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 »  Results
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Year : 2004  |  Volume : 52  |  Issue : 4  |  Page : 443-445

Does volume of extradural hematoma influence management strategy and outcome?

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore - 560029, India

Date of Acceptance19-Aug-2004

Correspondence Address:
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore - 560029, India
[email protected]

 » Abstract 

AIMS: To evaluate the management strategy of extradural hematomas (EDH), particularly with respect to its volume. METHODS AND MATERIALS: Two hundred and three patients with EDH and no other significant intracranial injuries were treated over a period of three years. RESULTS: The factors influencing management strategy and outcome were the Glasgow coma scale (GCS), volume of extradural hematoma (EDHV) and its location. The ultimate clinical outcome was significantly better in patients having EDHV of less than 30 ml. CONCLUSIONS: The key factors influencing the management strategy and clinical outcome are EDHV and GCS at the time of admission. A patient with EDH should not be considered for conservative management if EDHV is more than 30 ml and GCS is 13 or less.

How to cite this article:
Dubey A, Pillai SV, Kolluri SV. Does volume of extradural hematoma influence management strategy and outcome?. Neurol India 2004;52:443-5

How to cite this URL:
Dubey A, Pillai SV, Kolluri SV. Does volume of extradural hematoma influence management strategy and outcome?. Neurol India [serial online] 2004 [cited 2023 Mar 31];52:443-5. Available from: https://www.neurologyindia.com/text.asp?2004/52/4/443/13595

 » Introduction Top

Several reports have documented the possibility of safely managing patients with extradural hematoma (EDH) without surgery.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11] The volume of EDH which has been considered safe for conservative management has ranged from 10 ml to 55 ml in various reports.[5],[6],[8],[10] Both, volume of EDH and the neurological status of the patient have been reported to influence outcome following EDH.[3],[4],[12],[13],[14],[15],[16] Some authors have found that the volume of EDH has no influence on outcome.[17],[2] We aimed to evaluate our current management strategy of dealing with EDH, particularly with respect to its volume.

 » Materials and Methods Top

This is a retrospective analysis of 203 patients treated for EDH at our Institute over a period of three years. Patients with significant additional intracranial injuries like contusion, subdural or intracerebral hematoma were excluded from the analysis. Clinical details which were recorded included age of the patient, time from injury to management which was either surgery or start of conservative management (Time), Glasgow coma score (GCS)[18] after resuscitation and the outcome at one to two weeks after injury. Outcome was classified as favorable if the patient was normal or had moderate disability but was independent, and as unfavorable if the patient was not independent. The volume of the EDH (EDHV) was calculated using the Peterson and Espersen equation[19] - a x b x c x 0.5, where a, b, and c represented diameters of the hematoma in the sagittal, axial and coronal planes. The location of the EDH was classified into five groups: frontal, parietal, temporal, temporal-parietal and posterior-fossa depending on the location of the majority of the EDH. The differences between the two management groups (surgery versus conservative) and the two outcome groups (favorable versus unfavorable) were analyzed using the Chi-square test and the Student's unpaired t-test (two-tailed).

 » Results Top

Two hundred and three consecutive patients with EDH alone were managed over a period of three years. One hundred and fifty-six patients underwent a craniotomy or a craniectomy and evacuation of the hematoma. Forty-seven patients were managed conservatively. The details and comparison of the patients in the two groups are presented in [Table - 1]. The GCS of patients who were managed conservatively was higher and the EDHV lower than those managed surgically. Patients with a temporal or posterior-fossa EDH were more often managed surgically. The two patients with a posterior-fossa EDH who were managed conservatively had EDHV of 8 ml. The stepwise logistic regression analysis reveals that EDHV is the most important factor influencing management [Table - 2].

The details and comparisons of patients in the two outcome groups are presented in [Table - 3]. The most significant factors associated with unfavorable outcome were higher age, lower GCS, and higher EDHV. Posterior-fossa and temporal-parietal hematomas had worse outcome compared to hematomas in other locations. Patients who were managed conservatively had a better outcome than the surgically managed patients. When these factors were entered in a stepwise logistic regression analysis with outcome as the dependent variable, GCS was found to be the most important factor influencing outcome [Table - 4].

The outcome of patients with EDHV above and below 10 ml and every additional 5 ml above that was analyzed and only at and above 30 ml was there a significant difference in outcome [Table - 5], P=0.04). The proportion of unfavorable outcomes was higher in the >30 ml group.

 » Discussion Top

Our analysis has identified GCS, EDHV and location of EDH as the factors that influenced the management strategy. It was observed that the outcome was better in patients with an EDHV of less than 30 ml compared to those with more than 30 ml. This finding corroborates the finding of Bezircioglu et al[5] that patients with an EDHV less than 30 ml could be treated conservatively except when they were temporal in location with a heterogeneous density and the CT was performed less than six hours after trauma. Chen et al[8] reported that supratentorial EDH with volume more than 30 ml, a thickness more than 15 mm and a midline shift more than 5 mm tended to require surgery. Bullock et al[6] managed 12 patients with EDH volume 12-38 ml, conservatively. All the patients were conscious, had no history of deterioration of consciousness, and CT showed the midline shift to be less than 15 mm and basal cisterns were not effaced. Giordano et al[10] reported that patients with a few mild symptoms like headache which was regressing and EDHV less than 55 ml may be managed conservatively. The present analysis has not addressed the issue of posterior-fossa EDH because of inadequate sample size. Wong et al[9] have recommended that posterior-fossa EDH with EDHV less than 10 ml, a thickness less than 15 mm and midline shift less than 5 mm could be managed conservatively.

