22, 23, 27, 29, 31, 32, 35). These are predominantlycontusions and intracerebral hemorrhage followed by sub-dural hematoma (SDH) and diffuse brain swelling (8, 16, 29,32, 35). The incidence of associated lesions is less in the pedi-atric age group (25, 27, 30). SDH and/or parenchymal lesionsin association with EDH lower the chance of a good outcome.In two studies with a total of 315 patients operated on forevacuation of an EDH, the frequency of associated intracraniallesions was 33% (20, 22). In both studies, a significant relation-ship was found between the presence of other lesions inaddition to the EDH and an adverse outcome. Lee et al. (22)identified associated brain lesions as one of four independentpredictors of unfavorable outcome after surgery for EDH andthis has been confirmed by several others (8, 13, 16, 23, 32).Cranial fractures are present in between 70 and 95% of cases(15, 17, 20, 25, 30, 37). The impact of fractures on outcome iscontroversial. Kuday et al. (20) observed a significant relation-ship between cranial factures and adverse outcome in 115patients undergoing surgery for EDH. Lee et al. (22) did notsee this relationship in a series of 200 patients managed sim-ilarly, and Rivas et al. (32) actually reported a significantlylower mortality rate in patients with cranial fractures. Signif-icant extracranial injury is present in 7 to 23% of patientsoperated on for an EDH (8, 13, 17, 24, 27). Lobato et al. (24)
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found extracranial injury in 20% of their patients, and themortality rate in this subgroup was lower than the overallmortality (7.6% versus 28%). No data were found on theassociation of hypotension and outcome in patients with anacute EDH.
ICP
There is only one study available in which postoperativeICP and its relationship to outcome 6 months after trauma wasstudied. Lobato et al. (24) monitored ICP in 54 (83%) of 64comatose patients after removal of an EDH. Elevated ICP (�15mm Hg) was found in 67% of cases, and ICP greater than 35mm Hg was significantly associated with a higher mortality.
PROCESS
A MEDLINE computer search using the following key-words for the years 1975 to 2001 was performed: “traumaticbrain injury” or “head injury” and “epidural” or “extradural”and “hematoma” or “hematoma” or “hemorrhage.” Thesearch was narrowed by including the keywords “surgicaltreatment” or “surgery” or “operation” or “craniotomy” or“craniectomy” or “craniostomy” or “burr holes” and exclud-ing “spinal.” These searches combined yielded 168 articles.The reference lists of these publications were reviewed and anadditional 22 articles were selected for analysis. Case reports,publications in books, and publications regarding penetratingbrain injuries on spinal EDH and on exploratory burr holeswithout a preoperative CT scan were not included. Articleswere excluded if the diagnosis of EDH was not based on CTscanning, or if subgroups of patients who did not undergo CTscanning were not clearly identified. Publications with fewerthan 10 patients or publications that did not include informa-tion on outcome were excluded. Of these 190 articles, 18 wereselected for analysis.
SCIENTIFIC FOUNDATION
Indication for Surgery
The decision to operate on an acute EDH is based on thepatient’s GCS score, pupillary exam, comorbidities, CT find-ings, age, and, in delayed decisions, the patient’s ICP. Neuro-logical deterioration over time is also an important factorinfluencing the decision to operate. Trauma patients present-ing to the emergency room with altered mental status, pupil-lary asymmetry, and abnormal flexion or extension are at highrisk for either an SDH and/or EDH compressing the brain andbrainstem.
CT Characteristics and Outcome
CT is the imaging study of choice for the diagnosis of anEDH. CT scanning is recommended in patients at risk forharboring an acute EDH. It allows not only diagnosis of theprimary lesion but also identification of additional featuresthat affect outcome, such as MLS, traumatic subarachnoid
hemorrhage, obliteration of the basal cisterns, thickness of theblood clot, and hematoma volume.
In a series of 200 patients who were treated surgically forEDH, Lee et al. (22) found that a hematoma volume greaterthan 50 cm3 was significantly related to higher mortality andunfavorable functional outcome. Unfavorable functional re-covery was observed in 6.2% of patients with a hematomavolume less than 50 cm3, and in 24% of patients with ahematoma volume greater than 50 cm3. Mixed density of theblood clot, indicating acute bleeding, was observed in 32% oftheir patients and correlated with unfavorable outcome butnot with mortality. Patients with an MLS greater than 10 mmshowed a higher mortality and more unfavorable outcomewhen compared with those with less displacement. Partial ortotal obliteration of the basal cisterns was observed in 59% oftheir patients and correlated with both mortality and func-tional outcome. Multivariate analysis identified only hema-toma volume as an independent predictor of unfavorableoutcome.
