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Pisică D, Volovici V, Yue JK, van Essen TA, den Boogert HF, Vande Vyvere T, Haitsma I, Nieboer D, Markowitz AJ, Yuh EL, Steyerberg EW, Peul WC, Dirven CMF, Menon DK, Manley GT, Maas AIR, Lingsma HF. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. Neurosurgery 2024:00006123-990000000-01172. [PMID: 38771081 DOI: 10.1227/neu.0000000000002982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/05/2024] [Indexed: 05/22/2024] Open
Abstract
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.
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Affiliation(s)
- Dana Pisică
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - John K Yue
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Thomas A van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
- Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hugo F den Boogert
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital and University of Antwerp, Antwerp, Belgium
| | - Iain Haitsma
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Daan Nieboer
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Amy J Markowitz
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Ewout W Steyerberg
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Biomedical Data Sciences, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, the Netherlands
| | - Wilco C Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and Haga Teaching Hospital, Leiden and The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Clemens M F Dirven
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - David K Menon
- Division of Anaesthesia, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Hester F Lingsma
- Department of Public Health, Center for Medical Decision Making, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
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Charcos IB, Wong TW, Larsen BR, Azurdia AR, Gridley DG, Vail SJ, Hollingworth AK, Lettieri SC, Feiz-Erfan I. Location of Traumatic Cranial Epidural Hematoma Correlates with the Source of Hemorrhage: A 12-Year Surgical Review. World Neurosurg 2021; 152:e138-e143. [PMID: 34033954 DOI: 10.1016/j.wneu.2021.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 05/14/2021] [Accepted: 05/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Epidural hematoma (EDH) can result in a catastrophic outcome of traumatic brain injury. Current management guidelines do not consider the source of hemorrhage in decision making. The purpose of this study was to examine the relationship between EDH location and the source of hemorrhage. METHODS We report retrospectively reviewed, prospectively obtained surgical data of patients with acute traumatic cranial EDH treated between 2007 and 2018. Computed tomography (CT) scans were used to categorize EDH location as lateral or medial. The source of hemorrhage was identified intraoperatively by a single surgeon. RESULTS Overall, of 92 evacuated EDHs (in 87 patients), 71 (77.2%) were in the lateral location. Arterial bleeding was the cause of EDH in 63.4% of the lateral EDHs and 9.2% of the medial EDHs (P < 0.0001). In the cases where surgery was done primarily to treat EDH, 65.3% had an arterial bleed source (P < 0.0001). In those treated for primary reasons other than EDH evacuation, 75% had a venous bleed source (P = 0.002). CONCLUSIONS The location of EDH correlates with the source of hemorrhage. The decision to operate on EDH may be influenced by this factor.
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Affiliation(s)
- Iris B Charcos
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA
| | - Tina W Wong
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA
| | - Brett R Larsen
- Department of Radiology, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Adrienne R Azurdia
- Emergency Medicine, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Department of Emergency Medicine, HonorHealth Scottsdale, Scottsdale, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Daniel G Gridley
- Department of Radiology, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Sydney J Vail
- Division of Trauma, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Alexzandra K Hollingworth
- Division of Trauma, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Department of Surgery and Anesthesia, Midwestern University, Glendale, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Salvatore C Lettieri
- Division of Plastic Surgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Division of Plastic Surgery, Mayo Clinic, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA
| | - Iman Feiz-Erfan
- Department of Surgery, Division of Neurosurgery, Creighton University, School of Medicine Phoenix, Phoenix, Arizona, USA; Valleywise Health Medical Center, Phoenix, Arizona, USA; The University of Arizona, College of Medicine Phoenix, Phoenix, Arizona, USA.
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Jamous MA. The outcome of observation of acute traumatic extradural hemorrhage in pediatric age group. Eur J Trauma Emerg Surg 2019; 47:847-853. [PMID: 31748846 DOI: 10.1007/s00068-019-01262-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Accepted: 11/07/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE The non-operative management of extradural hemorrhage in the pediatric age group has been increasingly considered in the last decade with good clinical outcomes and comparable results to surgical intervention in carefully selected patients. The purpose of this study is to evaluate the outcome of observation in the management of pediatric patients with extra dural hematoma. PATIENTS AND METHODS All consecutive pediatric patients with traumatic EDH after TBI who were presented to a single neurosurgical institution between January, 2008 and November, 2018 were retrospectively reviewed. Mechanism of injury, Glasgow coma scale (GCS) on admission, presenting neurological examination, treatment modality, the first and last imaging findings, and outcome were analyzed. The outcome was measured using the Glasgow outcome scale (GOS) on discharge from the hospital. RESULTS A total of 83 patients were identified. The median age was 7.1 years (0.8-14 years) and 67% of the patients were male (n = 56). The median thickness of acute EDH was 1.1 cm (0.2-2.6 cm). 44 patients were managed conservatively with a close observation at a specialized neurotrauma unit for any clinical deterioration, and the remaining 39 patients were managed surgically. There was no significant difference in the patients age, hematoma thickness, presence of skull fractures, systemic injuries, and other types of cerebral injuries between the two groups. The presenting GCS was significantly lower in the surgical group which reflects the severity of the injury. Hospital stay was significantly longer among the surgical group, and the GOS was significantly better in the non-surgical group. The majority of the surgical group showed complete resolution of the hematoma on discharge, while only 50% of the non-surgical patients (n = 22) had a complete resolution of the hematoma one month after the TBI. CONCLUSION The conservative management is applicable in carefully selected pediatric patients with acute traumatic extradural hematoma provided that the observation is accomplished in a well-established and equipped neurosurgical unit. These results are congruent with similar earlier studies.
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Affiliation(s)
- Mohammad Ahmad Jamous
- King Abdullah University Hospital, Ar-Ramtha, Jordan. .,Department of Neurosurgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, Jordan.
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Role of follow-up CT scans in the management of traumatic pediatric epidural hematomas. Childs Nerv Syst 2019; 35:2195-2203. [PMID: 31177323 DOI: 10.1007/s00381-019-04236-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/27/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making. METHODS A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon. RESULTS Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline. CONCLUSION Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.
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Maugeri R, Anderson DG, Graziano F, Meccio F, Visocchi M, Iacopino DG. Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:811-7. [PMID: 26567227 PMCID: PMC4652627 DOI: 10.12659/ajcr.895231] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient: Male, 30 Final Diagnosis: Acute epidural hematoma Symptoms: — Medication: — Clinical Procedure: Observation Specialty: Neurosurgery
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Affiliation(s)
- Rosario Maugeri
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | | | - Francesca Graziano
- Department of Experimental Biomedicine and Clinical Neurosciences,School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | - Flavia Meccio
- Department of Experimental Biomedicine and Clinical Neurosciences,School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
| | - Massimiliano Visocchi
- Institute of Neurosurgery, Catholic University School of Medicine, Policlinico "A. Gemelli", Rome, Italy
| | - Domenico Gerardo Iacopino
- Department of Experimental Biomedicine and Clinical Neurosciences, School of Medicine, Neurosurgical Clinic, University of Palermo, Palermo, Italy
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