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

Acta Neurochir (Wien) (1997) 139:273-278 Acta Neurochirurgica �9 Springer-VerIag I997 Printed in Austria

Prognostic Factors in Severely Head Injured Adult Patients with Epidural aaematoma's

F. Servadei

Division of Neurosurgery, Ospedale M. Bufalini, Cesena, Italy

Summary A medline search back to 1975 was undertaken to identify rele-

vant 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, tn 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.

Keywords: Epidural haematoma; severe head injury; prognosis.

L Overview

Epidural haematoma is a well recognized surgical complication of head trauma. Mortality and morbidity could potentially approach zero if the patient is treated in a non comatose condition [2]. In the pre CT era patients sent to neurosurgery for treatment in a comatose condition constituted from 70% [24] to 90% [ 14] of all cases of extradural haematoma. At the beginning of the CT era comatose patients were still 60% of the case material published [7]. The increased availabitity of CT scanners has since then produced a decrease of the proportion of patients comatose at treatment to 41% [2], 35% [36] and 34% [6].

Patients harbouring epidural haematoma's (EDH) operated on in a comatose condition include patients in coma from the time of impact and patients with secondary deterioration to coma due to brain compression. Patients with direct onset of coma may present associated signs of diffuse axonal injury [32, 35]

due to high speed trauma's [22] and a significant proportion willl have associated intradural lesions (subdural haematoma, intracerebral posttraumatic damage and hemispheric swelling). The clinical course in these cases is variable and the outcome in most cases related to primary and secondary brain damage [15]. Patients showing the classic "lucid interval" usually have "pure" EDH's [31] with higher haematoma volumes and CT signs of active bleeding [22]. Prog- nosis in this group is related to degree and duration of brain compression and consequently entirely depends on early diagnosis and subsequent haematoma evacu- ation. Protocols on early diagnosis and management of low risk head injured patients have been shown to improve both mortality and morbidity in patients with epidural haematoma and coma, following clinical deterioration [37, 41]. Analysis of the overall treatment results in patients in coma with epidural haematoma is complicated by the policy of referral hospitals. If patients whose injury looked hopeless are not sent to the neurosurgical centre [9] the reported results from these centres will underestimate mortality and morbidity and will not represent the overall population results. Only a few papers [37, 38] have reported a referral area survey in the period of data collection. The aim of the present review is to evalu- ate relative prognostic criteria in patients comatose after head injury with an epidural haematoma and to formulate recommendations for improvement of therapy and suggestions for future research.

II. Process

A Medline search back to 1975 was undertaken using the following query: epidural hematoma,

274 F. Servadei: Severely Head Injured Adult Patients with Epidural Haematoma's

epidural haematoma, extradural hematoma, extradural haematoma and head injury and human subject. This produced 586 references. Only English language literature was reviewed, We narrowed down the Med- line list excluding case reports, papers dealing only with children and papers not including comatose patients. We reviewed the remaining papers and found 44 relevant reports. Most of the papers did not permit separate analysis of comatose and non comatose patients, It was difficult to rate the relative value of the identified parameters as only very few papers reported results on multivariate analysis (4 papers).

III. Scientific Foundation

The following parameters were found to be relevant in terms of prognosis:

(a) age (15 papers); (b) clinical pm:ameters, including aetiology and delay in referral/treatment (31 papers); (c) CT findings (18 papers); (d) ICP monitoring (3 papers),

Age

There is a clear tread towards a better outcome in younger age groaps [I, 7, 8, i3, 20, 22, 23, 30, 31, 36], but statistical significance was shown only in two papers [16, 38]. In two reports no significant relationship between age and outcome was found [19, 35]. Epidural haematoma's are uncommon in elderly patients [10] because of the strong adherence of the dura to the inner skull, Published casistics seldom contain more than 10% of patients aged over 50 years [1, 7, 8, 23] and the lack of statistical significance of the association between age and outcome for evacuat- ed epidural haematoma's is probably due to the small number of elderly patients [23]. No statistically significant difference concerning age was found between immediately comatose patients and those with a lucid interval [36]. The relationship between age and outcome is influenced by the incidence of associated intradural lesions: only 20% of patients aged 20 or less had associated intradural lesions, whereas such lesions were present in 80% of the patients over 60 years of age [15]. Another factor aged related is the timing of surgical intervention: Rivals e ta l , [31] report that 59% of patients <_20 years of age are operated within 12 hours after injury and 92% of patients older than 20 years. These data suggest a more active bleeding in patients over 20 years of age,