In contrast, in 98 patients with EDH who underwent sur-gery, van den Brink et al. (39) found that the status of the basalcisterns, MLS, and hematoma volume were not related tooutcome. The authors only identified the presence of trau-matic subarachnoid hemorrhage to be significantly associatedwith unfavorable outcome. Patients with favorable outcomehad a hematoma volume of 56 � 30 cm3 and, with unfavorableoutcome, the hematoma volume was 77 � 63 cm3, but thisdifference was not significant.
Rivas et al. (32) found that hematoma volume and severityof MLS were related to preoperative coma in patients withEDH. In comatose patients, a hematoma volume greater than150 cm3 and an MLS greater than 12 mm were associated withincreased mortality. Mixed-density blood clots were observedin 62% of their patients and were related to poor outcome.Location of the lesion did not influence outcome. Seelig et al.(35) did not find a relationship between location of blood clot,MLS, and outcome in 51 comatose patients undergoing sur-gery for EDH.
In summary, most authors could not detect a relationshipbetween blood clot location and outcome. However, it is likelythat hematoma volume, MLS, mixed density of the blood clot,and traumatic subarachnoid hemorrhage are related to out-come, but more studies are needed to clarify this issue.
Surgery and Nonoperative Treatment
Prospective, randomized trials comparing surgical treat-ment with nonoperative management are not available. Somestudies compared patients who were treated either surgicallyor nonoperatively, and used logistic regression analysis andmultivariate analysis models to determine factors that wereassociated with either treatment (36, 37). Some investigatorslooked at patient series that were initially all treated nonop-eratively and analyzed the factors associated with subsequent,delayed surgery (2, 7, 19, 37). There are no studies on nonop-erative treatment of comatose patients with EDH.
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What are the factors leading to surgery? The followingstudies compared characteristics between patients who weretreated with either surgery or were managed nonoperatively.The value of such analyses is doubtful because it merelydocuments the criteria used to select patients for surgery.
Servadei et al. (36) conducted a prospective study including158 consecutive patients with GCS 14 and 15 with EDH whowere admitted to three neurosurgical units. A treatment pro-tocol was not defined for these hospitals. One hundred-sixteenpatients underwent surgery and 42 patients were managednonoperatively. Ninety-three percent of patients with an MLSgreater than 5 mm, and 91% of patients with a hematomathickness greater than 15 mm underwent surgery. A logisticregression analysis identified hematoma thickness and MLS asthe factors associated with surgery. Location and the presenceof associated lesions did not reach significance. Outcome wasgood in all patients. Similar results were obtained in 33 pedi-atric patients, 20 of whom were treated surgically (1). Bothgroups did not differ in terms of age, GCS, and outcome.Multivariate logistic regression analysis revealed that MLS,hematoma thickness, and volume, as well as temporal locationof the blood clot were related to surgery. Hematoma volumeand MLS were 41 cm3 and 8 cm3, and 4 mm and 0.5 mm, forthe surgical and nonsurgical groups, respectively.
A review of 30 patients who were treated with craniotomyand 18 patients treated nonoperatively revealed that patientsmanaged with surgery had lower GCS scores, were morelikely to present with pupillary abnormalities and hemipare-sis, and had larger blood clots and more MLS (12). Temporallocation of the hematoma and the presence and location of afracture were not related to surgery.
Factors Determining Delayed Surgery
Bezircioglu et al. (2) conducted a prospective study on thenonoperative management of 80 patients with EDH and GCSscores between 9 and 15. Patients with a GCS score greaterthan 8, an EDH volume less than 30 ml, a hematoma thicknessless than 2 cm, and without neurological deficit were treatednonoperatively. Five patients deteriorated and underwent cra-niotomy. One of these patients died, the others had goodoutcomes. The only factor significantly associated with de-layed surgery was a temporal location of the hematoma,which was observed in all five surgical patients but only in24% of the 75 patients treated without operation.
In a study of 74 patients with initially asymptomatic EDHmanaged nonoperatively, 14 required delayed surgery be-cause of neurological deterioration or increase in the size ofthe hematoma (5). The authors found that a hematoma volumegreater than 30 cm3, a hematoma thickness greater than 15mm, and an MLS greater than 5 mm were significantly morefrequent in patients requiring surgery. A hematoma volumegreater than 30 cm3, an EDH thickness greater than 15 mm,and an MLS greater than 5 mm were observed in 5%, 27%, and28% of patients managed without surgery, and in 57%, 71%,and 79% of patients who had surgery, respectively. The au-
thors used the “ellipsoid” or “ABC/2” method to estimate thevolume of EDHs (see Appendix I). Hematoma location, bonefractures, and time-to-initial CT scan were not related to out-come. In a small study on 22 patients, 7 of whom required latersurgery, a time interval of less than 6 hours after injury to thefirst CT scan and a cranial fracture that crossed a major vesselwere significantly related to surgery (19).
