IABCR Journal Header

Article Viewer

Search

Article QR Code

ORIGINAL ARTICLE

10.21276/iabcr.2017.3.4.18
Extradural Haematoma: Protocol Needs Revision for Conservative Management
Download PDF     Print

October - December 2017 | Vol 3 | Issue 4 | Page : 70-74

Alok Gupta1, Avanish Kumar Saxena2*, Ankur Saxena3, Chandroday Kumar4, Amrita Gupta5

1Associate Professor; 2Professor; 4Post Graduate Resident, Dept. of Surgery; 3Post Graduate resident; 5Assistant Professor, Dept. of Anaesthesia & Critical care, S.N Medical College, Agra, UP, India.

How to cite this article: : Gupta A, Saxena AK, Saxena A, Kumar C, Gupta A. Extradural Haematoma: Protocol Needs Revision for Conservative Management. Int Arch BioMed Clin Res. 2017;3(4):70-74.

ABSTRACT

Background: Brain Trauma Foundation recommends EDH volume of greater than 30?cm3 warrants surgical evacuation irrespective of Glasgow Coma Scale. Often it is observed that Not all cases of acute EDH require immediate surgical evacuation, cases with lesser than 5 mm midline shift, no focal neurological deficits and GCS>8 and can be managed conservatively provided the patients are closely observed for any deterioration in GCS. For EDH with a volume more or less than 30ml in the supratentorial space and, a midline shift 6-10 mm, with a GCS score > 10, was attempted non-surgical management, with close observation and serial CT scanning. Aim: The aim of this study was to discover the most important factors influencing the management strategy and outcome of EDH. Methods: 70 adult patients treated for EDH were included in this retrospective study, 26 cases (37%) underwent urgent surgery, 44 cases (62.8%) were managed conservatively out of which one third of patient required delayed surgery. Results: Our study showed that out of 62 % of the patients who were conservatively managed, 72 % had a favorable outcome despite the presence of a midline shift of 6- 10 mm and an EDH volume of >30 ml but having a good GCS score. Conservatively managed patients with GCS >10, 77% had Good Recovery. Those with high EDH volume, 61% had a good outcome. 84 % of the patients having a midline shift between 6-10 mm had a good recovery. Patients with GCS < 8 had a poorer outcome than patients in good neurological status, regardless of the therapy. Conclusions: Hence we conclude, EDH must be promptly diagnosed by CT scan and considered as an emergency lest misdiagnosed and should be admitted into a neurosurgical care unit. Close neurological monitoring, appropriate follow up CT scans in the setting of improved GCS score resulting in good outcome in patient on conservative management

Keywords: Extradural hematoma, brain injury, conservative management.

INTRODUCTION

Extradural haematomas (EDH) occur in approximately 2% of all head injuries and account for a significant proportion of fatalities with mortality rates ranging from 1.2 to 33%.[1] It usually results from a brief linear contact force to the calvaria causing separation of the periosteal Dura from bone and disruption of interposed vessels due to shearing stress, extension being limited by suture lines owing to their attachment, although in minority of young patients epidural hematomas may actually traverse suture lines.[2] The source of bleeding can be an injured Middle Meningeal Artery, Diploic vein or venous sinus.[3] The usual cause of death is expanding hematoma leading to uncal herniation compressing brainstem causing respiratory arrest.[4] Thus, it considered to be the most serious complication of head injury, requiring immediate diagnosis and surgical evacuation.[5]

As per the BTF recommendations EDH volume of greater than 30?cm3 warrants surgical evacuation irrespective of Glasgow Coma Scale but many a times it has been observed that not all cases of acute EDH require immediate surgical evacuation in cases with lesser than 5mm midline shift, no focal neurological deficits and GCS>8.[6,7] and can be managed conservatively in non-comatose patients with less than 5mm midline shift, the patient requires very close observation for any deterioration in GCS. It has been observed that many patients may accommodate greater extra-axial blood volumes. Keeping this in mind, we believe the indications for surgical evacuation of EDH merit renewed consideration.

METHODS

A retrospective study is conducted on 70 cases of Extradural hematomas (EDH) admitted to the Neurosurgical Department of Sarojini Naidu Medical College and Hospital, Agra treated conservatively and surgically between August 1, 2014 to August 31, 2016. Patients diagnosed with EDH after CT scan, were included in this study.

Demographic data, the time and mechanism of head injury, neurological evaluation according to GCS before admission and the time of the first CT scan were documented. A thorough clinical assessment and a cranial CT scan were performed on all patients in our emergency department on admission. Repeated neurological examinations were also performed. Patients with a GCS score of 9-15 points were labeled as non-comatose and patients having a GCS <8points were included in the category of comatose. Subsequent CT scans were performed if clinically indicated. CT scans were performed using routine 10-mm scan slices. Petersen and Esperson formula was used for calculating hematoma volume: (A×B×C) × 0.52, where A, B and C represent the length, width and height of hematomas.[8] The locations of the EDH and associated intracranial traumatic lesions were noted.