Cl in ica lparameters (including aetiology and delay in referral and treatment)

Cause o f trauma, A poor correlation was found between trauma aetiology and outcome [ t9, 35, 38], Fa~ls as a mechanism of trauma were related with a worse prognosis [22] but Ibis is due to the influence of age (fall was the first cause of trauma over 60 years). High speed trauma's usually produce an immediate coma and concomitant diffuse axonal injury [31].

Time to treatment. The factor of the influence of the time of treatment on prognosis is difficult to examine. There is a clear influence if we take into account the delay between the nine of clinical deterioration and the time of surgery: the earlier intervention allows better results [26, 29]. On the other hand when we only consider time from injury to treatment, the outcome is paradoxycally better [13, 20, 22, 28, 30] in patients treated 12-24 hours or more after injury.

If the cut-off point is anticipated at two hours, the phenomenon is reversed with a better outcome in those treated within two hours [12]. Patients treated within the first posttraumatic hours have a more active Needing as also shown by the CT features of the haemaloma, including a larger volume [22]. Those cases presenting later have smaller volumes and a less active bleeding source allowing better outcomes. No deaths were recorded when the symptoms appeared more than 24 hours after injury [20]. Evalu- ation of the influence of time to treatment is complicated by factors related to referral policy [3], criteria for CT scanning and the percentage of patients admidded directly to the neurosurgical centre, which can vary from 5% [36] to 30% [2], 38% [28] and to 68% [29].

Immediate coma or lucid interval. The question is if the presence of an immediate coma or the occur-

Table 1. Mortality in Comatose Patients with Epidural Haema- toma's with a Coma of Immediate Onset and Following a Lucid Interval

Authors, years % Morta[ity~ [ramediate coma Lucid interval

Jones [16] 1991 61 24 Cordobes [7] 1981 50 15 Phonprasert [28] 1980 50 18

F. Servadei: Severely Head Injured Adult Patients with Epidural Haematoma's 275

rence of coma after a period of lucid interval influ- ences outcome. The percentage of patients with

immediate coma varies in the different series from 77% [35] to 57% [36], 50% [31] and 45% [22], thus

making it difficult to compare the outcome of comatose patients with epidural haematoma without knowledge of the clinical course of the patients. The level of coma was found to have more relevance than the clinical history [36]. A few comparable studies (Table 1) showed a statistically worse mortality between patients with immediate coma and those ones with coma after a period of lucid interval. The bad outcomes occurring in patients with a coma of immediate onset do not relate only to early diagnosis

and treatment, but result from other associated brain injuries.

Pupillary abnormalities. Pupillary abnormalities are associated with a significantly worse outcome

[6-8, 16, 28, 38]. Mortality increased from 17.5% in cases with midriasis ipsilateral to the haematoma to

100% in patients with bilateral fixed pupils [7]. Loba- to et al. [22] demonstrated in a series of comatose patients a mortality of 11% in patients with midriasis ipsilateral to the haematoma and of 82% when bilateral midriasis was present. Phonprasert et al. [28] reported that patients with bilateral dilated and fixed pupils had a mortality rate four times higher than

those with unilateral dilated ones. A recent paper [34] showed that out of 11 patients with an epidural haematoma and bilateral fixed pupils at treatment, six (55%) made a good recovery. Only when bilateral fixed pupils were associated with no response to painful stimula was the outcome always bad. Rivas [31] did not find a significant difference when outcome in comatose patients was related to ipsilateral

midriasis whereas there was a significantly worse outcome in the cases whith contralateral midriasis and

with bilateal fixed pupils. In order of severity concerning prognosis, the clin-

ical parameters were: one dilated pupil, hemiparesis, haemiparesis and one dilated pupil, decortiction, decerebration, both pupils fixed [2].