Studies Describing Successful Nonsurgical Management
Bullock et al. (4) treated 12 of 123 patients presenting withEDH nonsurgically. All patients were conscious (GCS 12–15)with a hematoma volume between 12 and 38 cm3 (mean, 26.8cm3) and an MLS less than 10 mm on the initial CT scan. Noneof the hematomas were in the temporal region. All patientsmade a good outcome. Cucciniello reported on 57 patientswith EDH who were treated nonoperatively (9). Initial GCSwas between 10 and 15. Five hematomas were in the temporalregion. The maximum hematoma thickness ranged between 6and 12 mm. Only one patient had an MLS. All patients madea good recovery.
Timing of Surgery
Time between Injury and Surgery
The effect of surgical timing on outcome from EDH isrelevant for a subgroup of patients in whom the EDH causescompression of brain structures that, with time, could causepoor outcome. This subgroup is usually categorized as havingpupillary abnormalities and/or a GCS score less than 9(coma). Generally, studies of EDH reveal that only 21 to 34%of patients present to the hospital with a GCS score less than8 or 9 (3, 20, 22, 25). Studies do not find a relationship betweensurgical timing and outcome if patients of all GCS scores areincluded. In 200 patients with EDH that were surgically evac-uated, Lee et al. (22) failed to demonstrate a significant rela-tionship between surgery within 4 hours of trauma or surgerywithin 2 hours of admission and outcome, using multivariateanalysis. However, a significant correlation was observed be-tween the duration of brain herniation, as evidenced by aniso-coria, and the outcome. The time lapse between the onset ofpupillary abnormalities and surgery is related to outcome.Cohen et al. (6) studied 21 patients with EDH and GCS scoreless than 9 who underwent surgery. Ten of these patientsdeveloped anisocoria after admission. All 5 patients withanisocoria for longer than 70 minutes before surgical evacua-tion of the EDH died. Patients with anisocoria for shorter than70 minutes achieved a good outcome. Haselsberger et al. (13)studied 60 patients with EDH, and 34 patients developedcoma before surgery. They found that patients treated within2 hours after loss of consciousness exhibited a mortality rate of17% and good recovery in 67%, compared with a mortalityrate of 56% and good results in 13% in patients operated onlater. Sakas et al. (33) found that all patients with either SDHor EDH with fixed and dilated pupils for longer than 6 hourdied.
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Patient Transfer and Timing of Surgery
The question of whether a patient with acute EDH shouldbe treated at the nearest hospital or transferred to a specializedtrauma center has been debated but poorly documented instudies. This is an important timing issue and is significant inthe group of patients who are deteriorating. Another issue isthe surgical evacuation of EDH by nonneurosurgeons withsubsequent transfer to a neurosurgical center. Obviously,these studies are uncontrolled with regard to the efficacy ofsurgery and the type of patients included in both arms. In theabove timing of surgery, the group of patients in a coma andwith pupillary abnormalities can be expected to do worse thelonger the interval to evacuation of the EDH. Thus, because ofthe delay, transferred patients would have longer intervaltimes to surgery.
Wester (40) studied 83 patients with acute EDH that under-went craniotomy. Twenty-eight patients were transferredfrom other hospitals and 11 of these underwent emergencysurgery at those outside institutions. Patients who underwentsurgery outside the parent institution by nonneurosurgeonshad a significantly worse outcome at 3 months as comparedwith patients who were directly admitted to the study hospi-tal. This was mainly attributed to the technical inadequacy ofthe primary operation at the outside institution. The authorsinterpreted this as support for the strategy of directly trans-ferring patients to an adequate trauma center, but they did notcontrol for other confounding variables, such as admissionGCS and pupillary exam.
Another study analyzed 107 patients operated on for EDH(3). The majority (67%) of these patients were transferred fromoutlying hospitals. The authors noted that only 6% of thedirect admissions experienced a poor outcome, as comparedwith 18% of patients who were transferred after undergoingCT scanning at an outside institution. This difference failed toreach statistical significance. Poon and Li (31) studied 71 pa-tients with EDH managed surgically primarily at a neurosur-gical hospital and 33 patients transferred from an outsideinstitution. Time delay from neurological deterioration to sur-gery was 0.7 � 1 hour and 3.2 � 0.5 hours for the direct versusindirect transferred group, respectively. Six-months outcomewas significantly better in patients who were directly admittedwith a minimal delay from deterioration in neurological examto surgery.
