Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report

The effectiveness of palliative middle meningeal artery embolization prior to craniotomy for large acute epidural hematoma: A case report

INTRODUCTION AND IMPORTANCE

Acute epidural hematoma is typically managed with craniotomy. However, there are a few reports on transcatheter arterial embolization (TAE) as an adjunctive therapy.

CASE PRESENTATION

A 70-year-old female with no obvious history of trauma was transported to our hospital. Computed tomography scan revealed an epidural hematoma of approximately 80 ml with a midline shift of 5 mm. We decided to perform an emergency craniotomy. However, the operating room (OR) was already occupied by a scheduled surgery and it would take 30 min to an hour to prepare it. We opted to wait for our OR, considering that, even if the patient was transferred to another hospital, it would take time for the craniotomy to commence.

CLINICAL DISCUSSION

We performed TAE for the middle meningeal artery (MMA) as a palliative measure to prevent hematoma enlargement. The MMA was selectively embolized with 20 % n-butyl-2-cyanoacrylate (NBCA), resulting in no hematoma enlargement or observed complications. The criteria for endovascular treatment of acute epidural hematoma are not yet well-established. This case demonstrates the potential role of endovascular treatment for large acute epidural hematomas in carefully selected patients.

CONCLUSION

If there is a time gap before craniotomy, TAE could be considered a viable option for large acute epidural hematomas as a palliative intervention before craniotomy.

Comparison of burr hole drainage and craniotomy for acute liquid epidural hematoma in pediatric patients

PURPOSE

To compare the impact of burr hole drainage and craniotomy for acute liquid epidural hematoma (LEDH) in pediatric patients.

METHODS

This retrospective study enrolled pediatric patients with LEDH who underwent surgery in the Affiliated Hospital of Nanyang Medical College, China, between October 2011 and December 2019. According to the surgical procedure, patients were divided into the craniotomy group and the burr hole drainage group.

RESULTS

A total of 21 pediatric patients were enrolled (14 males, aged 7.19 ± 2.77 years), including 13 cases in the burr hole drainage group and 8 patients in the craniotomy group. The operation time and hospitalization period in the burr hole drainage group were 33.38 ± 6.99 min and 9.85 ± 1.07 days, respectively, which were significantly shorter than that in the craniotomy group (74.25 ± 9.68 min and 13.38 ± 1.71 days, respectively; all p < 0.05). The Glasgow Coma Scale (GCS) score after burr hole drainage was significantly improved than before (median: 15 vs 13, p < 0.05). No serious complications were observed in either group; one patient in the craniotomy group developed an infection at the incision point. All patients were conscious (GCS score was 15) at discharge.

CONCLUSION

Compared with craniotomy, burr hole drainage was associated with better clinical outcomes and early recovery in patients with LEDH.

Intracranial Intraosseous Catheter Placement to Temporize an Epidural Hematoma

Acute epidural hematomas can lead to rapid neurologic decompensation and death. Epidural hematomas may require emergency surgical clot removal, but many patients live far away from a trauma center. This case report describes a pediatric patient with an acute epidural hematoma with significant neurologic compromise who initially presented to a nontrauma center. The emergency department (ED) had no neurosurgeon or equipment to perform burr hole craniostomy. The emergency physician at the nontrauma ED inserted an intraosseous catheter intracranially to temporarily decompress the hematoma due to long transport times. The patient survived with complete neurologic recovery. This is the youngest known patient in whom an intraosseous catheter was used to drain an intracranial hematoma.

Emergency department burr hole simulation using 3D-printed model

BACKGROUND

Traumatic epidural hematoma (EDH) with the potential to displace the brain tissue and increase intracranial pressure (ICP), is a life-threatening condition that requires emergent intervention. In rare circumstances, Emergency Physician (EP) may have to do skull trephination to reduce the ICP as a temporary measure.

SPECIFIC AIMS

To evaluate emergency medicine (EM) residents' comfort in performing emergency department (ED) burr holes and to assess their difficulties and evaluate comfort level before and after simulated EDH cases.

MATERIALS AND METHODS

A 3D-printed skull and electrical and manual drills were used for the simulation. Subjective comfort level pre and post-procedure, as well as objective procedural skills and time to complete the drill, were recorded.

