The influence of concomitant intradural pathology on the presentation and outcome of patients with acute traumatic extradural haematoma

Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study

BACKGROUND AND OBJECTIVES

Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery.

METHODS

This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling.

RESULTS

In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm3 below 30 cm3), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm3), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died.

CONCLUSION

Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.

The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas

Objective

Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist.

Methods

We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries.

Results

We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH.

Conclusions

An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.

Clinical Outcome of Patients Diagnosed Traumatic Intracranial Epidural Hematoma With Severe Brain Injury (Glasgow Coma Scale ≤8) Who Undergo Surgery: A Report From the Korean Neuro-Trauma Data Bank System

OBJECTIVE

To evaluate the clinical outcomes and prognostic factors in surgically treated patients with severe brain injury (Glasgow Coma Scale [GCS] score ≤8) diagnosed with traumatic epidural hematoma (EDH).

METHODS

From January 2018 to June 2021, 1,122 patients with an initial GCS score ≤8 were retrospectively enrolled in the Korean Neuro-Trauma Data Bank System. Clinical data of 79 surgically treated patients with EDH were compared between the unfavorable (scores of 1-4 on the Glasgow Outcome Scale-Extended [GOSE]) and favorable (score of 5-8 on the GOSE) outcome groups.

RESULTS

The overall mortality rate was 13.9%, and 60.8% of the patients had good outcomes at six months post-trauma. In the univariate analysis, increasing age (p=0.010), lower initial GCS score (p=0.001), higher Rotterdam computed tomography (CT) score (p=0.012), craniotomy rather than craniectomy (p=0.032), larger EDH volume (p=0.007), and loss of pupillary reactivity (unilateral unreactive pupil, p=0.026; bilateral unreactive pupils, p<0.001), were significantly correlated with unfavorable outcomes. Of these factors, increasing age (p=0.011) and bilateral unreactive pupils (p=0.002) were the most significant risk factors in the multivariate logistic regression analysis. The interval from admission to the brain CT scan was not correlated with the outcome; however, it was significantly longer in the unfavorable outcome group.

CONCLUSION

Despite severe brain injury, more than half of the patients with EDH had favorable outcomes after surgical treatment. Our findings suggest that prompt diagnosis and surgical treatment should be considered for such cases.

Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH)

INTRODUCTION

Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed.

METHODS AND ANALYSIS

This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury.

ETHICS AND DISSEMINATION

The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04229966.

AATF and SMARCA2 are associated with thyroid volume in Hashimoto's thyroiditis patients

Thyroid volume of Hashimoto’s thyroiditis (HT) patients varies in size over the course of disease and it may reflect changes in biological function of thyroid gland. Patients with subclinical hypothyroidism predominantly have increased thyroid volume whereas patients with more pronounced hypothyroidism have smaller thyroid volumes. Suggested mechanism for thyroid atrophy is thyrocyte death due to apoptosis. We performed the first genome-wide association study (GWAS) of thyroid volume in two groups of HT patients, depending on levothyroxine (LT4) therapy, and then meta-analysed across. Study included 345 HT patients in total and 6 007 322 common autosomal genetic variants. Underlying hypothesis was that genetic components that are involved in regulation of thyroid volume display their effect in specific pathophysiologic conditions of thyroid gland of HT patients. We additionally performed immunohistochemical analysis using thyroid tissues and analysed differences in expression levels of identified proteins and apoptotic marker between HT patients and controls. We found genome-wide significant association of two loci, both involved in apoptosis, with thyroid volume of HT patients: rs7212416 inside apoptosis-antagonizing transcription factor AATF (P = 8.95 × 10⁻⁹) and rs10738556 near chromatin-remodeling SMARCA2 (P = 2.83 × 10⁻⁸). In immunohistochemical analysis we observed that HT patients with homozygous AATF risk genotypes have decreased AATF expression (0.46-fold, P < 0.0001) and increased apoptosis (3.99-fold, P = 0.0001) in comparison to controls. HT patients with heterozygous SMARCA2 genotypes have decreased SMARCA2 expression, albeit without reaching statistical significance (1.07-fold, P = 0.5876), and significantly increased apoptosis (4.11-fold, P < 0.0001). By two lines of evidence we show that two highly plausible genetic loci, AATF and SMARCA2, may be involved in determining the thyroid volume of HT patients. The results of our study significantly add to the current knowledge of disturbed biological mechanisms in thyroid gland of HT patients.