SUMMARY
In patients with an acute EDH, clot thickness, hematomavolume, and MLS on the preoperative CT scan are related tooutcome. In studies analyzing CT parameters that may bepredictive for delayed surgery in patients undergoing initialnonoperative management, a hematoma volume greater than30 cm3, an MLS greater than 5 mm, and a clot thickness greaterthan 15 mm on the initial CT scan emerged as significant.Therefore, patients who were not comatose, without focalneurological deficits, and with an acute EDH with a thickness
of less than 15 mm, an MLS less than 5 mm, and a hematomavolume less than 30 cm3 may be managed nonoperativelywith serial CT scanning and close neurological evaluation in aneurosurgical center (see Appendix II for measurement tech-niques). The first follow-up CT scan in nonoperative patientsshould be obtained within 6 to 8 hours after TBI. Temporallocation of an EDH is associated with failure of nonoperativemanagement and should lower the threshold for surgery. Nostudies are available comparing operative and nonoperativemanagement in comatose patients. The literature supports thetheory that patients with a GCS less than 9 and an EDHgreater than 30 cm3 should undergo surgical evacuation of thelesion. Combined with the above recommendation, it followsthat all patients, regardless of GCS, should undergo surgery ifthe volume of their EDH exceeds 30 cm3. Patients with anEDH less than 30 should be considered for surgery but may bemanaged successfully without surgery in selected cases.
Time from neurological deterioration, as defined by onset ofcoma, pupillary abnormalities, or neurological deterioration tosurgery, is more important than time between trauma andsurgery. In these patients, surgical evacuation should be per-formed as soon as possible because every hour delay in sur-gery is associated with progressively worse outcome.
KEY ISSUES FOR FUTURE INVESTIGATION
•Effect of transfer versus direct admission to a traumacenter on timing of surgery and outcome from EDH.
•Identification of subgroups that do not benefit from sur-gery: old patients with low GCS scores, pupillary abnormali-ties, and associated intracerebral lesions.
•Surgical technique.
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32. Rivas J, Lobato R, Sarabia R, Cordobes F, Cabrera A, Gomez P: Extraduralhematoma: Analysis of factors influencing the courses of 161 patients.Neurosurgery 23:44–51, 1988.
33. Sakas D, Bullock M, Teasdale G: One-year outcome following craniotomyfor traumatic hematoma in patients with fixed dilated pupils. J Neurosurg82:961–965, 1995.
34. Schutzman S, Barnes P, Mantello M, Scott R: Epidural hematomas in chil-dren. Ann Emerg Med 22:535–541, 1993.
35. Seelig J, Marshall L, Toutant S, Toole B, Klauber M, Bowers S, Varnell J:Traumatic acute epidural hematoma: Unrecognized high lethality in coma-tose patients. Neurosurgery 15:617–620, 1984.
36. Servadei F, Faccani G, Roccella P, Seracchioli A, Godano U, Ghadirpour R,Naddeo M, Piazza G, Carrieri P, Taggi F, Pagni CA: Asymptomatic extra-dural haematomas. Results of a multicenter study of 158 cases in minor headinjury. Acta Neurochir (Wien) 96:39–45, 1989.
37. Sullivan T, Jarvik J, Cohen W: Follow-up of conservatively managed epi-dural hematomas: Implications for timing of repeat CT. AJNRAm J Neuroradiol 20:107–113, 1999.
38. Uzan M, Yentur E, Hanci M, Kaynar MY, Kafadar A, Sarioglu AC, Bahar M,Kuday C: Is it possible to recover from uncal herniation? Analysis of 71 headinjured cases. J Neurosurg Sci 42:89–94, 1998.
39. van den Brink WA, Zwienenberg M, Zandee SM, van der Meer L, Maas AI,Avezaat CJ: The prognostic importance of the volume of traumatic epiduraland subdural haematomas revisited. Acta Neurochir (Wien) 141:509–514,1999.
40. Wester K: Decompressive surgery for �pure� epidural hematomas: Doesneurosurgical expertise improve the outcome? Neurosurgery 44:495–500,1999.
41. Wu J, Hsu C, Liao S, Wong Y: Surgical outcome of traumatic intracranialhematoma at a regional hospital in Taiwan. J Trauma 47:39–43, 1999.
SURGICAL MANAGEMENT OF TBI AUTHOR GROUP
S2-12 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com
EVID
ENTI
AR
YTA
BLE
TAB
LE1.
