Letter to the Editor. Endovascular management of epidural hematomas

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  • All India Institute of Medical Sciences, New Delhi, India
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TO THE EDITOR: We read the article by Peres et al.6 with great interest (Peres CMA, Caldas JGMP, Puglia P Jr, et al: Endovascular management of acute epidural hematomas: clinical experience with 80 cases. J Neurosurg [epub ahead of print April 14, 2017. DOI: 10.3171/2016.11.JNS161398]). In this paper, the authors analyzed the safety and efficacy of embolization of the involved middle meningeal artery (MMA) and associated lesions in small- to medium-sized acute epidural hematomas (EDHs). They had treated 80 patients with small- to medium-sized EDHs using embolization of the MMA and its associated lesions. They compared their results with those in a historical cohort of 471 patients. After embolization of the MMA, there was no increase in the size of the EDH in any of the 80 patients in their study. They concluded that embolization is a highly effective and safe method for achieving size stability in nonsurgically treated acute EDHs. We congratulate the authors for considering endovascular treatment for small EDHs and thus avoiding an increase in the size of the lesions, repeated scans, and prolonged hospital stays. However, we would like to draw the reader’s attention to a few pertinent points.

In their study, the authors mentioned that the mean and median durations from admission to angiography were 4.6 and 4 days, respectively. It has been concluded in various studies that an increase in the size of EDH usually occurs within 24 hours.8–10 Sakai et al. demonstrated that small EDHs (65%) expanded in the 24 hours after trauma.8 Sullivan et al. found that 25% of EDHs enlarged in the first 24 hours.9 In a study by Knuckey et al., 22% of patients deteriorated within 24 hours and only 1 patient deteriorated after 10 days.4 In a study by Basamh et al., 11.2% patients deteriorated in a mean range of 5–30 hours.1 Progression of initially nonsurgically treated EDHs mostly occurs within the first 24 hours, is less likely within 48 hours, and rarely occurs beyond that.1 In the study by Peres et al., endovascular intervention was performed at a mean duration of 4.6 days, after which enlargement of EDH is rare. The authors did not include the time period from the time of injury to admission, which further increases the interval between trauma and intervention. Hence, it would not be appropriate to conclude that the EDH did not increase in size because of the endovascular therapy. Moreover, the utility of embolization in these cases in terms of preventing the need of surgery cannot be concluded until a case controlled trial is done.

Suzuki et al.10 showed that endovascular intervention is useful in patients with active contrast extravasation and an increase in the size of a hematoma. Only 61 patients had contrast extravasation in the study by Peres et al., but they did not mention an increase in the size of EDH. Although there is a theoretical risk of bleeding from a pseudoaneurysm, the usefulness of embolization in small EDHs cannot be commented on until the natural history of these lesions is known.2

In the study by Peres et al., 6 patients with normal angiographic findings, 8 patients with MMA wall irregularities, and 1 patient with choroidal blush and an internal carotid artery aneurysm each underwent embolization. The authors did not mention the reasons for embolization in these patients.

We agree with the authors that endovascular embolization is a safe and efficient method, but one cannot conclude that it is effective in preventing the morbidity and mortality associated with small EDHs until the natural history of these lesions is known and embolization is performed early and the intervention group is compared with a nonintervention group. We also believe that endovascular intervention is an excellent tool especially for controlling torrential bleeding from the MMA intraoperatively, in severely comorbid patients, and in cases of multiple lesions.3,5,7 It can be selectively done in patients with risk factors such as unstable EDH, active contrast extravasation, fracture running across the MMA, and enhancement of hematomas on MRI.11

Disclosures

The authors report no conflict of interest.

References

  • 1

    Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J: Epidural hematoma treated conservatively: when to expect the worst. Can J Neurol Sci J Can Sci Neurol 43:7481, 2016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RLO, Puglia P, et al.: Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery 62:416421, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Kim MH: Transcortical endoscopic surgery for intraventricular lesions. J Korean Neurosurg Soc 60:327334, 2017

  • 4

    Knuckey NW, Gelbard S, Epstein MH: The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurg 70:392396, 1989

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Ohshima T, Tajima H, Fujii K, Nagakura M, Nishizawa T, Kato K, et al.: Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health. Neurol Med Chir (Tokyo) 52:829831, 2012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Peres CMA, Caldas JGMP, Puglia P Jr, de Andrade AF, da Silva IAF, Teixeira MJ, et al.: Endovascular management of acute epidural hematomas: clinical experience with 80 cases. J Neurosurg [epub ahead of print April 14, 2017. DOI: 10.3171/2016.11.JNS161398]

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Ross IB: Embolization of the middle meningeal artery for the treatment of epidural hematoma. J Neurosurg 110:12471249, 2009

  • 8

    Sakai H, Takagi H, Ohtaka H, Tanabe T, Ohwada T, Yada K: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:566570, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Sullivan TP, Jarvik JG, Cohen WA: Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 20:107113, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Suzuki S, Endo M, Kurata A, Ohmomo T, Oka H, Kitahara T, et al.: Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 25:11771180, 2004

