Extradural haematoma in the Irish Republic: an analysis of 82 cases with emphasis on 'delay'

Outcomes of Evacuating Subacute Extradural Hematoma Through a Minicraniectomy: A 5-Year Study

Background Extradural hematoma (EDH) is a hematoma between the dura and the inner surface of the skull, found in 1 to 3% of all head-injured patients, rising to 9% among the unconscious ones. It is said to be subacute when about 2 to 4 days old. Further enlargement of the burr hole to about 3 to 5 cm wide (minicraniectomy) may allow its total evacuation.

Objective To recommend it as a treatment option, this study aims to evaluate the surgical outcomes of evacuating a subacute EDH through a minicraniectomy.

Method This was a 5-year prospective study in a Nigerian tertiary health institution.

Results In total, 108 patients, consisting of 96 males and 12 females with a male to female ratio of 8:1 were included. Their ages ranged from 10 to 69 years. Etiologies were road traffic accident (RTA, 73.2%), assault (18.5%), and falls (8.3%). Hematoma ages were 2 days (61.1%), 3 days (25%), 4 days (13.9%). GCS were mild (11%), moderate (56%), and severe (33%). Locations were right-sided (59.3%), left-sided (40.7%) with 73.1% in parietotemporal area. Active bleeding was encountered in 15% only. Postoperative complications were seizure (13.9%), death (12%), and surgical site infection (4.6%) among others. Outcomes at 2 weeks were good (83, 76.9%), moderate disability (12, 11.1%), severe disability (10, 9.3%), vegetative (1, 0.9%), and death (2, 1.9%).

Conclusion Considering the significant morbidity and mortality and the need for urgent interventions in EDH, most patients presenting in the subacute acute (2– 4 days) stage can be evacuated via a minicraniectomy with good outcomes.

Is the recommended target of 4 hours from head injury to emergency craniotomy achievable?

Guidelines recommend that head-injured patients who require life-saving decompressive surgery should undergo surgery within 4 h. To assess the compliance with this recommendation 100 consecutive head-injured patients admitted to a regional neurosurgical unit (RNU) were studied. Time points from head injury to craniotomy were documented and analysed. Twenty-four patients underwent emergency craniotomy, only one being operated on within 4 h. In this cohort of patients there was no relationship between timing of surgery and outcome. In order to investigate whether it is possible to reduce delays in transportation time, theoretical models were created to determine whether direct transfer to the RNU would be faster by land or air ambulance.

Treatment of extradural haemorrhage in Queensland: interhospital transfer, preoperative delay and clinical outcome

OBJECTIVES

To measure preoperative delays and clinical outcomes of patients with extradural haemorrhage, comparing patients presenting to hospitals with no neurosurgical facilities, with those presenting directly to neurosurgical centres.

METHODS

Retrospective case study with data collected from 10 centres. Patients were identified with a search of the Queensland Trauma Registry database. A total of 315 charts were reviewed, of patients presenting or referred to Queensland's public hospitals between 2002 and 2004 inclusive.

RESULTS

A total of 261 patients were included in the study. One hundred and fifty-nine patients presented to hospitals with no neurosurgical facilities; 102 presented directly to neurosurgical centres. Forty-six patients underwent interhospital transfer (IHT) before decompressive craniotomy; their median time interval from presentation to operation was 8 h 5 min. This delay was significantly greater than that for 25 patients admitted directly to neurosurgical centres (median 4 h 19 min; P = 0.0006). After excluding patients who had sustained hypoxic or hypotensive insults or serious extracranial injuries, all deaths (five) occurred in patients undergoing IHT before craniotomy.

CONCLUSIONS

IHT of patients with extradural haemorrhage causes significant preoperative delay.

The comparative impact of video-consultation on neurosurgical health services

This study evaluated the impact of telemedicine technology on the provision of neurosurgical health services. We focused on the differences between the use of real time audio-visual teleconferencing and teleradiology versus conventional telephone consultations in the referral of neurosurgical patients from a large district general hospital. All patients requiring emergency neurosurgical consultation were included for randomization into telephone consultation only (Mode A), teleradiology and telephone consultation (Mode B) and video-consultation (Mode C). Measures of effectiveness included diagnostic accuracy and adverse events during the transfer and Glasgow Outcome Score. In a 10-month period, 327 patients were recruited and randomized into the study: the male/female ratio was 2:1 and the number of patients required to be transferred to the neurosurgical unit was 125 (38%). There was a trend towards a more favourable outcome in the video-consultation mode (44%, Mode C), versus teleradiology (31%, Mode B), versus telephone consultation (38%, Mode A). The interim data of this prospective randomized trial suggests that video-consultation may have a favourable impact on emergency neurosurgical consultations.

Decompressive surgery for "pure" epidural hematomas: does neurosurgical expertise improve the outcome?