Indications for surgery were a hematoma volume greater than 30 ml in the supratentorial space and, a midline shift of more than 10-mm with Neurological deterioration, GCS<12. For EDH with a volume more or less than 30ml in the supratentorial space and, a midline shift 6-10 mm, with a GCS score > 10, with or without focal deficit, was attempted non-surgical management, with close observation and serial CT scanning.

In the case of neurological deterioration, a new CT scan was achieved and surgical removal (delayed surgery) of the hematoma was performed as soon as possible. Functional assessment was done at 6 months after trauma, according to Glasgow Outcome Scale (GOS), which include death (D), persistent vegetative state (PVS), severe disability (SD), moderate disability (MD) and good recovery (GD). Good outcome was considered in patients with good recovery or with moderate disability who recovered independence. Patients who were severely disabled, who died or who were in a persistent vegetative state were included in the poor outcome group. The distribution of the good and poor outcome in relation with different factors was taken into account.

RESULTS

Table. 1 showed the detail of patient undergoing urgent surgery. Most of the hematomas were frontal in location only seven patients had GCS <8 while 19 patients had GCS >9. 13 patients had good recovery after surgery.

Table 2 & 3 showed 29 patients who were managed conservatively the cases reported in the neuro surgical department were mostly due to RTA, fall and assault location of EDH were mostly parietal followed by frontal patient mostly had GCS between 9-15 patient having EDH volume <30ml were 16 out of which 13 had good response and 1 had moderate disability and 2 had persistent vegetative state. 13 patients had EDH volume >30ml in which 8 had good outcome and 4 had moderate disability while 1 had severe disability among the conservative group 15 patient had to be taken for delayed surgery due to deterioration of their neurological status. Table 4 showed that the patients having GCS >10, 77.7% had good outcome. Out of 16 patients having EDH volume <30 ml 81% had good outcome while the 13 patients with EDH volume >30 ml 61.5% had good recovery patient having MLS between 6-10, 84% had good outcome.


Table 1 Table 1: Details of the cases treated by immediate surgery-26 patients (Group I)
View Image
Table 2 Table 2: Details of the cases treated by immediate surgery-29 patients (Group I)
View Image
Table 3 Table 3: Management strategy in relation to the EDH volume in patients included in Group II
View Image
Table 4 Table 4: Patients having GCS >10
View Image

Figure 1 Figure 1: A patient Preeti, 18 yrs old female presented to SNMC emergency department as a case of road traffic accident with GCS 14 and her NCCT head done within 12 hours of accident and NCCT head shows (a) EDH volume 30 ml in left fronto-parietal region (b) CT repeated after 2 days showing resolving hematoma (c) CT repeated after 5 days hematoma resolved further with improving GCS.
View Image
Figure 2 Figure 2: Pt. Arav 22 yrs Male presented to SNMC emergency with GCS 13 due to RTA. (a) EDH volume 30 ml in left fronto-parietal region (b) CT repeated after 2 days showing resolving hematoma. (c) CT repeated after 5 days hematoma resolved further with improving GCS.
View Image
Figure 3 Figure 3:
View Image

DISCUSSION

Most traumatic EDH are not surgical at presentation. The decision to perform a surgery in a patient with a traumatic extra-axial hematoma is dependent on several factors (neurological status, size of hematoma, age of patients, CT findings) but also may depend on the judgment of the treating neurosurgeon.[9] In general, patients with an EDH volume greater than 30 cm3 in the supratentorial space regardless of GCS score and neurological signs, requires urgent evacuation as it may cause death. For patients with smaller hematomas, neurological status guides the treatment.

Craniotomy provides complete evacuation of the hematoma, identification and elimination of the source of the bleeding and prevention of the re-accumulation. On the other hand conservative management can be considered only in cases with an EDH volume less than 30 cm3 in the supratentorial space and less than 10cm3 in the infra tentorial space, a thickness less than 15mm, a midline shift less than 5mm, a GCS score greater than 8,without focal deficit.[3,4,10,12,13] Sullivan et al. reported a large series of 252 consecutive patients with acute epidural hematomas. Overall, 160 of the cases where managed non-surgically with generally favorable outcomes. Offner et al. studied 84 patients with epidural hematoma, and found that out of 64% of non-surgically treated patients, 87% of the patients were able to be successfully managed without surgery.[14,15]

Ford and McLaurin demonstrated that EDH achieves nearly full size within a very brief period following the injury, suggesting that physical and chemical effects other than increasing size may be the cause of neurologic deterioration in untreated cases. Several authors have emphasized the effects of cerebral edema, hypoxia, and/or impaired cerebrospinal fluid (CSF) drainage as causing the deleterious effects of the hematoma.[16,17] Many factors may play a role in the patient’s ability to tolerate a given clot volume, including rapidity of accumulation, presence of associated cerebral lesions, elasticity of the brain, combined volume of the sulci and other anatomic variations, as well as the location of the hematoma. EDH, both supratentorial and in the posterior fossa, can be managed non-surgically. A large volume EDH (>30 cm3) can be managed non-surgically provided the GCS at presentation and follow-up remains the same, with symptomatic improvement.[18]

