Traumatic Epidural Hematoma Research Articles

Vertebral artery dissection as an extremely rare cause of spinal epidural hematoma: case report and review of the literature

To present a patient with a cervico-thoracic ventrally located epidural hematoma caused by dissection and subsequent bleeding of the cervical portion of the vertebral artery. Non traumatic epidural hematoma is a rare entity. The etiology usually is not clarified: a venous origin is usually suspected although an arterial source is also possible. A 32-year-old woman presented with a ventrally located cervico-thoracic epidural hematoma caused by non traumatic dissection and dissecting aneurysm rupture of the cervical portion of the vertebral artery. The dissection was demonstrated by magnetic resonance imaging and digital subtraction angiography. The patient had no neurological symptoms and was treated by conservative methods. Follow up imaging showed healing of the vertebral artery and resorption of the epidural hematoma. Dissection of the cervical portion of the vertebral artery with subsequent perivascular bleeding is not well recognized as a possible cause of a spinal epidural hematoma. Even though this entity and the underlying cause may be rare, we suggest a vigilant search for vertebral artery injury in cases of ventrally located cervical and upper thoracic epidural hematoma.

Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience.

Acute epidural and subdural haematomas remain among the most common causes of mortality and disability resulting from traumatic brain injury. In the last three decades improvements in rescue, neuromonitoring and intensive care have led to better outcomes. The purpose of this study was to evaluate the impact of these strategies on outcome in patients treated in a single institution in Switzerland. A total of 76 consecutive patients who underwent emergency craniotomy for acute traumatic epidural and subdural haematoma at University Hospital Bern between January 2000 and December 2003 were included in this study. Thirty-seven patients presented with an epidural haematoma and 46 with a subdural haematoma. In seven patients both haematomas could be documented. The median age was 54 years (IQR 28). The median initial GCS score was 7 (IQR 6). The median time from primary injury to surgery was 3 hours (IQR 2.5 hours). The median stay in the ICU was 3 days (IQR: 3 days). The outcome was favourable (GOS 4 and 5) in 43 patients (57%). Thirteen patients (17%) remained severely or moderately disabled (GOS 3). Finally, a total of 21 patients (28%) died or remained in a persistent vegetative state (GOS 1 and 2). Mortality was 41% for acute subdural haematoma (19/46) and 3% (1/37) for patients with epidural haematoma. Only age, GCS at admission and pupil abnormalities seemed to be associated with outcome. Time to surgery was not. In patients admitted with acute traumatic epidural and subdural haematomas that are treated within a median of 3 hours after primary injury, factors such as age, initial GCS and pupil abnormalities still appear to be the most important factors correlating with outcome.

Outcome after acute traumatic subdural and epidural haematoma in Switzerland: a single-centre experience.

Acute epidural and subdural haematomas remain among the most common causes of mortality and disability resulting from traumatic brain injury. In the last three decades improvements in rescue, neuromonitoring and intensive care have led to better outcomes. The purpose of this study was to evaluate the impact of these strategies on outcome in patients treated in a single institution in Switzerland. A total of 76 consecutive patients who underwent emergency craniotomy for acute traumatic epidural and subdural haematoma at University Hospital Bern between January 2000 and December 2003 were included in this study. Thirty-seven patients presented with an epidural haematoma and 46 with a subdural haematoma. In seven patients both haematomas could be documented. The median age was 54 years (IQR 28). The median initial GCS score was 7 (IQR 6). The median time from primary injury to surgery was 3 hours (IQR 2.5 hours). The median stay in the ICU was 3 days (IQR: 3 days). The outcome was favourable (GOS 4 and 5) in 43 patients (57%). Thirteen patients (17%) remained severely or moderately disabled (GOS 3). Finally, a total of 21 patients (28%) died or remained in a persistent vegetative state (GOS 1 and 2). Mortality was 41% for acute subdural haematoma (19/46) and 3% (1/37) for patients with epidural haematoma. Only age, GCS at admission and pupil abnormalities seemed to be associated with outcome. Time to surgery was not. In patients admitted with acute traumatic epidural and subdural haematomas that are treated within a median of 3 hours after primary injury, factors such as age, initial GCS and pupil abnormalities still appear to be the most important factors correlating with outcome.