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Tomida M, Muraki M, Uemura K, Yamasaki K: Postcontrast magnetic resonance imaging to predict progression of traumatic epidural and subdural hematomas in the acute stage. Neurosurgery 43:6671, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
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  • 1 University of São Paulo School of Medicine (FMUSP), São Paulo, Brazil; and
  • | 2 Hospital Santa Júlia, Manaus, Brazil

Response

We thank Dr. Samala et al. for their interest in our study of endovascular embolization of acute EDHs. We would like to take this opportunity to clarify some issues concerning our study. The first point to discuss is about the time from admission to angiography. Given features of the Brazilian health care system, our hospital receives patients from low-complexity centers where they were previously admitted. Therefore, the time from admission to angiography is, indeed, the interval between head injury and embolization. Additionally, we should acknowledge that multidisciplinary case-by-case discussion (especially in the first cases of our series), as well as scheduling difficulties in our busy hemodynamic suite, might have prevented earlier treatment in some cases. We fully agree that early angiography in these cases would be the best option.

The acute phase is far more important in the setting of EDH,10 but there is always the possibility of late rebleeding of MMA pseudoaneurysms, even after 3–30 days.8 Even so, there are no guidelines for routine follow-up CT scanning or CT angiography in traumatic brain injury. The optimal timing for follow-up images in EDH is an unanswered question.1–3 There may be relative stability in the level of consciousness despite marked enlargement of these lesions. Can we discharge to home those patients with a fracture crossing the MMA sulcus and a 15-mm-thick, conservatively treated EDH 36 hours after trauma? A more careful reading of the cited literature may lead us to other interpretations.

In the articles by Sakai et al.7 and Knuckey et al.,5 it is really impossible to know if there were enlargements after 48 hours because only a second CT was obtained after the initial scan. In the words of Sakai et al.: “In this study only two CT examinations were conducted, so the exact course of hematoma enlargement could not be clarified.”7 They also emphasized that “acute extradural hematoma is a progressively enlarging lesion . . . rather than a lesion completed early after the onset of hemorrhage.” Sullivan et al.9 also followed up patients with only a single CT scan, and enlargements were observed up to 36 hours. And these authors also remarked on the fact that EDHs may not attain their maximum size in the first hours of formation.

Delayed enlargement of EDH is presumably caused by an unstable vascular injury associated with the lowering of previously high intracranial pressure (in the setting of associated brain swelling) or the resolution of MMA vasospasm. Conservative management of these lesions must take into account the long time for observation (sometimes more than a week), increasing costs of hospitalization and monitoring, and, worst of all, making us lead with uncertainty—a rare but sometimes devastating effect of late enlargement and brain herniation.

The second issue is about the usefulness of occluding MMAs without contrast extravasation. In our cases, all 6 patients with normal angiographic findings had fractures clearly crossing the MMA sulcus. We admitted that the normal aspect could be due to arterial vasospasm—which is very commonly observed in treating other diseases via MMA microcatheterization. So, it seemed to us very safe to occlude this artery via superselective catheterization. The patient with choroidal blush presented with a pseudoaneurysm and active contrast extravasation (as clearly depicted in our Fig. 5). It should be emphasized that a pseudoaneurysm may represent a dangerous unstable lesion, as severe as contrast extravasation.6,11 It has been reported that they can rupture as late as 1 month after injury.8

We fully agree that the natural history of these lesions is unclear. Nonetheless, there are clear ethical limitations and a lack of clinical equipoise in performing natural history studies on these potentially dreadful lesions. Unfortunately, such a study may never be available for our analysis. Instead, we must retrospectively and prospectively assess the role of embolization in the treatment of small EDHs, as has been done at our institution.

We concur with Dr. Samala and colleagues’ statement that MMA embolization is a safe and efficient method. And we ask ourselves if it should be considered, if it is immediately available, even in selected surgical cases of EDH: identifying the source of bleeding and the foramen spinosum in a surgical field obscured by blood and/or brain swelling is something that many of us have experienced as extremely disturbing and dangerous.4

We thank Samala et al. for bringing up for debate these relevant concerns, and we agree that the longer the EDH is small and asymptomatic, the greater the likelihood that it will remain so. However, arterial MMA embolization will give us peace of mind in discharging these patients home early and safely.

References

  • 1

    AbdelFattah KR, Eastman AL, Aldy KN, Wolf SE, Minei JP, Scott WW, et al.: A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg 73:685688, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al.: Surgical management of acute epidural hematomas. Neurosurgery 58 (3 Suppl):S7S15, Si–Siv, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Ding J, Yuan F, Guo Y, Chen SW, Gao WW, Wang G, et al.: A prospective clinical study of routine repeat computed tomography (CT) after traumatic brain injury (TBI). Brain Inj 26:12111216, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Kim DH, Lee JY, Jeon HJ, Cho BM, Park SH, Oh SM: Intraoperative endovascular embolization of middle meningeal artery and a pseudoaneurysm by using N-butyl 2-cyanoacrylate for hemostasis during operation of acute epidural hemorrhage. Korean J Neurotrauma 11:167169, 2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Knuckey NW, Gelbard S, Epstein MH: The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurg 70:392396, 1989

