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CC BY-NC-ND 4.0 · Asian J Neurosurg 2024; 19(03): 452-461
DOI: 10.1055/s-0043-1775731
Original Article

Predictive Factors for Regression versus Progression of Nonevacuated Posttraumatic Acute Extradural Hematoma

Hany Elkholy 
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
,
Hossam Elnoamany
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
,
Mohamed Adel Hussein
1   Department of Neurosurgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
› Author Affiliations Funding None.
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Abstract

Study Design This study was a retrospective study conducted from October 2020 to October 2022 on 106 posttraumatic patients with acute extradural hematomas (EDHs) who were initially planned for conservative treatment. 74 patients had spontaneous EDH regression (EDHR), while 32 patients developed EDH progression (EDHP) and were shifted for surgery. The two groups were statistically compared regarding the different demographic, clinical, and radiographic factors to identify the significant predictors for regression versus progression of acute posttraumatic EDH.

Objectives Conventionally, urgent evacuation is the accepted management for EDH. However, several recent reports have described successful conservative management in selected patients. There are no adequate clues to verify patients who will have spontaneous EDHR from those at risk for EDHP and delayed surgery. The main objective of this study was to identify the significant predictors for possible regression versus progression of acute posttraumatic EDH initially planned for nonsurgical treatment.

Materials and Methods A retrospective study conducted over 2 years, included 106 head trauma patients with acute EDH, who were admitted to our department and were initially planned for conservative treatment. Various demographic, clinical, and radiographic factors were analyzed to verify the significant predictors for spontaneous EDHR (EDHR group) versus EDHP and subsequent surgical evacuation (EDHP group).

Results The mean age was 20.37 ± 12.712 years and the mean Glasgow Coma Scale score (GCS) was 12.83 ± 2.113. Total 69.8% of patients showed spontaneous EDHR, while 30.2% developed EDHP and were shifted for surgical evacuation. Statistical comparison showed that higher GCS (p = 0.002), frontal location (p = 0.022), and concomitant fissure fracture (p =  0.014) were the significant predictors for EDHR, while younger age (p = 0.006), persistent nausea/vomiting (p = 0.046), early computed tomography (CT) after trauma (p = 0.021), temporal location (p < 0.001), and coagulopathy (p = 0.001) were significantly associated with EDHP.

Conclusion Patients with traumatic EDH fitting the criteria of initial nonsurgical treatment necessitates 48 hours of close observation and serial CT scans at 6, 12, 24, and 48 hours to confirm the regression or early detect the EDHP. Patients with high GCS, frontal hematomas, and associated fissure fracture are at low risk for EDHP. Increased alertness is mandatory for young age and patients with persistent nausea/vomiting, early CT scan, temporal hematomas, or coagulopathy.

Keywords

head injury - extradural hematoma - conservative management - surgical evacuation - progression

Note

This article has been read and approved by all the authors. This work was self-funded by the authors. This study was approved by the clinical research committee of the Menoufia University Hospital (IRB approval number: 3-2023.NEUS 1–5) and it followed the tenets of the Declaration of Helsinki.


Availability of Data and Materials

All data and materials included in this work are available.


Ethical Approval

Our local ethics committee approved our study.


Authors' Contributions

All authors made a significant contribution to the work reported, whether that was in the conception; study design; execution; and acquisition, analysis, and interpretation of data. All authors took part in drafting, revising, and final approval of the article. All agreed to be accountable for all aspects of the work.




Publication History

Article published online:
24 June 2024

© 2024. Asian Congress of Neurological Surgeons. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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  • References