Retinal hemorrhages in patients with epidural hematomas

To present a series of infants found to have sparse retinal hemorrhages associated with isolated epidural hematomas. None of these infants had other intracranial or subdural hemorrhages present. Children less than 3 years of age admitted to an urban children's hospital between January 1998 and December 2002 with radiographic evidence of an isolated epidural hematoma at the time of presentation were eligible for this study. During the time period of the study, 15 children were admitted with traumatic epidural hematomas. Nine patients had an ophthalmologic examination, of which five had evidence of sparse retinal hemorrhages. All five patients with retinal hemorrhages were less than 8 months of age and all required surgical evacuation of the epidural hematomas. Of the five patients with retinal hemorrhages, four were unilateral, one was bilateral, and in all cases, the retinal hemorrhages were superficial, few in number, and confined to the posterior pole. There were no deep retinal or subretinal hemorrhages present. The institutional child protection team evaluated all five patients with retinal hemorrhages and each case was felt to be consistent with the history provided and no history of shaking was elicited. We found sparse retinal hemorrhages in five of nine patients who presented to our hospital with isolated epidural hematomas and who had had an ophthalmologic examination. All nine patients were evaluated by the institutional child protection team, who did not feel that there was sufficient evidence to be suspicious of nonaccidental trauma.

Drilling skull plus injection of urokinase in the treatment of epidural haematoma: A preliminary study

Primary objective: This study was performed to evaluate the effectiveness of a minimally invasive approach to manage patients with epidural haematoma (EDH). The surgical indication and key points were investigated.Research design: Descriptive, retrospective study.Methods and procedures: Twenty-one patients with traumatic EDH were treated through the following method: After anaesthesia, twist drill trepanations were performed followed by a placement of drainage tubes. Twenty ku urokinase in 3 ml saline was injected into the haematoma cyst through the tube, which was closed for 3 hours before connection to a vacuum ball with negative pressure. The injection was repeated three times a day after operation. The fibrinolytic agents were not used in the ‘acute group’ because of the risk of rebleeding. CT scans were performed according to the changes of clinical manifestations.Main outcomes and results: The drainage tubes were left for 3–5 days before most clots were resolved. The patients discharged after 7 days’ hospitalization on average. No infections or recurrence of EDHs were observed in this series.Conclusion: Drilling skull plus injection of urokinase through drainage tube is a safe and effective method with less injury in the treatment of a selected part of patients with EDHs.

Surgical treatment of a traumatic intracranial epidural haematoma in a dog

A 10-month-old Czech wolf dog was unconscious after being kicked in the head by a horse. The following day, the dog was ataxic and collapsed after several steps. The level of consciousness was decreased. Cranial nerve examination was normal and right postural reactions were decreased. Spinal reflexes were intact in all limbs. The diagnostic work-up included a computed tomography (CT) scan of the head with IV contrast. A lenticular shaped, hyperdense, non-enhancing lesion was observed in the left fronto-parietal region. A diagnosis of intracranial epidural haematoma was made. Two craniotomies were performed on a different day and most of the haematoma was removed. Corticosteroids and antimicrobial therapy were administered. Fifteen days after the surgery, the clinical examinations were unremarkable. Fifteen months later, the owners considered the dog normal. Intracranial subdural or intraparenchymal haematomas have been described in the veterinary literature. To the authors' knowledge, this is the first report of the successful management of an intracranial epidural haematoma in the dog. In humans, these lesions are well described. Common locations are temporal, parietal and frontal regions or a combination of these regions. Patients can be asymptomatic, present with varying clinical signs, or be unconscious. Based on the human literature, following trauma to the head, a CT scan should be performed even if the patient is asymptomatic. Some authors believe that there are not any absolute indications for conservative management versus surgical management.

