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Minimizing Morbidity & Mortality: Clinical Pearls & Complication Management” Epidural Hematoma (EDH)



Epidural Hematoma

One of the most common but potentially most gratifying neurotrauma procedures is the treatment of epidural hematoma (EDH).  Given the frequency of EDHs worldwide, and the importance of rapid intervention, optimizing the neurosurgical treatment in terms of simplicity and rapidity of the procedure is imperative.

The surgical intervention for EDH has three goals:

  1. Evacuate the hematoma on order to reduce intracranial pressure (ICP).
  2. Control the bleeding.
  3. Prevent re-accumulation of the blood.

It is generally thought that a craniotomy is required to accomplish these three goals, since a craniotomy can allow evacuation of the blood, eliminate any sources of intracranial bleeding (except for coagulopathy), and prevent the re-accumulation of blood through the use of dural tack-up sutures.

However, in certain circumstances a much simpler approach may be appropriate – drainage of the EDH by burr hole rather than by full craniotomy.1-6  Most of these studies have been retrospective analyses but one recent investigation of burr hole drainage of traumatic EDH in children age 0 to 14 was prospective.6  Ijaz et al studied 50 children (34 male, 16 female) who presented with traumatic EDH over a 26 month period (2014-16).  All but one of the patients had a supratentorial EDH.  Glasgow Coma Score (GCS) was 13-15 in 42%, 9-12 in 36%, and 3-8 in 22%.  Mean hematoma volume was 50 ml (SD +/- 27 ml).  

Based on the CT or MRI findings, a burr hole was made over the center of the EDH, and the hematoma evacuated by gentle suction and dissection of the epidural space until the dura became apposed to the inner table of the skull.  No drain was placed.  The mean operative time was 28 minutes.

One patient who presented with GCS 3 and EDH volume of 120 ml expired.  Another patient who presented with GCS 6 and EDH volume of 113 ml only improved to GCS 9 postoperatively; CT showed a residual volume EDH of 49 ml.  This patient underwent a second burr hole drainage, with resolution of clinical status to GCS 15.  Thus 49 out of 50 patients were discharged with GCS 15.  Postoperative complications or sequellae included: one patient (later found to have factor V deficiency) who had a recurrent EDH after minor head trauma that was treated by craniotomy at another hospital; one patient with a recurrent headache 10 days after discharge who had residual or recurrent EDH that was treated by drainage through the same burr hole at another hospital; two patients with complaints of occasional headache (managed by analgesics); two patients with learning difficulties due to memory problems; and one patient with mood swings.

In this era of limited resources and cost-containment, if a straightforward minimally invasive and resource-friendly procedure provides satisfactory clinical results – such a procedure warrants consideration by the wider neurosurgical community.  Burr hole drainage of EDH may be a favorable option in many circumstances.  To employ a more complicated treatment option than is necessary represents a step backward in the quest for optimal neurosurgical care.

References

  1. Liu JT, Tyan YS, Lee YK, Wang JT.  Emergency management of epidural hematoma through burr hole evacuation and drainage.  A preliminary report.  Acta Neurochir (Wien) 2006; 148:313-317.
  2. Nelson JA.  Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma.  Acad Emerg Med 2011; 18:78-85.
  3. Habibi Z, Meybodi AT, Mirsadeghi SM, Miri SM.  Burr-hole drainage for the treatment of acute epidural hematoma in coagulopathic patients: a report of eight cases.  J Neurotrauma 2012; 29:2103-2107.
  4. Ansari I, Futane S, Ansari A.  Endoscope-assisted, minimally invasive evacuation of sub-acute/chronic epidural hematoma: novelty or paradox of Theseus?  Acta Neurochir (Wien) 2016; 158:1473-1478.
  5. Wang W.  Minimally invasive surgical treatment of acute epidural hematoma: case series.  BioMed Res International 2016; #6507350, pp 8.
  6. Ijaz L, Nadeem MM, Laeeq-ur-Rehman.  Minimal invasive burr-hole management of traumatic EDH.  Pak J Neurol Surg 2016; 20:149-153. 

     

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