Surg
ical
man
agem
ent
ofac
ute
epid
ural
hem
atom
asa
Aut
hors
(ref
.no
.)N
o.of
pati
ents
Cla
ssIn
clus
ion
GC
STr
eatm
ent
Out
com
eD
escr
ipti
onC
oncl
usio
n
Bej
jani
etal
.(1
)33
IIIA
llG
CS
Surg
ery
and
nons
urgi
cal
Dis
char
geR
etro
spec
tive
anal
ysis
offa
ctor
saf
fect
ing
the
deci
sion
toop
erat
ein
33pe
diat
ric
patie
nts
with
EDH
.13
patie
nts
unde
rwen
top
erat
ive
trea
tmen
t.
Mas
sef
fect
,te
mpo
ral
loca
tion
ofbl
ood
clot
,M
LS,
thic
knes
sof
clot
,an
dvo
lum
ew
ere
inde
pend
ently
rela
ted
tosu
rger
y.O
ther
clin
ical
fact
ors,
such
asag
e,G
CS,
and
asso
ciat
edfr
actu
res
wer
eno
t.O
utco
me
was
good
in�
90%
ofpa
tient
s.
EDH
Ope
rati
vetr
eatm
ent
Non
oper
ativ
etr
eatm
ent
Thic
knes
s(m
m)
209
Vol
ume
(cm
3 )41
8
MLS
(mm
)4
0.5
Bez
irci
oglu
etal
.(2
)80
IIIG
CS
�8
Surg
ery
and
nons
urgi
cal
GO
Sat
2m
oPr
ospe
ctiv
est
udy
onno
nope
rativ
em
anag
emen
tof
patie
nts
with
EDH
.Pa
tient
sw
itha
EDH
volu
me
�30
ml,
thic
knes
s�
2cm
,G
CS
�8,
none
urol
ogic
alde
ficit,
and
adm
itted
with
in24
hof
TBI
wer
etr
eate
dno
nope
rativ
ely.
Of
80pa
tient
sw
how
ere
trea
ted
nono
pera
tivel
y,5
dete
rior
ated
and
need
edsu
rger
y.O
nedi
ed,
and
4ha
da
good
outc
ome.
Tem
pora
llo
beED
Hw
asre
late
dto
dela
yed
surg
ery.
Bri
colo
and
Pasu
t(3
)10
7III
All
GC
SA
llsu
rger
yG
OS
at6
mo
Neu
rolo
gica
lsi
gns
onad
mis
sion
No.
ofpa
tien
tsG
ood
outc
ome
(%)
Non
e17
100
One
dila
ted
pupi
l8
100
Hem
ipar
esis
only
2391
Hem
ipar
esis
and
one
dila
ted
pupi
l10
90
Dec
ortic
atio
n9
44
Dec
ereb
ratio
n4
25
Bot
hpu
pils
fixed
10
GC
Son
adm
issi
onN
o.of
pati
ents
GR
/MD
(%)
SD/V
S(%
)D
ead
(%)
3–4
425
2550
5–7
3278
139
8–1
571
973
0
Bul
lock
etal
.(4
)12
IIIG
CS
12–1
5N
onsu
rgic
alD
isch
arge
Ret
rosp
ectiv
ean
alys
isof
the
nono
pera
tive
trea
tmen
tof
12pa
tient
sw
ithED
H.
All
patie
nts
mad
ea
good
reco
very
.N
ote
mpo
ral
EDH
patie
nts
wer
ein
clud
ed,
and
basa
lci
ster
nsw
ere
open
oron
lypa
rtia
llyef
face
din
all
patie
nts.
MLS
was
�10
mm
inal
lpa
tient
s.M
ean
volu
me
ofth
eED
Hw
as26
.8cm
3 .
Che
net
al.
(5)
74III
GC
S�
12Su
rger
yan
dno
nsur
gica
lG
OS
at1
mo
Ret
rosp
ectiv
ean
alys
isof
111
of46
5pa
tient
sw
ithED
Hw
houn
derw
ent
initi
alno
nope
rativ
etr
eatm
ent.
All
nono
pera
tive
case
sha
da
GC
S�
12,
and
14pa
tient
sun
derw
ent
dela
yed
surg
ery
beca
use
ofne
urod
eter
iora
tion
orin
crea
sein
the
size
ofth
eED
H.
37pa
tient
sw
ere
excl
uded
beca
use
ofin
com
plet
eC
Tda
ta.
All
patie
nts
achi
eved
ago
odG
OS.
Patie
nts
requ
irin
gde
laye
dsu
rger
ypr
esen
ted
mor
efr
eque
ntly
with
anED
Hvo
lum
e�
30cm
3 ,cl
otth
ickn
ess
�15
mm
,or
MLS
�5
mm
onth
ein
itial
CT
scan
.