RESULTS

Twenty EM residents participated in the simulation study. The median time to perforate through the skull was 4 s for the electric drill and 10 s for the manual drill. A comfort level of 5 and above was reported by 12 participants for the manual drill and by 17 participants for the electric drill. Six participants had mild and 2 participants had moderate observed difficulty in handling the manual and electric drill. Most participants performed both procedures successfully with one attempt only. Three participants have an overall comfort level above 5 before the simulation and 13 participants had a post-simulation.

CONCLUSION

The 3D-printed model assisted the ED burr hole simulation and the residents could perform the procedure with minimum difficulties.

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.

A minimally invasive strategy to evacuate hematoma by synergy of an improved ultrasonic horn with urokinase: an in-vitro study

OBJECTIVES

In this study, Ultrasound Needle-an improved minimally invasive ultrasonic horn device was used to explore its potential of synergizing with urokinase in enhancing clots lysis in an in-vitro intracranial hematoma model.

MATERIALS AND METHODS

10 ml bovine blood was incubated for 3 h at 37 ℃, and coagulated into clot to mimic intracranial hematoma in-vitro. Ultrasound Needle was an improved ultrasonic horn with a fine tip (1.80 mm) and metallic sheath, and had a frequency of 29.62 kHz. 10000 IU urokinase was injected through the metallic sheath during the vibration of Ultrasound Needle tip to lyse the clots for 8 minutes under different working parameter settings (n = 8) to explore the influence of parameters Amplitude (%) and Duty (%) on clot lysis weight (W₀ ). The maximum temperatures were measured by an infrared thermometer during the treatment process. The W₀ of different treatment groups (US (Ultrasound Needle), US+NS (normal saline), UK (urokinase), US+UK, n = 8) were compared to verify the synergistic lysis effect of Ultrasound Needle combined with urokinase at optimal working parameters (40% Amplitude, 20% Duty; input power 4.20 W; axial tip-vibration amplitude 69.17 μm). Clots samples after treatment were fixed overnight for macroscopic examination. And fluorescent frozen sections and scanning electron microscopy examination were performed to show microscopic changes in clots and evaluate the cavitation effect of Ultrasound Needle on promoting drug diffusion within the clots.

RESULTS

The clot lysis weight W₀ increased with the parameters Amplitude (%) and Duty (%), reached a peak (2.435±0.137 g) at 40% Amplitude and 20% Duty (input power 4.20 W), and then decreased. Higher Amplitude (%) and Duty (%) led to higher maximum temperature, and W₀ was negatively correlated with the maximum temperature after the peak (r = -0.958). At the optimal parameter setting, the maximum temperature was 33.8±0.9 ℃, and the W₀ of the US+UK group was more than 4 times of UK alone group (2.435±0.137 g vs 0.607±0.185 g). Fluorescent frozen sections confirmed that the ultrasound energy of Ultrasound Needle could mechanically damage the clot tissues and promote the intra-clots drug diffusion. Macroscopic examination showed that US+UK group caused larger clots lysis area than UK alone group (2.08 cm² vs 0.65 cm² ). In addition, electron microscopy examination exhibited that the fibrin filaments of the clots in US+UK group were lysed more thoroughly compared to single treatment groups.

CONCLUSIONS

Ultrasound Needle, an improved ultrasonic horn device, can mechanically damage the clot tissues and exhibit an excellent synergistic lysis effect with thrombolytic drugs. Therefore, Ultrasound Needle has great potential in providing a new minimally invasive strategy for rapid intracranial hematoma evacuation. This article is protected by copyright. All rights reserved.

Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review

PURPOSE OF REVIEW

The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers.

RECENT FINDINGS

To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.

An evaluation of outcomes in patients with traumatic brain injury at a referral hospital in Tanzania: evidence from a survival analysis

OBJECTIVE

The purpose of this study was to determine if patients with traumatic brain injury (TBI) in low- and middle-income countries who receive surgery have better outcomes than patients with TBI who do not receive surgery, and whether this differs with severity of injury.