Surgical management of traumatic extradural haematoma: Experiences with 610 patients and prospective analysis

This study was carried out to find out the age, sex, mode of injury, localization, clinical presentation, CT findings, operative measures and outcome of extradural haematoma in the patient population at Dhaka Medical College. 610 consecutive patients with cranial extradural haematoma who underwent surgery in department of Neurosurgery from 1st January 2006 to 6th October 2008 were included in this prospective study. Each of the patients were evaluated in term of age, sex, mode of injury, localization of haematoma, clinical presentation, CT findings, operative measures and outcome. Out of 610 cases 86.32 % were male and 13.78 % were female. The male and female ratio was 6.27: 1. Age ranged from 2.5 to 83 years. Commonest age group was 21 to 30 years. Commonest mode of injury was Road traffic Accident 53.45%, followed by Assaults. Most common clinical presentation was headache / Vomiting 63.61 %, followed by altered sensorium 60.66 %. In this present prospective study of 610 cases of EDH, temporo parietal site was involved in 33.45 % followed by frontal region in 23.28 %. Sixty five patients (10.66 %) died; 19 of these had associated brain injuries and 28 cases were deeply unconscious. Extradural haematoma is a neurosurgical emergency where early surgical intervention is associated with the best prognosis. Many factors affects the outcome of extradural haematoma surgery and the most important one is the duration of time between incident/accident and operation in neurosurgical operation theater; mortality can be close to 0% if this time interval can be minimized.

[Guidelines for the management of severe traumatic brain injury. Part 3. Surgical management of severe traumatic brain injury (Options)]

Traumatic brain injury (TBI) is one of the main causes of mortality and severe disability in young and middle age patients. Patients with severe TBI, who are in coma, are of particular concern. Adequate diagnosis of primary brain injuries and timely prevention and treatment of secondary injury mechanisms markedly affect the possibility of reducing mortality and severe disability. The present guidelines are based on the authors' experience in developing international and national recommendations for the diagnosis and treatment of mild TBI, penetrating gunshot wounds of the skull and brain, severe TBI, and severe consequences of brain injury, including a vegetative state. In addition, we used the materials of international and national guidelines for the diagnosis, intensive care, and surgical treatment of severe TBI, which were published in recent years. The proposed recommendations for surgical treatment of severe TBI in adults are addressed primarily to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and intensivists who are routinely involved in treating these patients.

Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.

Post-Traumatic Frontal and Parieto-Occipital Extradural Haematomas: a Retrospective Analysis of 41 Patients and Review of the Literature

The purpose of this study was to analyse the differences between patients with frontal (FEDH) or parieto-occipital (POEDH) epidural haematomas and evaluate possible statistically significant prognostic factors.

In this retrospective study of a group of 41 patients with a FEDH (17) or POEDH (24 individuals), the authors analysed the influence of gender, age, type of injury, clinical presentation, Glasgow coma scale (GCS) score on admission, radiological findings, and time interval from trauma to surgery on outcomes. A good recovery and moderate disability were considered a “good” or “favourable outcome”, whereas severe disability, a vegetative state or death was a “poor outcome”.

In the POEDH subgroup, a higher GCS score on admission and a younger age were statistically significant prognostic factors for a better outcome (p=0.006, rs=0.702). In the subgroup of patients with FEDHs, the results were not significant. However, patients with FEDHs more frequently had “good outcomes” than members of the POEDH subgroup (88.2 vs. 70.9%). Children (≤ 18 years old) constituted a smaller portion of the POEDH subgroup (12.5%) than those in the FEDH subgroup (41.2%). The evaluation of time intervals between the accident and surgery (≤ 24 h vs. > 24 h) showed no significant influence on outcomes in any of the studied subgroups. However, patients undergoing surgery within 24 h of their injury had a less favourable GCS score on admission than those operated on more than 24 h after their injury. Subacute and chronic clinical courses predominated in patients with a FEDH (10/17 FEDH vs. 11/22 POEDH). Different accompanying intradural lesions occurred in 12 patients of the POEDH subgroup, but only in 2 of the FEDH subgroup (50 vs. 11.8%). However, the presence of such lesions did not significantly deteriorate surgical outcomes in either of the subgroups.