Spontaneous extracranial decompression of epidural hematoma

Epidural hematoma (EDH) is a common sequela of head trauma in children. An increasing number are managed nonsurgically, with close clinical and imaging observation. We report the case of a traumatic EDH that spontaneously decompressed into the subgaleal space, demonstrated on serial CT scans that showed resolution of the EDH and concurrent enlargement of the subgaleal hematoma.

Retinal hemorrhages in patients with epidural hematomas

Purpose: This article presents a series of infants found to have epidural hematomas (EDHs) from accidental etiologies with associated retinal hemorrhages (RH). Methods: From January 1998 to December 2002, 15 children under 3 years of age with radiographic evidence of a traumatic epidural hematoma were found to be eligible for this study, 9 of which had eye examinations. Results: Five patients, all children less than 8 months of age and requiring surgical evacuation of the EDH, had evidence of RHs.

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Inflicted Childhood Neurotrauma: New Insight into The Detection, Pathobiology, Prevention, and Treatment of Our Youngest Patients with Traumatic Brain Injury

Recombinant activated factor VII for neurological and neurosurgical bleeding emergencies

SUMMARYThe management of central nervous system bleeding emergencies is a common clinical challenge. The most common scenarios include spontaneous intracerebral hemorrhage (ICH), aneurysmal subarachnoid hemorrhage (SAH), traumatic epidural and subdural hematomas, hemorrhagic infarction and spinal epidural bleeding. A recent phase II clinical trial demonstrated that ultra‐early hemostatic therapy with recombinant activated factor VII (rFVIIa) limits ongoing bleeding, reduces hematoma volume and improves survival and functional outcome, despite a small increase in the risk of thromboembolic complications. A definitive phase III study (the FAST [rFVIIa in Acute Hemorrhagic Stroke Treatment] Trial) is now in progress to confirm these results. A pilot trial of continuous rFVIIa infusion to prevent re‐bleeding after SAH was stopped because of concerns regarding ischemic complications related to vasospasm. Intravenous vitamin K and fresh frozen plasma are the mainstays of therapy for coagulopathic intracranial bleeding, but normalization of coagulation can take many hours, and outcomes are often unsatisfactory. Successful off‐label use of rFVIIa to stabilize patients with warfarin‐associated ICH and subdural hematoma or to expedite emergency surgery has been reported, but questions remain regarding the optimal dose for this indication. Clinical trials are urgently needed to confirm that rFVIIa can safely arrest active bleeding and expedite life‐saving emergency neurosurgical procedures in anticoagulated patients with intracranial hemorrhage.

Supratentorial epidural hematoma of traumatic etiology in infants

Traumatic epidural hematoma (EDH) represents a rare head injury complication in infants. Its diagnosis can be quite challenging because its clinical presentation is usually subtle and nonspecific. In our current communication, we present our data regarding the presentation of infants with EDH, their management, and their long-term outcome. In a retrospective study, the hospital and outpatient clinic charts and imaging studies (head CT and skull X-rays) of 31 infants with pure, supratentorial EDH of traumatic origin were meticulously reviewed. Children Coma Scale score and Trauma Infant Neurologic Score (TINS) were also reviewed. The most common presenting symptom was irritability, which occurred in 18/31 (58.1%) of our patients. Pallor (in 30/31 patients) and cephalhematoma (in 21/31 patients) were the most commonly occurring clinical signs upon admission; both signs represent signs of significant clinical importance. Surgical evacuation via a craniotomy was required in 24/31 of our patients, while 7/31 patients were managed conservatively. The mortality rate in our series was 6.5% (2/31 patients), and our long-term morbidity rate was 3.2% (1/31 patients). EDH in infants represents a life-threatening complication of head injury, which requires early identification and prompt surgical or conservative management depending on the patient's clinical condition, size of EDH, and presence of midline structure shift on head CT scan. Mortality and long-term morbidity are low with early diagnosis and prompt treatment.