METHODS

The authors generated a series of Kaplan-Meier plots and performed multiple Cox proportional hazard models to assess the relationship between TBI surgery and TBI severity. The TBI severity was categorized using admission Glasgow Coma Scale scores: mild (14, 15), moderate (9-13), or severe (3-8). The authors investigated outcomes from admission to hospital day 14. The outcome considered was the Glasgow Outcome Scale-Extended, categorized as poor outcome (1-4) and good outcome (5-8). The authors used TBI registry data collected from 2013 to 2017 at a regional referral hospital in Tanzania.

RESULTS

Of the final 2502 patients, 609 (24%) received surgery and 1893 (76%) did not receive surgery. There were significantly fewer road traffic injuries and more violent causes of injury in those receiving surgery. Those receiving surgery were also more likely to receive care in the ICU, to have a poor outcome, to have a moderate or severe TBI, and to stay in the hospital longer. The hazard ratio for patients with TBI who underwent operation versus those who did not was 0.17 (95% CI 0.06-0.49; p < 0.001) in patients with moderate TBI; 0.2 (95% CI 0.06-0.64; p = 0.01) for those with mild TBI, and 0.47 (95% CI 0.24-0.89; p = 0.02) for those with severe TBI.

CONCLUSIONS

Those who received surgery for their TBI had a lower hazard for poor outcome than those who did not. Surgical intervention was associated with the greatest improvement in outcomes for moderate head injuries, followed by mild and severe injuries. The findings suggest a reprioritization of patients with moderate TBI-a drastic change to the traditional practice within low- and middle-income countries in which the most severely injured patients are prioritized for care.

Minicraniotomy Under Local Anesthesia and Monitored Sedation for the Operative Treatment of Uncomplicated Traumatic Acute Extradural Hematoma

BACKGROUND

Major craniotomy is currently the de facto operative treatment for traumatic acute extradural hematoma (AEDH). This craniotomy, involving extensive scalp dissection (the trauma flap) and major cranial bone opening, can be impracticable in the remote regions of some Western countries, and even more so in the low-resource health systems of most developing countries.

METHODS

We describe the surgical technique of minicraniotomy under local anesthesia plus monitored sedation as a much less invasive operative treatment for AEDH. The results of its use in a preliminary patient group are also presented.

RESULTS

The procedure has been carried out in 10 consecutive patients (7 men), including an infant 4 months of age. The age range was 4 months to 56 years. The patients suffered varying severity of head injury, with a median Glasgow Coma Scale (GCS) score of 11 out of 15 (range, 4-15). The median trauma to surgery time was 25 hours (range, 13-192 hours). The surgery was successfully completed, with hematoma evacuated and hemostasis achieved. The median duration of surgery was 90 minutes. The in-hospital outcome was Glasgow Outcome Scale score of normal status in 6 patients, moderate deficit in 2 patients, and vegetative state in the patient whose preoperative GCS score was 4. One other patient, admitted with a GCS score of 11, died 5 days postoperatively from extracranial causes. The surviving patients have been followed-up for a median time of 15 months with no new deficits.

CONCLUSIONS

Compared with full craniotomy under general anesthesia, minicraniotomy under local anesthesia plus sedation may be a more pragmatic, less invasive, and low-cost surgical treatment option for uncomplicated traumatic acute extradural hematoma.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ± 3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ± 1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma: Endovascular Embolization Combined with Drainage Surgery and Use of Urokinase

BACKGROUND

Hematoma evacuation is regular treatment for acute traumatic epidural hematoma (ATEDH) patients meeting with surgery indications. However, it is an invasive approach performed under general anesthesia. Here, a novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia.

METHODS

A novel minimally invasive method of endovascular embolization with subsequent drainage surgery and use of urokinase was established to treat ATEDH under local anesthesia. Firstly, 23 ATEDH patients with hematomas in the temporal area underwent digital subtraction angiography detecting the bleeding point. Next, embolization was performed. After embolization, drainage surgery was taken and urokinase was injected into the hematoma cyst by drainage tube to lyse hematoma twice per day.

RESULTS

The results showed that the middle meningeal artery was the bleeding source. Embolization immediately ceased bleeding. Most clots were resolved and drained after treatment. No recurrence of hematoma or infection was observed.