Heinzelmann et al, Mohanty et al, and Kuday et al have reported that lower GCS correlated with a more unfavorable outcome.[12],[15],[13] Rivas et al[3] found that unfavorable outcome was determined by rapid clinical deterioration and EDHV of more than 150 ml. Lobato et al, Lee et al and Servadei et al have reported that outcome was influenced by GCS and EDHV among other factors.[4],[14],[16] In contrast, van den Brink et al[17] found no correlation between EDHV and GCS, and outcome at six months. Paterniti et al[2] reported that when an EDH was operated within six hours then EDHV did not correlate with outcome. We observed that the GCS was the single most important predictor of outcome. Factors like gender, and time from injury to management had no influence on outcome. It appears that the adoption of appropriate criteria to select patients for conservative or surgical management can help avoid unnecessary surgery without affecting the outcome.

The main drawback of our study is that only the early outcome was used for analysis because of difficulty or inability to have a longer follow-up on each patient. This probably has resulted in a higher number of patients (n=18) being categorized as severely disabled.  

 » References Top

1.Bricolo AP, Pasut LM. Extradural hematoma: Toward zero mortality. A prospective study. Neurosurgery 1984;14:8-12.  Back to cited text no. 1  [PUBMED]  
2.Paterniti S, Falcone MF, Fiore P, Levita A, La Camera A. Is the size of an epidural haematoma related to outcome? Acta Neurochir (Wien) 1998;140:953-5.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Rivas JJ, Lobato RD, Sarabia R, Cordobes F, Cabrera A, Gomez P. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988;23:44-51.  Back to cited text no. 3  [PUBMED]  
4.Lobato RD, Rivas JJ, Cordobes F, Alted E, Perez C, Sarabia R, et al. Acute epidural hematoma: An analysis of factors influencing the outcome of patients undergoing surgery in coma. J Neurosurg 1988;68:48-57.  Back to cited text no. 4  [PUBMED]  
5.Bezircioglu H, Ersahin Y, Demircivi F, Yurt I, Donertas K, Tektas S. Nonoperative treatment of acute extradural hematomas: Analysis of 80 cases. J Trauma 1996;41:696-8.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Bullock R, Smith RM, van Dellen JR. Nonoperative management of extradural hematoma. Neurosurgery 1985;16:602-6.  Back to cited text no. 6  [PUBMED]  
7.Cook RJ, Dorsch NW, Fearnside MR, Chaseling R. Outcome prediction in extradural haematomas. Acta Neurochir (Wien) 1988;95:90-4.  Back to cited text no. 7  [PUBMED]  
8.Chen TY, Wong CW, Chang CN, Lui TN, Cheng WC, Tsai MD, et al. The expectant treatment of "asymptomatic" supratentorial epidural hematomas. Neurosurgery 1993;32:176-9; discussion 179.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]
9.Wong CW. The CT criteria for conservative treatment-but under close clinical observation-of posterior fossa epidural haematomas. Acta Neurochir (Wien) 1994;126:124-7.  Back to cited text no. 9  [PUBMED]  
10.Giordano C, Morello G, Rossano A, Chiloiro C, Boccuzzi F. The benign acute epidural haematoma. J Neurosurg Sci 1985;29:313-6.  Back to cited text no. 10  [PUBMED]  
11.Servadei F, Faccani G, Roccella P, Seracchioli A, Godano U, Ghadirpour R, et al. Asymptomatic extradural haematomas. Results of a multicenter study of 158 cases in minor head injury. Acta Neurochir (Wien) 1989;96:39-45.  Back to cited text no. 11  [PUBMED]  
12.Heinzelmann M, Platz A, Imhof HG. Outcome after acute extradural haematoma, influence of additional injuries and neurological complications in the ICU. Injury 1996;27:345-9.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Kuday C, Uzan M, Hanci M. Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases. Acta Neurochir (Wien) 1994;131:203-6.  Back to cited text no. 13  [PUBMED]  
14.Lee EJ, Hung YC, Wang LC, Chung KC, Chen HH. Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery. J Trauma 1998;45:946-52.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]
15.Mohanty A, Kolluri VR, Subbakrishna DK, Satish S, Mouli BA, Das BS. Prognosis of extradural haematomas in children. Pediatr Neurosurg 1995;23:57-63.  Back to cited text no. 15  [PUBMED]  
16.Servadei F. Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien) 1997;139:273-8.  Back to cited text no. 16  [PUBMED]  
17.van den Brink WA, Zwienenberg M, Zandee SM, van der Meer L, Maas AI, Avezaat CJ. The prognostic importance of the volume of traumatic epidural and subdural haematomas revisited. Acta Neurochir (Wien) 1999;141:509-14.  Back to cited text no. 17  [PUBMED]  [FULLTEXT]
18.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81-4.  Back to cited text no. 18  [PUBMED]  
19.Petersen OF, Espersen JO. Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology 1984;26:363-7.  Back to cited text no. 19  [PUBMED]  


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