Ope
rati
vetr
eatm
ent
Non
oper
ativ
etr
eatm
ent
Pva
lue
No.
ofpa
tient
s14
97
Tem
pora
l/fr
onto
tem
pora
llo
catio
nof
EDH
42.8
%36
.6%
n.s.
EDH
�30
cm3
83
P�
0.00
1
MLS
�5
mm
1117
P�
0.00
1
EDH
�15
mm
thic
knes
s10
16P
�0.
01
(Tab
leco
ntin
ues)
ACUTE EPIDURAL HEMATOMAS
NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-13
TAB
LE1.
Con
tinu
ed
Aut
hors
(ref
.no
.)N
o.of
pati
ents
Cla
ssIn
clus
ion
GC
STr
eatm
ent
Out
com
eD
escr
ipti
onC
oncl
usio
n
Coh
enet
al.
(6)
21III
GC
S�
8A
llsu
rger
yN
otdo
cum
ente
dPr
ospe
ctiv
eda
taco
llect
ion
on21
adul
tpa
tient
sad
mitt
eddu
ring
3yr
with
acut
eED
Han
dG
CS
�8,
who
unde
rwen
tsu
rger
y.10
patie
nts
deve
lope
dne
wan
isoc
oria
afte
rad
mis
sion
.O
nly
14pa
tient
sha
dC
Tsc
ans.
3pa
tient
sha
dem
erge
ncy
cran
ioto
my
with
out
radi
ogra
phic
stud
ies.
Ani
socr
iafo
rm
ore
than
70m
inw
asas
soci
ated
with
100%
mor
talit
y,an
dfo
rle
ssth
an70
min
with
GO
S4
and
5.
Tim
efr
oman
isoc
oria
tocr
anio
tom
yN
o.of
pati
ents
GR
/MD
(%)
Dea
d(%
)
�71
min
510
00
�89
min
50
100
Cuc
cini
ello
etal
.(9
)57
IIIG
CS
10–1
5N
onsu
rgic
alN
otdo
cum
ente
dR
etro
spec
tive
anal
ysis
ofa
case
seri
esof
57pa
tient
sou
tof
144
with
EDH
who
wer
em
anag
edno
nope
rativ
ely.
All
patie
nts
had
good
outc
ome.
Onl
yon
epa
tient
dem
onst
rate
dM
LSan
dm
axim
umhe
mat
oma
thic
knes
sw
asbe
twee
n6
and
12m
m.
Ham
ilton
and
Wal
lace
(12)
48III
All
GC
SSu
rger
yan
dno
nsur
gica
lD
isch
arge
Ret
rosp
ectiv
ean
alys
isof
patie
nts
who
unde
rwen
tsu
rgic
alan
dno
nope
rativ
etr
eatm
ent
for
EDH
.
Patie
nts
who
unde
rwen
tsu
rgic
altr
eatm
ent
had
low
erG
CS
scor
es,
mor
epu
pilla
ryab
norm
aliti
es,
larg
erED
H,
grea
ter
MLS
,an
dw
ere
mor
elik
ely
tosh
owun
cal
hern
iatio
non
CT.
Has
elsb
erge
ret
al.
(13)
60III
All
GC
SA
llsu
rger
yN
otdo
cum
ente
dA
revi
ewof
171
patie
nts
who
pres
ente
dw
ithei
ther
subd
ural
(111
patie
nts)
orep
idur
al(6
0pa
tient
s)he
mat
oma.
The
influ
ence
ofsu
rgic
altim
ing
onm
orta
lity
and
func
tiona
lre
cove
ryw
asan
alyz
ed.
Patie
nts
with
anac
ute
subd
ural
orep
idur
alhe
mat
oma
had
alo
wer
mor
talit
yan
dim
prov
edfu
nctio
nal
reco
very
whe
nop
erat
edon
�2
haf
ter
onse
tof
com
a.
Tim
efr
omco
ma
onse
tto
surg
ery
No.
ofpa
tien
tsG
R/M
D(%
)SD
/VS
(%)
D(%
)
�2
h18
6716
17
�2
h16
1331
56
Knu
ckey
etal
.(1
9)22
IIIA
llG
CS
Surg
ery
and
nons
urgi
cal
Not
docu
men
ted
Ret
rosp
ectiv
ean
alys
isof
22pa
tient
sof
all
age
grou
psw
how
ere
initi
ally
trea
ted
nono
pera
tivel
y.7
patie
nts
need
edsu
bseq
uent
cran
ioto
my.
Earl
yC
Tsc
an�
6h
afte
rtr
aum
aan
dcr
ania
lfr
actu
res
cros
sing
big
vess
els
orth
em
iddl
em
enin
geal
arte
ryw
ere
asso
ciat
edw
ithde
teri
orat
ion.