CONCLUSION

The findings suggest that the combined treatments can be an alternative minimally invasive option for ATEDHs, especially for elderly patients or those contraindicated for general anesthesia.

Trephination mini-craniectomy for traumatic posterior fossa epidural hematomas in selected pediatric patients

PURPOSE

Posterior fossa epidural hematomas (PFEDH) are uncommon in children but usually require timely surgical intervention due to the risk of life-threatening brainstem compression. We attempt to make the surgical procedure less invasive by treating selected pediatric patients with trephination mini-craniectomy.

METHODS

We retrospectively reviewed the clinical courses, radiological findings, surgical procedures, and prognoses of the pediatric patients who were treated in our departments for traumatic PFEDH from January 2010 to January 2015.

RESULTS

During this period, a total of 17 patients were surgically treated for PFEDH and 7 were managed with trephination mini-craniectomy for hematoma evacuation. The outcomes were good in all 7 patients as evaluated with Glasgow Outcome Score. There was no mortality in this series. The on average 30-month clinical follow-up showed that patients experienced satisfactory recoveries without complications.

CONCLUSION

Our results suggest that trephination mini-craniectomy is a safe surgical technique for selected PFEDH patients with moderate hematoma volume and stabilized neurological functions. However, standard craniectomy is recommend when there are rapid deteriorations in patients' neurological functions or the hematomas are large and exerted severe mass effects.

Endoscope-assisted, minimally invasive evacuation of sub-acute/chronic epidural hematoma: Novelty or paradox of Theseus?

BACKGROUND

Sub-acute/chronic epidural hematoma (EDH) may present with nagging symptoms of headache, nausea, vomiting, lethargy, etc. We attempted to offer a minimally invasive, single burr hole, endoscope-assisted evacuation of EDHs instead of a conventional craniotomy.

METHODS

Seven patients with sub-acute/chronic EDH (six supratentorial and one infratentorial) presented to us 3 to 7 days after low-velocity road traffic accidents with complaints of headache and lethargy. The EDH volumes measured between 20 to 50 ml, and the patients were operated on using a single burr hole made through a small incision. We used 0-, 30- and 70-degree, angulated, rigid, high-definition endoscopes to identify and evacuate the organized clots in the extradural space. Flexible catheters were used for suction and irrigation. After achieving hemostasis, the dura was hitched back to the burr hole site. The wound was closed over a negative suction drain.

RESULTS

All patients had prompt recovery from symptoms. Postoperative CT scans showed complete or near complete evacuation of the hematomas. The hospital stay and analgesic requirements were minimal. There was no infective complication or conversion to conventional open surgery. The average time for surgery was 77.8 min, and average blood loss was 328.5 ml.

CONCLUSION

Endoscope-assisted evacuation of sub-acute/chronic EDH is a novel concept, which offers quick relief from symptoms in a minimally invasive fashion and a cosmetically acceptable way. None of the standard principles of surgery are hampered. It avoids extensive dissection of the temporalis or sub-occipital muscles. However, achieving hemostasis can be difficult. Further study and better equipment will validate the procedure.

A tale of two acute extradural hematomas

Background:

In much of the Western hemisphere, mortality from traumatic acute extradural hematomas (AEDH) has been drastically brought down toward 0%. This is still not the case however in most developing countries.

Case Description:

This report represents a tragi-comic tale of two cases of traumatic AEDH managed by an academic neurosurgeon in a neurosurgically ill-resourced private health facility during a nationwide industrial strike action preventing clinical-surgical care in the principal author's University Teaching Hospital. A young man presented with altered consciousness, Glasgow Coma Score (GCS) 14/15, following a road accident. The cranial computed tomography (CT) scan was obtained only 9 h after its request, long after the man had actually deteriorated to GCS 7/15 with pupillary changes. The neurosurgeon, summoned from the nearby University Teaching Hospital for the operative care of this man, arrived on-site and was about moving the patient into the operative room when he took the final breaths and died, all within 2 h of the belated neuroimaging. This scenario repeated itself in the same health facility just 24 h later with another young man who presented GCS 7/15 and another identical CT evidence of traumatic AEDH. With more financially able relations, the diagnostic/surgical care of this second patient was much more prompt. He made a very brisk recovery from neurosurgical operative intervention. He is alive and well, 5-month postoperative.