Many cases of EDH of considerable size are reported in the literature, with good outcome even if they were not treated surgically.[19,20] When non-surgical management is attempted, the patient should be admitted in a neurosurgical center, under very close neurological observation, with serial CT scans, in order to act quickly on sudden decompensation. The first follow-up CT scan should be obtained within 6 to 8 hours after trauma.[3]

Our study is in compliance with the same, where 62 % of the patients were conservatively managed and 72 % had a favorable outcome despite the presence of a midline shift of 6- 10 mm and an EDH volume of >30 ml but having a good GCS score. Conservatively managed patients having a GCS >10, 77% showed Good Recovery. Those with high EDH volume, 61% had a good outcome. 84 % of the patients having a midline shift between 6-10 mm had a good recovery. Therefore, we can predict that a good GCS score at presentation may be the determining factor in deciding the management strategy. Similar result was reported by chauvet et al, they observed resolution of 62.5cm left occipital Extradural haematoma (EDH) and recorded a good outcome. Though the CT image may take 3-15 weeks for resolution of hematoma, the patient may show improvement in a span of 4-12 weeks with subsequent resolution in the CT image.[21] Since, our study group is small which the main limitation of the study is, further research is required to review the criteria laid down for conservative management.

CONCLUSION

We conclude that even high axial volume patients with large midline shift can be managed conservatively if the neurological status at presentation is good (GCS>10).

REFERENCES
  1. Wai Cheong Soon, Hani Marcus Imperial, Mark Wilson. Traumatic acute Extradural haematoma – Indications for surgery revisited: British Journal of Neurosurgery 2016; 30 (2) Pg 233-4
  2. Huisman TA, Tschirch FT. Epidural hematoma in children: Do cranial sutures act as a barrier? J Neuroradiol. 2008.
  3. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas. Neurosurgery. 2006;58(Suppl): S7-S1
  4. Greenberg MS. Head trauma. Handbook of Neurosurgery: Thieme; 2006. p. 632-97
  5. David S Liebeskind. Epidural Hematoma Neurology, drugs and disease http://emedicine.medscape.com/article/1137065; Apr’ 2014
  6. Chen TY, Wong CW, Chang CN. The expectant treatment of "asymptomatic" supratentorial epidural hematomas. Neurosurgery. 32(2):176-179.
  7. Offner PJ, Pham B, Hawkes A. Non operative management of acute epidural hematomas: a "no-brainer". Am J Surg. 2006 Dec. 192(6):801-5
  8. Petersen O F, Esperson J O. Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology. 1984;26(5):363-7.
  9. Rosario Maugeri, David Greg Anderson Francesca Graziano, Flavia Meccio Massimiliano Visocchi, and Domenico Gerardo Iacopino. Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature. Am J Case Rep. 2015; 16: 811–817
  10. Timmons SD. Extra-axial hematomas. Neurosurgical Emergencies. 2nd ed: Thieme Medical Publishers;2008: 53-67.
  11. Mathur V, Jallo J. Summary and synopsis of the Brain Trauma Foundation head injury guidelines. Neurosurgical Emergencies.2nd ed: Thieme Medical Publishers;2008: 172-194.
  12. Laidlaw J. Extradural hematoma. Operative Neurosurgery London: Churchill Livingstone; 2000:223-31.
  13. Sullivan TP, Jarvik JG, Cohen WA. Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. Am J Neuroradiol. 1999;20:107–13
  14. Offner PJ, Pham B, Hawkes A. Non operative management of acute epidural hematomas: a “no-brainer” Am J Surg. 2006;192(6):801–5
  15. LE, McLaurin RL. Mechanisms of extradural hematomas. J Neurosurg. 1963; 20:760–69.
  16. Knuckey NW, Gelbard S, Epstein MH. The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurgm. 1989;70:392–96
  17. Zakaria Z, Kaliaperumal C, Kaar G, O'Sullivan M, Marks C Extradural haematoma--to evacuate or not? Revisiting treatment guidelines. Clin Neurol Neurosurg. 2013 Aug; 115(8):1201-5.
  18. Tuncer R, Kazan S , Ucar T, Acikbas C, Saveren M. Conservative management of epidural haematomas. Prospective study of 15 cases. Acta neurochirurgica.1993; 121(1-2):48-52.
  19. Chen T Y, Wong C W, Chang C N, Lui T N, Cheng W C, Tsai M D, Lin T K. The expectant treatment of "asymptomatic" supratentorial epidural hematomas. Neurosurgery.1993Feb;32(2):176-179
  20. Hamilton M, Wallace C. Non operative management of acute epidural hematoma diagnosed by CT: the neuro radiologist's role. AJNR American journal of neuroradiology. 1992;13(3):853-9.
  21. Chauvet D1, Reina V, Clarencon F, Bitar A, Cornu P. Conservative management of a large occipital extradural haematoma. Br J Neurosurg. 2013 Aug;27(4):526-8

Published by Ibn Sina Academy of Medieval Medicine & Sciences, registered in 2001 under Indian Trusts Act, 1882.
Publication Manager: Dr. Tayyaba Farhan
Index Copernicus