GCS/motor score. There is a highly significant correlation between outcome and GCS/motor score [2, 6, 19, 23, 31, 36] at treatment. The presence of hemiparesis at treatment did not influence the outcome [31] unless it was associated with controlateral midriasis [2]. Patients treated with a GCS of 3-5 pre-

sented bad outcomes (including SD, PVS and D at the

GOS) in 41% [22], 60% (but only including GCS

3-4) [2] and 68% [35]. Patients treated with a GCS of 6-8 presented bad outcomes as above mentioned in 12% [22], 20% (only GCS 5-7) [2] and 31% [35]. Even patients with a GCS of 3 at treatment may have

a chance of good outcome when harbouring "pure" epidural haematoma's. In a series of 111 adult patients treated with a GCS of 3, only those with epidural haematoma had a chance of good outcome [18].

CT Findings

Haematoma volume and site. No correlation was found between haematoma localisation and outcome [19, 22, 31, 36] and no correlation was present between haematoma location and clinical presentation [22, 31, 36]. These results are in contrast with those ones of the preCT are when temporal haematoma's were believed to carry the worst prognosis [10, 25]. Haematoma volume correlated well both with the clinical presentation and with the outcome [22, 31, 36]. Bad outcomes were 20% in patients with clots's volume < 150 cc and 58% with a volume >150 cc, with a statistical significance [22]. Nevertheless, good outcomes are rare but still possible with haematoma volumes exceeding 200 cc [22, 27].

Midline shift. Midline shift also correlated well with clinical presentation and outcome [31, 36]. Lobato et al. [22] found that the relationship was significant only at extreme values when comparing a midline shift of 4 mm versus a shift of more than 12 mm. The outcome did not differ in the intermedi- ate values. Patients showing a midline shift of more than 10 mm have 39% chance of bad outcome [36] versus a 12% when the shift was less than 10 mm. All

the patients with a shift of the midline over 12 mm were found to have at treatment a GCS of 6 or less [5]. Only in the paper by Seelig et al. [35] midline shift was not correlated with outcome.

Active haematoma bleeding. Active haematoma bleeding on CT as described by Zimmermann et al. [44] (presence of heterogenous haematoma with mixed high-low CT density) was reported to influence prognosis. Patients with heterogenous clots had a poorer outcome [31] when compared with those with homogeneous clots.


Assoc ia t ed intradural lesions. Presence of intradural associated lesions also influenced outcome [12, 15, 16, 19, 22, 31, 38]. Only two reports did not confirm this relationship [35, 36]. Jamjoom et al. [15] compared two series of patients with and without intradural lesions and showed with a statistical significance that patients with intradural lesions were older, had more falls as a mechanism of injury, had a lower GCS score at treatment and presented more extracranial injuries. Rivas et al. [31] showed that the influence on outcome of intradural pathology was due to the presence of hemispheric swelling and of multifocal brain contusions. These lesions were seen only in deeply comatose patients.

Haselberger et aI. [12] demonstrated that patients with "pure" epidural haematoma's had a good outcome of 70% as compared to 44% of those with associated intradural lesions. Phonprasert [28] reviewing cases operated in the preCT period showed that mortality was 37% in the case of associated subdural haematoma and 17-25% in the case of associated contusion/laceration.

When studying the influence of associated lesions on outcome we have to consider the definition of "principal diagnosis". Many papers[2, 36] refer to that one of Gennarelli et al. [ 11 ]: "patients grouped as epidural haematoma's had their surgery performed because of the epidural clot. Another lesion might have been treated surgically at operation or may be present on CT scan". The interpretation of this assumption is subjective: it is possible that a comatose patient wiht signs of DAI operated because of a small epidural haematoma is included in the group of epidural haematoma patients hence altering the outcome of the whole series. Among 22 comatose patients with EDH without associated lesions, 17 (77%) had a lucid interval compared to only three out of 12 (25%) patients who exhibited concomitant brain injuries on CT [12].