Initi
alG
CS,
age,
and
size
ofth
eED
Hw
ere
not.
Kud
ayet
al.
(20)
115
IIIA
llG
CS
All
surg
ery
GO
Sat
6m
oR
etro
spec
tive
anal
ysis
ofpr
ospe
ctiv
ely
colle
cted
data
on11
5pa
tient
sof
all
age
grou
psun
derg
oing
surg
ery
for
�sig
nsof
hern
iatio
n.�
GC
Sis
the
para
met
erco
rrel
atin
gm
ost
clos
ely
with
outc
ome.
The
pres
ence
ofa
cran
ial
frac
ture
and
“lon
g”in
terv
albe
twee
non
set
ofsy
mpt
oms
and
inte
rven
tion
also
affe
ctou
tcom
e.
Lee
etal
.(2
2)20
0III
All
GC
SA
llsu
rger
yG
OS
at1
yrA
retr
ospe
ctiv
est
udy
of20
0pa
tient
sw
ithep
idur
alhe
mat
omas
requ
irin
gop
erat
ion.
Ana
lysi
sof
fact
ors
lead
ing
toa
poor
outc
ome.
Func
tiona
lou
tcom
eco
rrel
ated
with
decr
ease
dle
ngth
ofhe
rnia
tion
time,
nopo
stur
ing,
norm
alpu
pils
,an
da
high
GC
Ssc
ore.
Unf
avor
able
radi
olog
ical
sign
sw
ere
asso
ciat
edbr
ain
inju
ry,
MLS
�1
cm,
oblit
erat
edba
sal
cist
erns
,an
dsi
zean
dde
nsity
ofth
ebl
ood
clot
.
Inte
rval
betw
een
anis
ocor
iaan
dde
com
pres
sion
(h)
No.
ofpa
tien
tsSD
/VS/
D(%
)
No
126
7.9
�1.
518
22.2
1.5–
2.5
2725
.9
2.5–
3.5
1330
.8
3.5–
4.5
1353
.8
�4.
53
66.7
Hem
atom
avo
lum
e(m
l)N
o.of
pati
ents
SD/V
S/D
(%)
�50
816.
2
51–1
0081
14.8
101–
150
3138
.7
�15
07
71.4
MLS
(mm
)N
o.of
pati
ents
SD/V
S/D
(%)
�5
859.
4
6–1
069
8.7
11–1
535
37.1
�15
1163
.6
(Tab
leco
ntin
ues)
SURGICAL MANAGEMENT OF TBI AUTHOR GROUP
S2-14 | VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT www.neurosurgery-online.com
TAB
LE1.
Con
tinu
ed
Aut
hors
(ref
.no
.)N
o.of
pati
ents
Cla
ssIn
clus
ion
GC
STr
eatm
ent
Out
com
eD
escr
ipti
onC
oncl
usio
n
Poon
and
Li(3
1)10
4III
All
GC
SA
llsu
rger
yG
OS
at6
mo
Apr
ospe
ctiv
est
udy
of10
4pa
tient
sof
all
age
grou
psw
ithis
olat
edED
H.
One
-thi
rdof
the
patie
nts
wer
etr
ansf
erre
dfr
oman
outs
ide
hosp
ital.
Asi
gnifi
cant
incr
ease
inm
orta
lity
and
mor
bidi
tyw
asre
late
dto
incr
ease
dtim
efr
omne
urol
ogic
alde
teri
orat
ion
tosu
rger
y.
No.
ofpa
tien
ts
Tim
ebe
twee
nde
teri
orat
ion
ofco
nsci
ous
leve
lan
dsu
rger
y(h
)
D(%
)V
S/SD
/MD
(%)
GR
(%)
710.
7�
14
1086
333.
2�
0.5
2427
49
Saka
set
al.
(33)
11III
“Com
atos
e”A
llsu
rger
yG
OS
at1
yrA
naly
sis
of40
seve
reTB
Ipa
tient
sw
houn
derw
ent
cran
ioto
my
afte
rde
velo
ping
bila
tera
lfix
edan
ddi
late
dpu
pils
.
Patie
nts
with
SDH
had
asi
gnifi
cant
incr
ease
inm
orta
lity
(64%
)co
mpa
red
with
thos
ew
ithED
H(1
8%).
Patie
nts
who
unde
rwen
tde
laye
d(�
3h)
surg
ery
had
aw
orse
outc
ome.
Tim
efr
ompu
pilla
ryno
nrea
ctiv
ity
tosu
rger
y
No.
ofpa
tien
tsG
R/M
D(%
)SD
(%)
VS/
D(%
)
�3
h20
3030
40
�3
h16
2512
63
Seel
iget
al.