Clinical features of temporal tip epidural hematomas

OBJECT

The purpose of this paper was to clarify the clinical features of temporal tip epidural hematomas (EDHs).

METHODS

A retrospective chart review was conducted for 53 patients who had suffered an EDH. They were divided into two groups, those whose hematoma occurred in the temporal tip (23 patients) and others (30 patients). The following variables were analyzed: age, sex, Glasgow Coma Scale score, systolic blood pressure on admission, Injury Severity Score, incidence of hematomas in intracerebral regions, location of skull fracture, incidence of cranial nerve injury, type of operation, and Glasgow Outcome Scale (GOS) score at 3 months postinjury.

RESULTS

A greater incidence of zygomatic arch or lateral orbital cavity fracture was found in the "temporal tip" group than in the "other" group. There was a greater incidence of cranial nerve injury in the temporal tip (26.0%) than in the other group (6.6%; p < 0.05). Surgery to treat the EDH was more frequently performed in the other group (36.6%) than in the temporal tip group (two patients, 8.6%; p = 0.01). There were no significant differences between the groups in terms of the GOS score.

CONCLUSIONS

A temporal tip hematoma is not a rare injury among patients with EDHs. This hematoma tends to be induced by lateral orbital cavity and/or zygomatic arch fractures. It tends to be associated with cranial nerve injury, but it rarely requires an operation. The outcome of patients with this hematoma depends on the associated intracerebral lesions, thus indicating it to be similar to an EDH in other places.

Surgical Management of Acute Epidural Hematomas

RECOMMENDATIONS (see Methodology)

Indications for Surgery

Timing

Methods

Surgical Management of Traumatic Parenchymal Lesions

RECOMMENDATIONS (see Methodology)

Indications

Timing and Methods

A new reproducible model of an epidural mass lesion in rodents. Part I: Characterization by neurophysiological monitoring, magnetic resonance imaging, and histopathological analysis

OBJECT

The goal of this study was to characterize a new model of an epidural mass lesion in rodents by means of neurophysiological monitoring, magnetic resonance imaging, and histopathological analysis.

METHODS

Changes in intracranial pressure (ICP), cerebral perfusion pressure (CPP), and laser Doppler flowmetry (LDF) values, intraparenchymal tissue partial oxygen pressure (PtiO2), and electroencephalography (EEG) activity were evaluated in the rat during controlled, epidural expansion of a latex balloon up to a maximum ICP of 60 mm Hg. The initial balloon inflation was followed by periods of sustained inflation (30 +/- 1 minute) and reperfusion (180 +/- 5 minutes). Histopathological analysis and magnetic resonance (MR) imaging were performed to characterize the lesion. The time to maximum balloon expansion and the average balloon volume were highly reproducible. Alterations in EEG activity during inflation first appeared when the CPP decreased to 57 mm Hg, the LDF value to 66% of baseline values. and the PtiO2 to 12 mm Hg. During maximum compression, the CPP was reduced to 34 mm Hg, the LDF value to 40% of baseline, and the PtiO2 to 4 to 5 mm Hg. The EEG tracing was isoelectric during prolonged inflation and the values of LDF and PtiO2 decreased due to accompanying hypotonia. After reperfusion, the CPP was significantly decreased (p < 0.05) due to the elevation of ICP. Both the LDF value and EEG activity displayed incomplete restoration, whereas the value of PtiO2 returned to normal. Histological analysis and MR imaging revealed brain swelling with a midline shift and a combined cortical-subcortical ischemic lesion beyond the site of balloon compression.

CONCLUSIONS

This novel model of an epidural mass lesion in rodents closely resembles the process observed in humans. Evaluation of pathophysiological and morphological changes was feasible by using neurophysiological monitoring and MR imaging.