I C P

The mortality rate was significantly higher (p<0.001) with a postoperative ICP over 35 mm Hg [22]. Patients with elevated ICP presented at CT scan ipsilateral or contralateral bulk enlargement of a cere- bral hemisphere (seven patients), multifocal brain contusions (four patients) and diffuse brain swelling (four patients). In a series of 17 patients operated for an epidural haematoma, only those five cases with a postoperative acute hemispheric swelling had their

ICP values over 35 mm Hg [21]. ICP persistently over 20 mm Hg was observed in a study only in patients with associated intracerebral lesions [7]. Preoperative ICP monitoring should be regarded as not totally reliable in patients harbouring epidural haematoma's [33]: out of five monitored patients, in three cases ICP values remained stable at 10-20 mm Hg in spite of marked haematoma enlargement. In the remaining two the ICP showed a sharp increase after a period of stability. Serial CT scan examinations are required together with ICP monitoring for detecting new epidural haematoma or enlargement of previous- ly identified ones in comatose patients. To such respect, two factors appear to be of most importance: time elapsed from trauma to CT examination (epidural haematoma's detected within six hours from injury present a higher rate of evolution [17, 39]) and the presence of hypotension in a polytrauma patient at the time of the first CT examination [4].

Discussion and Conclusion

Patients harbouring pure "active bleeding" epidural haematoma's should be treated in the nineties before clinical deterioration and coma. Protocols for management of mild and minor head injuries applied in an area are effective in detecting the epidural clot in an asymptomatic phase. The mortality of such cases (now ranging from 15 to 24%) with the diffu- sion of CT scanners should be close to 0. Unfortu- nately this is not the case: mortality and morbidity in the last years did not improve dramatically [35, 40]: it was from 33% to 54% in studies of the preCT era [10, 13, 14, 24] and it is from 14% to 41% (excluding patients travelling long distances as in Dan et al. [8]) in the CT era (Table 2). Resources of additional CT scans in periferal hospitals are unfortunately not directed at the head injury population. Only too often are mild head injury patients at risk for epidural haematoma's observed waiting for clinical deterioration before appropriate CT examination and referral to neurosurgical centres. Bricolo and Pasut [2] reported the highest mortality in cases showing clinical deterioration in whom a CT scan was obtained in a community hospital before transfer to neurosurgery. Aim of the European neurosurgeons must be to lead the process of developing guidelines for management of "low risk" patients together with emergency physi- cians, radiologists, neurologists, pediatricians and intensivists as has recently been done in Great Britain

F. Servadei: Severely Head Injured Adult Patients with Epidural Haematoma's 277

Table 2. Mortality and Favourable Recoveries (GOS: GR and MD)

in Comatose Patients with Epidural Haematoma's; Data from CT

Era

Authors, years % Mortality % Favourable recoveries

Phonprasert [28] 1980 24 na Cordobes [7] 1981 26 na Oennarelli [11] 1982 (GCS 3-5) 36 34 Gennarelli [11] 1982 (GCS 6-8) 9 83 Bricolo [2] 1984 14 76 Seelig [41] 1984 41 54 Reale [30] 1984 27 na Dan [8] 1986 59 na Haselsberger [12] 1988 38 38 Lobato [21] 1988 28 68 Servadei [37] 1988 27 54 Marshall [23] 1991 18 47

na not available.

[42] and Italy [43]. Acco rd ing to these reports a CT

scan is manda tory in the presence o f a skull fracture

in adult age [42, 43] and it should be pe r fo rmed

w h e n e v e r poss ible in all minor head injured patients

[43].

M o r e detai led informat ion is requi red on ou tcome

of epidural h a e m a t o m a patients not only in the neuro-

surgical centre but also in the referral area of the spe-

c ia l ized hospital , as wel l as the informat ion about the

percen tage of patients with c l inical deter iorat ion and

the number o f direct admissions. Only with the

knowledge o f the above men t ioned parameters will

we be able to compare di f ferent publ i shed casistics,

conf i rm the va lue of early diagnosis and adequate

referral policy, and improve on organiza t ional aspects

of neuro t rauma care.

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Comment The author has to be commended on he has performed this

analysis on a selection of papers drawn from a total of about 1000 papers. His personal experience is remarkable and the reviews are interesting. They are performed for the Brain Trauma Foundation (New York) and part of what is reported here in these articles (with permission of the B.T.F.) will form a chapter of a book devoted to the guidelines for managing head injured patients which will be published by the same Foundation.

Editorial Comment

Correspondence: F. Servadei, M. D., Division of Neurosurgery, Ospedale M. Bufalini, Viale Ghirotti 286, Cesena 47023, Italy.

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

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