Rom J Leg Med [22] 45-50 [2014] DOI: 10.4323/rjlm.2014.45 © 2014 Romanian Society of Legal Medicine Extradural hematoma – is surgery always mandatory? Ligia Tataranu1,2,*, Vasile Ciubotaru2, Dan Paunescu2, Andrei Spatariu2, Mugurel Radoi1 _________________________________________________________________________________________ Abstract: Although surgery remains the treatment of choice for extradural hematomas (EDH), there were many cases reported in the literature with good outcome, even if they were not treated surgically. The aim of this study was to discover the most important factors influencing the management strategy and outcome of EDH and to outline a set of guidelines for the treatment. Fifty-six consecutive adult patients treated for EDH between 2008 and 2012 formed the base of this retrospective study. The patients were treated as follows: 28 cases (50.0%) underwent urgent surgery, 13 cases (23.2%) were managed nonoperatively and 15 cases (26.8%) required delayed surgery. The conservative management was directly related to the volume of the EDH, and the EDH volume over 30 cm3 was a significant prognostic factor for conversion to surgery (95 % CI, p < 0.001). Patients in coma (Glasgow Coma Score < 8) have a poorer outcome than patients in good neurological status, regardless of to the therapy followed (95% CI, p = 0.0034). The volume of the EDH was not demonstrated to be a prognostic factor related to outcome (95 % CI, p = 0.2031). In conclusion, the diagnosis of the EDH must be promptly made by CT scan and the patient should be handled as an emergency and admitted into a neurosurgical center. Surgical indications mainly rely on the patient’s neurological status and CT findings. Key Words: extradural hematoma, brain injury, outcome. eing one of the leading causes of severe disability hematoma and the neurological status of the patient have and death among young people, traumatic been reported to influence the outcome of EDH [14-16, B brain injury (TBI) is a very important health and social 18]. problem. Mortality rate associated with EDH is between 5 Though the majority of EDHs continue to % and 50 % [27, 30]. Death is usually due to respiratory require urgent surgical evacuation, adult patients with arrest from uncal herniation causing compression of the a supratentorial EDH less than 30 cm3, less than 15 mm brainstem [25]. in thickness and with less than 5 mm midline shift, with Although surgery remains the treatment of choice a Glasgow Coma Scale (GCS) score greater than 8 and for many epidural hematomas, in the last decades more without focal deficit could be managed nonoperatively and more studies reporting conservative treatment of small given serial CT scanning and close neurological observation and moderate sized hematomas having a good outcome in a neurosurgical center [2, 5]. appeared [12-18]. This management policy needs a close The aim of this study was to discover the most im- observation of the patient, both clinical and imagistic, as it portant factors influencing the management strategy and is well known that even a previously stable patient’s state outcome of EDH and to outline a set of guidelines for the can deteriorate rapidly. Both the volume of extradural treatment of patients with EDH - conservative or surgical. 1) “Carol Davila” University of Medicine, Bucharest, Romania * Corresponding author: MD, PhD, “Bagdasar-Arseni” Emergency Clinical Hospital, Dept. of Neurosurgery, Sos. Berceni 10, 041914 Bucharest, Romania, Tel. +40744375000, Email [email protected] 2) “Bagdasar-Arseni” Emergency Clinical Hospital, Dept. of Neurosurgery, Bucharest, Romania 45 Tataranu L. et al Extradural hematoma – is surgery always mandatory? MATERIAL AND METHODS into two: subgroup II A – patients who were treated conservatively, and subgroup II B – patients who were We conducted a retrospective study on 56 initially treated conservatively, but, in the clinical course a consecutive cases of extradural hematomas admitted to neurological deterioration appeared after at least 72 hours the 3rd Neurosurgical Department of “Bagdasar-Arseni” and a delayed surgery was required. Emergency Hospital in Bucharest, treated conservatively Functional assessment was done at 6 months after and surgically between January 1, 2008 to December 31, trauma, according to Glasgow Outcome Scale (GOS), 2012. Patients diagnosed with EDH after CT scan, but which include death (D), persistent vegetative state (PVS), without open or penetrating head injury were included severe disability (SD), moderate disability (MD) and in this study. Patients with concomitant cerebral lesions good recovery (GD). Good outcome was considered in were also included, but only if the relevant lesion was the patients with good recovery or with moderate disability extradural accumulation of blood. who recovered independence. Patients who were severely Demographic data, the time and mechanism of disabled, who died or who were in a persistent vegetative head injury, neurological evaluation according to GCS state were included in the poor outcome group. The before admission and the time of the