The difference in the outcome of surgery for traumatic extradural hematoma between patients who are admitted directly to the neurosurgical unit and those referred from another hospital

In this study of 120 cases that had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the author attempts to outline the influence on the outcome of surgery for EDH of whether the patient is admitted directly to the neurosurgical unit or via another hospital. Only 15% of the patients were admitted directly, while 85% were referred. The results show that although the directly admitted patients included significantly more unconscious patients exhibiting clinical signs of herniation, their outcome was not significantly worse. Therefore, in support of previous reports, it is recommended that all head injured patients be admitted to the primary care of neurosurgeons.

Prognostic factors in severely head injured adult patients with epidural haematoma's

A medline search back to 1975 was undertaken to identify relevant papers published on epidural haematomas. The search was restricted, whenever possible, to adult age and to comatose patients. Forty four relevant reports were identified. Only 4 papers reported results on multivariate analysis. In terms of prognosis, the following parameters were found to be significant: age, time from injury to treatment, immediate coma or lucid interval, presence of pupillary abnormalities, GCS/motor score on admission. CT findings (haematoma volume, degree of midline shift, presence of signs of active haematoma bleeding, associated intradural lesion) and post-operative ICP. To compare different casistics we need more informations about patients's outcome in the referral area of the neurosurgical centers, about the number of direct admissions and about the number of patients showing clinical deterioration.

Outcome after acute extradural haematoma, influence of additional injuries and neurological complications in the ICU

The purpose of this study was to evaluate the influence of additional, extracranial injuries and subsequent neurological complications in the intensive care unit on the functional outcome after head injury with extradural haematoma. The retrospective analysis included 139 adult patients with acute extradural haematomas admitted to the intensive care unit. Fifty-seven patients (41 per cent) were multiply injured (Injury Severity Score (ISS) = 36.5), and 82 (59 per cent) had a single head injury (ISS = 24.9). Fifty-four patients (39 per cent) developed neurological complications such as intracranial pressure (ICP) increase alone (N = 16), intracranial bleeding, ischaemic brain lesions or epileptic seizures with an associated ICP increase (N = 24) or without (N = 14). Overall, 77 per cent of the patients had a functional outcome (Glasgow outcome score 4 or 5); 46 per cent had a good recovery, 31 per cent were moderately disabled, 10 per cent were severely disabled, 4 per cent were persistently vegetative, and 9 per cent died. Differences were found between (1) patients with and without complications, (2) patients with extradural haematomas and patients with additional intracranial lesions, and (3) patients with a 'severe' Glasgow Coma Score (GCS) of 3-8 and patients with a GCS of 9-15. The presence of additional intracerebral injuries, and not extracerebral injuries, as well as the management of elevated ICP determines the final outcome in patients with extradural haematomas.

Statistical analysis of the factors affecting the outcome of extradural haematomas: 115 cases

115 traumatic extradural haematoma cases who were treated surgically at Cerrahpasa Medical Faculty Neurosurgery Department between 1987 and 1992 are evaluated. When factors affecting the outcome were examined, a strong correlation was found between the result and Glasgow coma scale (GCS) (p < 0.00001). The existence of a fracture, the interval between onset of haematoma symptoms and intervention and the existence of an intracerebral haematoma together with contusion accompanying intradural haematoma, affect the outcome in a negative direction. There was no statistical correlation between the outcome and the age of patient, localization of the haematoma and aetiology.

Clinical characteristics of traumatic extradural hematoma: a comparison between children and adults

In this study of 43 children who had surgery for traumatic extradural hematoma (EDH) at Frenchay Hospital, England, between 1975 and 1987, the authors attempt to outline the various clinical characteristics of EDH which are different in children (age range 1-15 years) and adults (age range 16-84 years). The results confirm that children with traumatic EDH are less likely to have injury be caused by an RTA, are less likely to remain unconscious from the time of injury to the time of the operation, and are less likely to require immediate surgery (less than 6 hours after injury). In addition, the CT scan is less likely to show in associated intradural injury, and the outcome is significantly better.