(35)
51III
“Com
atos
e”A
llsu
rger
yG
OS
at3
mo–
2yr
Pros
pect
ive
mul
ticen
ter
data
base
anal
yzed
retr
ospe
ctiv
ely,
look
ing
atth
efa
ctor
sin
fluen
cing
outc
ome
afte
rsu
rger
yfo
rED
H.Th
em
ost
pow
erfu
lin
dica
tor
ofou
tcom
ew
asm
otor
scor
ebe
fore
surg
ery.
Mot
orsc
ore
No.
ofpa
tien
tsG
R/M
D/S
D(%
)V
S/D
(%)
1–3
1932
68
4–
632
6931
Serv
adei
etal
.(3
6)15
8III
GC
S14
/15
Surg
ery
and
nons
urgi
cal
GO
Sat
6m
oPr
ospe
ctiv
est
udy
of15
8co
nsec
utiv
epa
tient
sw
ithm
inor
TBI
(GC
S14
/15)
adm
itted
to3
neur
osur
gica
lun
its.
No
trea
tmen
tpr
otoc
olw
assp
ecifi
edan
da
logi
stic
regr
essi
onan
alys
isw
asco
nduc
ted
toid
entif
yth
efa
ctor
sle
adin
gto
surg
ery.
116
patie
nts
unde
rwen
tsu
rger
yan
d42
patie
nts
wer
em
anag
edno
nope
rativ
ely.
Of
all
fact
ors
anal
yzed
,on
lyth
ickn
ess
ofhe
mat
oma
and
MLS
wer
ere
late
dto
the
deci
sion
toop
erat
e.O
utco
me
was
the
sam
ein
both
grou
ps.
MLS
(mm
)N
o.of
pati
ents
Cra
niot
omy
(%)
Non
oper
ativ
em
anag
emen
t(%
)
0–5
130
7030
6–1
019
89.5
10.5
�10
810
00
van
den
Bri
nket
al.
(39)
98III
All
GC
SA
llsu
rger
yG
OS
at6
mo
Ret
rosp
ectiv
ean
alys
isof
CT
para
met
ers
and
outc
ome
in98
patie
nts
ofal
lag
egr
oups
with
acut
eED
H.
Vol
ume
ofth
eED
Hdi
dno
tco
rrel
ate
with
outc
ome.
Suba
rach
noid
bloo
dan
dpu
pilla
rydy
sfun
ctio
n,ag
e�
20yr
,an
dG
CS
onad
mis
sion
wer
epa
ram
eter
sco
rrel
atin
gw
ithou
tcom
e.
Age
(yr)
SD/V
S/D
(%)
�20
6
21–
4017
41–
6031
�60
50
Mot
orsc
ore
SD/V
S/D
(%)
1–3
50
4–
67
Pupi
lsSD
/VS/
D(%
)
Nor
mal
3
Uni
late
ral
fixed
and
dila
ted
35
Bila
tera
lfix
edan
ddi
late
d50
Wes
ter
(40)
83III
All
GC
SA
llsu
rger
yG
OS
at3
mo
Ret
rosp
ectiv
est
udy
ofth
em
anag
emen
tof
pure
EDH
inpa
tient
sof
all
age
grou
psin
Nor
way
.In
form
atio
non
thei
rin
itial
neur
olog
ical
exam
islim
ited.
The
outc
ome
of11
patie
nts
trea
ted
atth
epr
imar
yho
spita
lw
asw
orse
than
the
outc
ome
ofpa
tient
sth
atw
ere
adm
itted
dire
ctly
.Th
eau
thor
sco
nclu
deth
atpa
tient
ssh
ould
betr
ansf
erre
ddi
rect
lyfo
rne
uros
urgi
cal
man
agem
ent.
aG
CS,
Gla
sgow
Com
aSc
ale;
EDH
,ep
idur
alhe
mat
oma;
MLS
,m
idlin
esh
ift;
GO
S,G
lasg
owou
tcom
esc
ore;
TBI,
trau
mat
icbr
ain
inju
ry;
GR
,go
odre
cove
ry;
MD
,m
oder
ate
disa
bilit
y;SD
,se
vere
disa
bilit
y;V
S,ve
geta
tive
stat
e;D
,de
ath;
CT,
com
pute
dto
mog
raph
icsc
an;
n.s.
,no
tsi
gnifi
cant
.
ACUTE EPIDURAL HEMATOMAS
NEUROSURGERY VOLUME 58 | NUMBER 3 | MARCH 2006 SUPPLEMENT | S2-15
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