  • 1 Gupta SK, Tandon SC, Mohanty S, Asthana S, Sharma S. Bilateral traumatic extradural haematomas: report of 12 cases with a review of the literature. Clin Neurol Neurosurg 1992; 94 (02) 127-131
    CrossrefPubMedSearch in Google Scholar
  • 2 Bullock MR, Chesnut R, Ghajar J. et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute epidural hematomas. Neurosurgery 2006; 58 (3, suppl): S7-S15 , discussionSi-iv
    PubMedSearch in Google Scholar
  • 3 Guo C, Liu L, Wang B, Wang Z. Swirl sign in traumatic acute epidural hematoma: prognostic value and surgical management. Neurol Sci 2017; 38 (12) 2111-2116
    CrossrefPubMedSearch in Google Scholar
  • 4 Yilmazlar S, Kocaeli H, Dogan S. et al. Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases. Acta Neurochir (Wien) 2005; 147 (12) 1241-1248
    CrossrefPubMedSearch in Google Scholar
  • 5 Bhau KS, Bhau SS, Dhar S, Kachroo SL, Babu ML, Chrungoo RK. Traumatic extradural hematoma - role of non-surgical management and reasons for conversion. Indian J Surg 2010; 72 (02) 124-129
    CrossrefPubMedSearch in Google Scholar
  • 6 Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J. Epidural hematoma treated conservatively: when to expect the worst. Can J Neurol Sci 2016; 43 (01) 74-81
    CrossrefPubMedSearch in Google Scholar
  • 7 Jamous MA, Abdel Aziz H, Al Kaisy F, Eloqayli H, Azab M, Al-Jarrah M. Conservative management of acute epidural hematoma in a pediatric age group. Pediatr Neurosurg 2009; 45 (03) 181-184
    CrossrefPubMedSearch in Google Scholar
  • 8 OpenEpi. Sample Size for X-Sectional, Cohort, and Clinical Trials. (n.d.). Retrieved from May 31, 2022, at: https://www.openepi.com/SampleSize/SSCohort.htm
  • 9 Petersen OF, Espersen JO. Extradural hematomas: measurement of size by volume summation on CT scanning. Neuroradiology 1984; 26 (05) 363-367
    CrossrefPubMedSearch in Google Scholar
  • 10 Wilson JT, Pettigrew LE, Teasdale GM. Structured interviews for the Glasgow outcome scale and the extended Glasgow outcome scale: guidelines for their use. J Neurotrauma 1998; 15 (08) 573-585
    CrossrefPubMedSearch in Google Scholar
  • 11 Offner PJ, Pham B, Hawkes A. Nonoperative management of acute epidural hematomas: a “no-brainer”. Am J Surg 2006; 192 (06) 801-805
    CrossrefPubMedSearch in Google Scholar
  • 12 De Souza M, Moncure M, Lansford T. et al. Nonoperative management of epidural hematomas and subdural hematomas: is it safe in lesions measuring one centimeter or less?. J Trauma 2007; 63 (02) 370-372
    PubMedSearch in Google Scholar
  • 13 Satyarthee GD, Satyarthee R, Satyarthee L, Agrawal A. Mirror image extradural hematoma in elderly population: management strategy with surgical bilateral or unilateral evacuation or conservative treatment modality with literature review. Romanian Neurosurgery 2017; 31 (04) 555-559
    CrossrefSearch in Google Scholar
  • 14 Zwayed ARH, Lucke-Wold B. Conservative management of extradural hematoma: a report of sixty-two cases. Neurol Clin Neurosci 2018; 2 (02) 5-9
    PubMedSearch in Google Scholar
  • 15 Zakaria Z, Kaliaperumal C, Kaar G, O'Sullivan M, Marks C. Extradural haematoma–to evacuate or not? Revisiting treatment guidelines. Clin Neurol Neurosurg 2013; 115 (08) 1201-1205
    CrossrefPubMedSearch in Google Scholar
  • 16 Ding J, Yuan F, Guo Y. et al. A prospective clinical study of routine repeat computed tomography (CT) after traumatic brain injury (TBI). Brain Inj 2012; 26 (10) 1211-1216
    CrossrefPubMedSearch in Google Scholar
  • 17 Crone KR, Lee KS, Kelly Jr DL. Correlation of admission fibrin degradation products with outcome and respiratory failure in patients with severe head injury. Neurosurgery 1987; 21 (04) 532-536
    CrossrefPubMedSearch in Google Scholar
  • 18 Chang EF, Meeker M, Holland MC. Acute traumatic intraparenchymal hemorrhage: risk factors for progression in the early post-injury period. Neurosurgery 2006; 58 (04) 647-656 , discussion 647–656
    CrossrefPubMedSearch in Google Scholar
  • 19 Mayr R, Troyer S, Kastenberger T. et al. The impact of coagulopathy on the outcome of traumatic epidural hematoma. Arch Orthop Trauma Surg 2012; 132 (10) 1445-1450
    CrossrefPubMedSearch in Google Scholar
  • 20 Knuckey NW, Gelbard S, Epstein MH. The management of “asymptomatic” epidural hematomas. A prospective study. J Neurosurg 1989; 70 (03) 392-396
    CrossrefPubMedSearch in Google Scholar
  • 21 Moussa AA, Mahmoud ME, Yousef HA. Conservative management of significant epidural haematomas. Egypt J Neurosurg 2018; 33: 17
    CrossrefSearch in Google Scholar
  • 22 Dubey A, Pillai SV, Kolluri SV. Does volume of extradural hematoma influence management strategy and outcome?. Neurol India 2004; 52 (04) 443-445
    PubMedSearch in Google Scholar
  • 23 Bullock R, Smith RM, van Dellen JR. Nonoperative management of extradural hematoma. Neurosurgery 1985; 16 (05) 602-606
    CrossrefPubMedSearch in Google Scholar
  • 24 Subodh PU, Hamza Q. Traumatic extradural hematoma: ourcomparative experience between conservative and surgical management in rural India. IOSR J Dent Med Sci 2012; 1 (03) 7-11
    CrossrefSearch in Google Scholar
  • 25 Bezircioğlu H, Erşahin Y, Demirçivi F, Yurt I, Dönertaş K, Tektaş S. Nonoperative treatment of acute extradural hematomas: analysis of 80 cases. J Trauma 1996; 41 (04) 696-698
    CrossrefPubMedSearch in Google Scholar
  • 26 Tuncer R, Açikbas C, Uçar T, Kazan S, Karasoy M, Saveren M. Conservative management of extradural haematomas: effects of skull fractures on resorption rate. Acta Neurochir (Wien) 1997; 139 (03) 203-207
    CrossrefPubMedSearch in Google Scholar
  • 27 Sullivan TP, Jarvik JG, Cohen WA. Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 1999; 20 (01) 107-113
    PubMedSearch in Google Scholar