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Ko JH, Kim YJ: Traumatic pseudoaneurysm of the middle meningeal artery with an arteriovenous fistula on a non-fractured site. Interv Neuroadiol 20:352356, 2014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Sakai H, Takagi H, Ohtaka H, Tanabe T, Ohwada T, Yada K: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:566570, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Salazar Flores J, Vaquero J, Garcia Sola R, Rossi E, Martinez R, Martinez P, et al.: Traumatic false aneurysms of the middle meningeal artery. Neurosurgery 18:200203, 1986

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Sullivan TP, Jarvik JG, Cohen WA: Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 20:107113, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Suzuki S, Endo M, Kurata A, Ohmomo T, Oka H, Kitahara T, et al.: Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 25:11771180, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Wu X, Jin Y, Zhang X: Intraparenchymal hematoma caused by rupture of the traumatic pseudoaneurysm of middle meningeal artery. J Craniofac Surg 25:e111e113, 2014

    • Search Google Scholar
    • Export Citation
  • 1

    Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J: Epidural hematoma treated conservatively: when to expect the worst. Can J Neurol Sci J Can Sci Neurol 43:7481, 2016

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 2

    de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RLO, Puglia P, et al.: Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery 62:416421, 2008

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

    Kim MH: Transcortical endoscopic surgery for intraventricular lesions. J Korean Neurosurg Soc 60:327334, 2017

  • 4

    Knuckey NW, Gelbard S, Epstein MH: The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurg 70:392396, 1989

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Ohshima T, Tajima H, Fujii K, Nagakura M, Nishizawa T, Kato K, et al.: Combined endovascular and endoscopic surgery for acute epidural hematoma in a patient with poor health. Neurol Med Chir (Tokyo) 52:829831, 2012

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Peres CMA, Caldas JGMP, Puglia P Jr, de Andrade AF, da Silva IAF, Teixeira MJ, et al.: Endovascular management of acute epidural hematomas: clinical experience with 80 cases. J Neurosurg [epub ahead of print April 14, 2017. DOI: 10.3171/2016.11.JNS161398]

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Ross IB: Embolization of the middle meningeal artery for the treatment of epidural hematoma. J Neurosurg 110:12471249, 2009

  • 8

    Sakai H, Takagi H, Ohtaka H, Tanabe T, Ohwada T, Yada K: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:566570, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Sullivan TP, Jarvik JG, Cohen WA: Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 20:107113, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Suzuki S, Endo M, Kurata A, Ohmomo T, Oka H, Kitahara T, et al.: Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 25:11771180, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Tomida M, Muraki M, Uemura K, Yamasaki K: Postcontrast magnetic resonance imaging to predict progression of traumatic epidural and subdural hematomas in the acute stage. Neurosurgery 43:6671, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 1

    AbdelFattah KR, Eastman AL, Aldy KN, Wolf SE, Minei JP, Scott WW, et al.: A prospective evaluation of the use of routine repeat cranial CT scans in patients with intracranial hemorrhage and GCS score of 13 to 15. J Trauma Acute Care Surg 73:685688, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al.: Surgical management of acute epidural hematomas. Neurosurgery 58 (3 Suppl):S7S15, Si–Siv, 2006

    • Search Google Scholar
    • Export Citation
  • 3

    Ding J, Yuan F, Guo Y, Chen SW, Gao WW, Wang G, et al.: A prospective clinical study of routine repeat computed tomography (CT) after traumatic brain injury (TBI). Brain Inj 26:12111216, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Kim DH, Lee JY, Jeon HJ, Cho BM, Park SH, Oh SM: Intraoperative endovascular embolization of middle meningeal artery and a pseudoaneurysm by using N-butyl 2-cyanoacrylate for hemostasis during operation of acute epidural hemorrhage. Korean J Neurotrauma 11:167169, 2015

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 5

    Knuckey NW, Gelbard S, Epstein MH: The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurg 70:392396, 1989

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 6

    Ko JH, Kim YJ: Traumatic pseudoaneurysm of the middle meningeal artery with an arteriovenous fistula on a non-fractured site. Interv Neuroadiol 20:352356, 2014

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Sakai H, Takagi H, Ohtaka H, Tanabe T, Ohwada T, Yada K: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:566570, 1988

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Salazar Flores J, Vaquero J, Garcia Sola R, Rossi E, Martinez R, Martinez P, et al.: Traumatic false aneurysms of the middle meningeal artery. Neurosurgery 18:200203, 1986

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Sullivan TP, Jarvik JG, Cohen WA: Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 20:107113, 1999

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Suzuki S, Endo M, Kurata A, Ohmomo T, Oka H, Kitahara T, et al.: Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol 25:11771180, 2004

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Wu X, Jin Y, Zhang X: Intraparenchymal hematoma caused by rupture of the traumatic pseudoaneurysm of middle meningeal artery. J Craniofac Surg 25:e111e113, 2014

    • Search Google Scholar
    • Export Citation

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