first CT scan were distribution of the good and poor outcome in relation with documented. A thorough clinical assessment and a cranial different factors was examined. CT scan were performed on all patients in our emergency The data were analyzed using Microsoft Excel® department on admission. Repeated neurological 2013 and IBM SPSS Statistics 21.0. examinations were also performed. Patients with a GCS score of 9-15 points were labeled as non-comatose and RESULTS patients having a GCS < 8 points were included in the category of comatose. Traumatic symptoms and signs The age ranged from 16 to 81 years, with a median were analyzed. Subsequent CT scans were performed if of 32 years. Most patients were in the active period of their clinically indicated. All CT scans were performed using life: 35 patients having between 30-49 years. Men were more routine orbital baseline and 10-mm scan slices. The volume affected than women (44 men, 12 women, men-to-women of the hematoma was calculated from CT studies by using ratio = 3.66:1). The mechanisms of trauma included: road the Petersen and Esperson formula: (A×B×C) × 0.52, traffic accidents (29 cases – 51.8%), falls (13 cases – 23.2%), where A, B and C represent the length, width and height of assault (10 cases – 17.9%) and others (4 cases – 7.1%). hematomas [19]. The locations of the EDH and associated The symptoms and signs of the patients are intracranial traumatic lesions were noted. summarized in Table 1. A GCS score < 12 was recorded in Patients were evaluated and treated according 19 patients, but 12 of them were comatose with a GCS score to currently accepted international guidelines [2, 20]. < 8. When present, the lucid interval lasted between few Indications for surgery were a hematoma volume greater hours and 3 days (28 patients – 50.0%). than 30 cm3 in the supratentorial space and greater than In our series, temporal region was involved in 13 10 cm3 in the infratentorial space, a midline shift greater patients (23.2%), followed by frontal (10 patients – 17.85%) than 5-mm, a clot thickness greater than 15-mm and/or and parietal regions (8 patients – 14.28%). Others locations neurological deterioration. For EDH with a volume less include: occipital region (5 patients – 8.93 %), temporo- than 30 cm3 in the supratentorial space and less than 10 cm3 parietal region (8 patients – 14.28%), fronto-parietal region in the infratentorial space, a midline shift less than 5-mm, a (5 patients – 8.93 %), fronto-temporo-parietal region (5 clot thickness less than 15-mm, with a GCS score > 8, without patients – 8.93 %) and posterior cranial fossa (2 patients – focal deficit, we attempted nonsurgical management, with 3.57 %). close observation and serial CT scanning. In the case of The patients diagnosed with EDH admitted in neurological deterioration, a new CT scan was achieved our study were treated as follows: 28 patients (50.0%) and surgical removal of the hematoma was performed as underwent urgent surgery (group I), 13 patients (23.2%) soon as possible. Craniotomy provided the removal of the were managed nonoperatively (group IIA) and 15 patients EDH in supratentorial location. Craniectomy was used (26.8%) required delayed surgery because of neurological when the EDH was located infratentorial. deterioration or increase of the size of the hematoma (group For the study, the patients suffering from EDH IIB). were divided into two groups, according to the treatment Details of the cases treated by immediate surgery management. In group I we included patients who required are shown in Table 2. immediate surgery for EDH. Group II was further divided Details of the cases treated by conservative Table 1. Clinical features of the series Signs/Symptoms Number of patients Percentage Lucid interval 28 50.0% Headache and vomiting 34 60.7% Altered state of consciousness (GCS < 12) 19 33.9% Neurodeficits 19 33.9% Homolateral pupillary changes 7 12.5% Bilateral pupillary changes 5 8.9% Bradycardia 14 25.0% 46 Romanian Journal of Legal Medicine Vol. XXII, No 1(2014) measures are shown in Table 3. There were 13 patients Patients in coma (GCS < 8) have a poorer outcome than in this group, 11 of them having a GCS score ≥ 12 at patients in good neurological status, regardless of to the admission. Two patients were comatose; they had associated therapy followed (Table 5). This is statistically significant posttraumatic SAH on admission CT scan and presented (95% CI, p = 0.0034). In contrast with these findings, when a poor outcome. One death was recorded, in an elderly we analyzed the volume of the EDH in relation to the man with a GCS score of 12 at admission, with associated patient’s outcome, the results are not statistically significant. intracranial lesions and no lucid interval. Two hematomas This demonstrated that the volume of the EDH is an with a volume greater than 30 cm3 were recorded, located important parameter for conversion of the treatment from in the frontal and parietal region, respectively; the patients conservative to surgery, but it is not a prognostic factor related had a GCS score of 15 and a good outcome.