Conclusions:

In most low-resourced health systems of the developing countries, a significant proportion of potentially salvageable cases of AEDH still perish from this disease condition.

Gradual and controlled decompression for brain swelling due to severe head injury

Patients suffering from uncontrollable intracranial hypertension due to posttraumatic brain swelling (BS) generally either die or survive in an extremely disabled state. Decompressive craniectomy (DC) with dural augmentation may be the best method to assist these patients. However, the efficacy of DC on functional outcomes remains controversial. One of the factors contributing to poor outcomes could be intraoperative brain extrusion, which is an acute potential complication of DC. The authors have adopted a new surgical technique for traumatic BS that can prevent and control massive intraoperative BS (IOS). In the past 3 years, the authors have used a unique technique, called "gradual and controlled decompression", in the treatment of posttraumatic BS. This procedure consists of creating numerous small dural openings and removing clots; enlarging fenestration in the frontal and temporal basal regions to detect and treat brain contusion; making U-shaped, discontinuous, small dural incisions around the circumference of the craniotomy; and performing an augmentation duraplasty through the discontinuous small opening with dural prosthetic substances. This technique has been employed in 23 patients suffering from posttraumatic BS. In all cases, IOS was prevented and controlled through gradual stepwise decompression, and expanded duraplasty was performed successfully. This new surgical approach for posttraumatic BS can prevent severe extrusion of the brain through the craniotomy defect and allows the gradual and gentle release of the subdural space. Further clinical studies should be conducted to estimate the impact of this new technique on morbidity and mortality rates.

Traumatic extradural hematoma in enugu, Nigeria

Aim:

Acute traumatic extradural hematoma (EDH) is life threatening and requires prompt intervention. This is a study of incidence and outcome of consecutive patients with EDH managed in Enugu, Nigeria against a background of delayed referral.

Materials and Methods:

We retrospectively examined all consecutive trauma cases managed between 2003 and 2009 and analyzed patients with acute traumatic extradural hematoma in isolation or in combination with other intra cranial lesions. Age, sex, cause of injury, time of presentation, Glasgow Coma Score (GCS), pupil reactivity, treatment and clinical outcomes were determined.

Results:

Of 817 head injuries, 69 (8.4%) had EDH, a mean of 9.9 patients per year. Males were 57 (83%) and females 12 (17%). Peak age incidences were the second and third decades of life, with a mean age of 30.2 years. Causes were road traffic accidents (57%), assault (22%) and falls (9%). Twenty-six (38%) patients presented within 24 h of injury and only one patient presented within 4 h. The average time lag before presentation was 94.2 h. At presentation 39% had GCS of 13-15, 27% had 9-12 and 34% had 3-8. The most common location of hematoma was temporal (27.5%). Forty (59%) patients had surgery while 14 (20%) were managed conservatively. Ten patients (14.5%) died and of these 70% had GCS <8 and 60% had a seizure.

Conclusion:

We conclude that early appropriate treatment of EDH results in good high quality survival (Glasgow Outcome Score 4 or 5). Low GCS should not be an absolute contraindication for surgery. Seizure prophylaxis should be considered in patients with GCS <8.

Burr-hole drainage for the treatment of acute epidural hematoma in coagulopathic patients: a report of eight cases

Craniotomy has been accepted as the treatment of choice for the management of acute epidural hematomas (AEDH). However, in practice, it seems possible to evacuate AEDH via a single burr hole instead of the traditional craniotomy in certain circumstances. Among 160 patients with AEDH meeting criteria for evacuation admitted to the emergency and accident division of our center between 2006 and 2009, we found 8 cases of hematoma appearing isodense to brain parenchyma on computed tomography (CT), who had concomitant coagulopathy. These patients were managed by burr-hole drainage for treatment of the liquefied AEDH. A closed drainage system was then kept in the epidural space for 3 days. In all 8 patients, AEDH was evacuated successfully via burr-hole placement over the site of hematoma. The level of consciousness and other symptoms improved within the first day, and no patient required an additional routine craniotomy. For patients with slowly-developing AEDH in the context of impaired coagulation, burr-hole evacuation and drainage might be a less invasive method of treatment compared to conventional craniotomy.

Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma

OBJECTIVES

The patient with epidural hematoma and cerebral herniation has a good prognosis with immediate drainage, but a poor prognosis with delay to decompression. Such patients who present to nonneurosurgical hospitals are commonly transferred without drainage to the nearest neurosurgical center. This practice has never been demonstrated to be the safest approach to treating these patients. A significant minority of emergency physicians (EPs) have advised and taught bedside burr hole drainage or skull trephination before transfer for herniating patients. The objective of this study was to assess the effect of nonneurosurgeon drainage on neurologic outcome in patients with cerebral herniation from epidural hematoma.

METHODS

A structured literature review was performed using EMBASE, the Cochrane Library, and the Emergency Medicine Abstracts database.

RESULTS

No evidence meeting methodologic criteria was found describing outcomes in patients transferred without decompressive procedures. For patients receiving local drainage before transfer, 100% had favorable outcomes.

CONCLUSIONS

Although the total number of patients is small and the population highly selected, the natural history of cerebral herniation from epidural hematoma and the best available evidence suggests that herniating patients have improved outcomes with drainage procedures before transport.

Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly

BACKGROUND

Blunt head trauma patients who have been alert but are deteriorating (talk and deteriorate [T&D]) due to a rapidly expanding epidural hematoma (EDH) usually have poor outcome if they must wait for hospital transfer for evacuation. We therefore have continued to teach skull trephination to emergency physicians (EPs). We are unaware of any literature on EP trephination for EDH in the age of computed tomography (CT) scanning.

METHODS

Patients with EDH from blunt trauma, either in our institution or known to our graduate network, who were T&D with anisocoria despite intubation plus medical therapy, and who had pre-transfer EP trephination, were compared to those who were transferred without trephination.

RESULTS

There were 5 patients with blunt trauma and CT-proven EDH who were T&D with anisocoria who underwent Emergency Department (ED) trephination at outlying hospitals before transfer. All 5 had improvement in condition and good outcomes. Three had complete recovery without disability and 2 others had mild disability with good cognitive function. None had complications. Two patients with T&D and anisocoria were transferred without trephination. Both had good neurologic outcomes. The mean time to pressure relief in the trephination group vs. transfer group was 55 vs. 207 min, respectively.

CONCLUSION

In T&D patients with CT-proven EDH and anisocoria, ED skull trephination before transfer resulted in uniformly good outcomes without complications. Time to relief of intracranial pressure was significantly shorter with trephination. Neurologic outcomes were not different.

Thrombolytic evacuation of post-craniotomy epidural haematomas using closed suction drains: a pilot study

BACKGROUND

As an effective treatment for post-craniotomy epidural haematomas (EDHs), a novel method of urokinase instillation using a closed suction drain is presented and the procedure feasibility and outcomes assessed.

METHOD

A closed system, comprising a closed suction drain with a three-spring 200 mL evacuator, fluid bag with urokinase, and syringe, was constructed to instill urokinase and evacuate a postoperative EDH. Nine patients with a symptomatic, localised EDH under a bone flap after a craniotomy underwent successive urokinase instillation following the proposed protocol. Measurement of the EDH volume and clinical evaluation were performed.

FINDINGS

An improvement of computerised tomography findings and clinical state after urokinase instillation was observed in all patients. Six urokinase instillations lasting 12 h in 6 patients with an EDH (18.2 +/- 2.4 mL) and 12 urokinase instillations lasting 24 h in the other 3 patients with an EDH (33.0 +/- 7.9 mL) succeeded in achieving a minimal residual EDH (6.1 +/- 2.8 mL). The EDH volume decreased at a rate of 13.0 +/- 2.3 mL/12 h. The GCS scores increased immediately after thrombolytic evacuation of the EDHs in 6 out of the 9 patients. For the other three patients who did not show a change of GCS score, the severe headaches were improved. All the patients were successfully treated using the proposed technique with no procedural complications such as haemorrhage or infection in the operative wound.

CONCLUSIONS

This pilot study demonstrated that thrombolytic evacuation of a post-craniotomy EDH using a closed suction drain is feasible without complications and may be associated with better outcomes.

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.