BULLOCK - HED

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: [email protected]

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)

SURGICAL MANAGEMENT OF TBI AUTHOR GROUP

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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.

ACUTE EPIDURAL HEMATOMAS


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.



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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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.



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)



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)



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

.



Documents

BULLOCK - HED