The management of “asymptomatic” epidural hematomas

A prospective study

Restricted access

✓ Standard neurosurgical management mandates prompt evacuation of all epidural hematomas to obtain a low incidence of mortality and morbidity. This dogma has recently been challenged. A number of authors have suggested that in selected cases small and moderate epidural hematomas may be managed conservatively with a normal outcome and without risk to the patient. The goal of this study was to define the clinical parameters that may aide in the management of patients with small epidural hematomas who were clinically asymptomatic at initial presentation because there was no clinical evidence of raised intracranial pressure or focal compression. A prospective study was conducted of 22 patients (17 males and five females) aged from 1 to 71 years, who had a small epidural hematoma diagnosed within 24 hours of trauma and were managed expectantly. Of these, 32% subsequently required evacuation of the epidural hematoma 1 to 10 days after the initial trauma.

Analysis of the patients revealed that age, sex, Glasgow Coma Scale score, and initial size of the hematoma are not risk factors for deterioration. However, deterioration was seen in 55% of patients with a skull fracture transversing a meningeal artery, vein, or major sinus, and in 43% of those undergoing computerized tomography (CT) within 6 hours of trauma. In contrast, only 13% of patients in whom the diagnosis of a small epidural hematoma was delayed over 6 hours subsequently required evacuation of the epidural collection. Of patients with both risk factors, 71% required evacuation of the epidural hematoma. None of the patients suffered neurological sequelae attributable to this management protocol.

It was concluded that patients with a small epidural hematoma, a fracture overlaying a major vessel or major sinus, and/or who are diagnosed less than 6 hours after trauma are at risk of subsequent deterioration and may require evacuation. Conversely, patients without these risk factors may be managed conservatively with repeat CT and careful neurological observation, because of the low risk of delayed deterioration.

Article Information

Address reprint requests to: Neville W. Knuckey, F.R.A.C.S., 110 Lockwood Street, Providence, Rhode Island 02903.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Block graph showing the percentage of deterioration among patients studied related to the time of computerized tomography (CT) after trauma and the location of the skull fracture to a major dural vessel.

References

1.

Bullock RSmith RMvan Dellen JR: Nonoperative management of extradural hematoma. Neurosurgery 16:6026061985Bullock R Smith RM van Dellen JR: Nonoperative management of extradural hematoma. Neurosurgery 16:602–606 1985

2.

Ericson KHåkansson S: Computed tomography of epidural hematomas. Association with intracranial lesions and clinical correlation. Acta Radiol 22:5135191981Ericson K Håkansson S: Computed tomography of epidural hematomas. Association with intracranial lesions and clinical correlation. Acta Radiol 22:513–519 1981

3.

Fankhauser HUske Ade Tribolet N: [Delayed epidural hematoma. Apropos of a series of 8 cases.] Neurochirurgie 29:2552601983 (Fre)Fankhauser H Uske A de Tribolet N: [Delayed epidural hematoma. Apropos of a series of 8 cases.] Neurochirurgie 29:255–260 1983 (Fre)

4.

Ford LEMcLaurin RL: Mechanisms of extradural hematomas. J Neurosurg 20:7607691963Ford LE McLaurin RL: Mechanisms of extradural hematomas. J Neurosurg 20:760–769 1963

5.

Hooper R: Observations of extradural haemorrhage. Br J Surg 47:71871959/1960Hooper R: Observations of extradural haemorrhage. Br J Surg 47:71–87 1959/1960

6.

Illingworth RShawdon H: Conservative management of intracranial extradural haematoma presenting late. J Neurol Neurosurg Psychiatry 46:5585601983Illingworth R Shawdon H: Conservative management of intracranial extradural haematoma presenting late. J Neurol Neurosurg Psychiatry 46:558–560 1983

7.

Jamieson KGYelland JDN: Extradural hematoma. Report of 167 cases. J Neurosurg 29:13231968Jamieson KG Yelland JDN: Extradural hematoma. Report of 167 cases. J Neurosurg 29:13–23 1968

8.

McKissock WTaylor JCBloom WHet al: Extradural haematoma. Observations on 125 cases. Lancet 2:1671721960McKissock W Taylor JC Bloom WH et al: Extradural haematoma. Observations on 125 cases. Lancet 2:167–172 1960

9.

Mendelow ADKarmi MZPaul KSet al: Extradural haematoma: effect of delayed treatment. Br Med J 1:124012421979Mendelow AD Karmi MZ Paul KS et al: Extradural haematoma: effect of delayed treatment. Br Med J 1:1240–1242 1979

10.

Munro DMaltby GL: Extradural hemorrhage. A study of forty-four cases. Ann Surg 113:1922031941Munro D Maltby GL: Extradural hemorrhage. A study of forty-four cases. Ann Surg 113:192–203 1941

11.

Pang DHorton JAHerron JMet al: Nonsurgical management of extradural hemaotomas in children. J Neurosurg 59:9589711983Pang D Horton JA Herron JM et al: Nonsurgical management of extradural hemaotomas in children. J Neurosurg 59:958–971 1983

12.

Pozzati ETognetti F: Spontaneous healing of acute extradural hematomas: study of twenty-two cases. Neurosurgery 18:6967001986Pozzati E Tognetti F: Spontaneous healing of acute extradural hematomas: study of twenty-two cases. Neurosurgery 18:696–700 1986

13.

Sakai HTakagi HOhtaka Het al: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:5665701988Sakai H Takagi H Ohtaka H et al: Serial changes in acute extradural hematoma size and associated changes in level of consciousness and intracranial pressure. J Neurosurg 68:566–570 1988

14.

Tochio HWaga STashiro Het al: Spontaneous resolution of chronic epidural hematomas: report of 3 cases. Neurosurgery 15:961001984Tochio H Waga S Tashiro H et al: Spontaneous resolution of chronic epidural hematomas: report of 3 cases. Neurosurgery 15:96–100 1984

15.

Weaver DPobereskin LJane JA: Spontaneous resolution of epidural hematomas. Report of two cases. J Neurosurg 54:2482511981Weaver D Pobereskin L Jane JA: Spontaneous resolution of epidural hematomas. Report of two cases. J Neurosurg 54:248–251 1981

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 55 55 23
Full Text Views 144 144 27
PDF Downloads 98 98 12
EPUB Downloads 0 0 0

PubMed

Google Scholar