OBJECTIVE

The goal of this study was to determine whether patients with "pure" epidural hematomas can now be transferred safely to a neurosurgical unit for decompression or whether general or orthopedic surgeons must still be prepared to perform emergency craniotomies.

METHODS

Between 1984 and 1996, 83 patients were surgically treated in our department for pure epidural hematomas, i.e., without associated intracranial lesions. The patient records were analyzed with respect to hematoma thickness, signs of herniation, delays from accident to decompression, results of any surgical attempts in local hospitals before admittance to our department, and clinical outcomes.

RESULTS

The mortality rate was low (1 patient death, 1.2%). Seventy-nine patients (95%) experienced good or moderate outcomes (Glasgow Outcome Scale scores of 4 or 5). Twenty-four children all experienced good outcomes (Glasgow Outcome Scale scores of 5). The median delay from accident to decompression was 6.5 hours (mean, 7.1 h). When emergency surgery was attempted by general or orthopedic surgeons in local hospitals, the effective decompression was delayed (median, 4 h; mean, 12.5 h), and the final outcomes were considerably worse than for patients who were transferred without such surgical attempts.

CONCLUSION

Patients with pure epidural hematomas have better prognoses than previously assumed. There is usually enough time to safely transfer patients to a neurosurgical unit, provided that transport is rapid and anesthesiological services are available during the transport. Surgeons without training in neurosurgery should not perform emergency craniotomies in local hospitals but, rather, should transfer patients as quickly as possible to the nearest department of neurosurgery.

Report of a national neurosurgical emergency teleconsulting system

OBJECTIVE

The goal was to develop a low-cost, national, neurosurgical emergency teleconsulting system that is independent of vendor computed tomographic (CT) or magnetic resonance imaging (MRI) scanner type.

METHODS

Charge-coupled device scanners are used to digitize hard copies of CT and MRI scans. An enhanced optical density range is achieved by using an algorithm to fuse data from multiple exposures at different integration periods. The system is based on personal computers using Microsoft Windows 3.11. Data are transmitted on a wide-area network at 128 kilobits/s, over Integrated Systems Digital Network lines. The network connects both neurosurgical departments in Ireland to all major hospitals with CT/MRI scanners.

RESULTS

The scanner optical density is 0.05 to 3.0, with 2.24 to 2.5 line pairs/mm. Five-megabyte images are transmitted uncompressed in 6 minutes. To date, more than 750 CT and MRI scans have been transmitted. The system is completely automated, and operator acceptance has been very high. Images are automatically stored and displayed at the receiving workstation, where the images can be viewed and manipulated on-screen. This system has significantly enhanced acute neurosurgical patient care.

CONCLUSION

The system is cost effective and simple to use, has gained widespread physician acceptance, and delivers an image quality superior to that of many commercially available systems.

Report of a national neurosurgical teleradiology system

An emergency neurosurgical teleradiology system was initially installed in two referring hospitals in ireland to transmit images to the neurosurgical department in Cork. It was subsequently expanded to six major referring hospitals transmitting to both neurosurgical departments in ireland serving the entire population of 3.5 million people, effectively becoming a national teleradiology system. The system was based on PCs interconnected by leased data circuits and ISDN. The network was operational 24 hours a day. Over 750 emergency computerized tomography scans were transmitted and transmission failures occurred in only 6% of cases. We conclude that current PC technology can be used to form a peer-to-peer wide-area network upon which a robust emergency teleradiology system can be based.

Use of computed tomography of the head in the hypotensive blunt-trauma patient

STUDY OBJECTIVE

To identify patients presenting with hypotension due to blunt trauma who should undergo computed tomography (CT) of the head before urgent chest or abdominal operation.

DESIGN

Retrospective registry-based record review.

SETTING

Urban Level I trauma center.

PARTICIPANTS

Consecutive trauma patients with suspected head injury, blunt mechanism of injury, and hypotension who were discharged between January 1, 1989, and December 31, 1991. Patients who were dead on arrival or died within 15 minutes of arrival were judged unsalvageable and excluded. Review of 3,224 trauma patients identified 212 as the study population.

INTERVENTIONS

Frequency of neurosurgical intervention or general surgical intervention within 6 hours of admission and the time required for completion of CT of the head were noted.

RESULTS

Overall, 40 general surgical operations (19%) and 16 craniotomies (8%) were performed, with a mortality rate of 18%. Patients with Glasgow Coma Scale scores of less than 8 had a 19% rate of craniotomy, and those with scores between 8 and 13 had a 9% rate. Sixteen patients had CT before surgery, with an average delay of 68 minutes. No patient who responded to initial resuscitation experienced hemodynamic instability in the CT suite, including 15 patients with positive diagnostic peritoneal lavage.

CONCLUSION

CT scan of the head before general surgical operation appears to be safe in patients who respond to initial resuscitation. The likelihood of craniotomy in patients with Glasgow Coma Scale scores of 13 or less is comparable to the likelihood of general surgical operation. Physicians should be encouraged to make CT of the head a high priority in this group.