Endovascular Treatment of Incoercible Epistaxis and Epidural Cerebral Hematoma

A young patient with a facial trauma after a road accident was admitted to our department with incoercible epistaxis. A CT scan showed a right pterional acute epidural hematoma (EDH). Angiography demonstrated multiple sources of bleeding of the right sphenopalatine arteries, cause of the epistaxis, and an intracranial leakage of the right middle meningeal artery, responsible for the EDH. The patient immediately underwent embolization of the right internal maxillary artery and right middle meningeal artery. The procedure stopped the epistaxis and no further enlargement of the EDH was observed, avoiding its surgical treatment. Endovascular surgery may be an effective procedure to stop the arterial meningeal bleeding sustaining acute EDH and may be a useful tool in the management of special cases of post traumatic EDH.

Cleaning of Traumatic Epidural Hematoma by Drilling Combined with Lysis with Urokinase and Drainage

目的 探讨外伤性硬膜外血肿的微创治疗方法及疗效.方法将98例符合条件的外伤性硬膜外血肿患者随机分配到传统手术治疗组和钻孔尿激酶治疗组,比较传统的骨瓣开颅血肿清除术和钻孔尿激酶灌注引流术治疗外伤性硬膜外血肿的治疗结果及疗效.结果钻孔尿激酶灌注引流术手术时间短、术中出血量少、并发症少、病人恢复快、住院时间短,与传统手术治疗组比较差异有显著性.结论钻孔尿激酶灌注引流术治疗外伤性硬膜外血肿是一种安全有效的治疗方法,值得临床推广应用。

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

Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3-5 days. CT scans were performed daily from days 1 to 5. In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8-12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.

Traumatic Spinal Epidural Hematoma-Unusual Cause of Torticollis in a Child

Traumatic spinal epidural hematoma is rare in children. The presentation could be nonspecific, leading to a delay in diagnosis. We present an infant who sustained an epidural hematoma after a "trivial" injury. The delay in diagnosis led to minor neurological deficit at 6-week follow-up. Irritability and torticollis after a neck trauma in an afebrile child should alert to the possibility of spinal cord compression. Early imaging and early decompression will minimize morbidity.

Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases

The purpose was to analyse the clinical and radiological findings, and management approaches used in 30 consecutive cases of traumatic epidural haematoma of nonarterial origin treated at one centre. Medical records for 30 patients surgically treated for epidural haematoma of nonarterial origin between 1997 and 2003 were reviewed. Epidural haematoma of nonarterial origin was diagnosed based on computed tomography (CT) and the bleeding source was confirmed intra-operatively. Admission status, outcome, fracture location, haematoma location/size/volume, and additional intracranial pathology were among the data noted. Two groups were formed for analysis: venous sinus bleeding (group 1) and other venous sources (group 2). The 30 cases accounted for 25% of the total number of traumatic epidural haematomas (n = 120) treated during the same period. The epidural haematomas of nonarterial origin locations were transverse sigmoid sinus (n = 11; 36.7%), superior sagittal sinus (n = 6; 20%), venous lakes (n = 5; 16.6%), diploë (n = 5; 0.16%), arachnoid granulations (n = 2; 6.7%), petrosal sinus (n = 1; 3.3%). There were 12 postoperative complications in 9 patients: recurrence (n = 4; 13.3% of the 30 total), pneumonia (n = 4; 13.3%), meningitis (n = 2; 6.7%), hydrocephalus (n = 1; 3.3%) and subdural effusion (n = 1; 3.3%). All recurrence cases were re-explored. Six (20%) patients died. Glasgow Outcome Scale (GOS) scores (mean follow-up 13.3 +/- 7.8 months) revealed 22 (73.3%) patients with favourable results (GOS 4-5) and 8 (26.7%) had poor results (GOS 1-3). Cases of epidural haematoma of nonarterial origin differ from the more common arterial-origin epidural haematomas with respect to lesion location, surgical planning, postoperative complications, and outcome. Epidural haematoma of nonarterial origin should be suspected if preoperative CT shows a haematoma overlying a dural venous sinus or in the posterior fossa and convexity. The sinus-origin group had a high frequency of fractures which crossed the sinuses, and this might be diagnostically and surgically useful in such cases.

Rapid spontaneous resolution of a traumatic cervical epidural haematoma

Rapid spontaneous resolution of a traumatic cervical epidural haematoma

Acute traumatic spinal epidural hematoma: imaging and neurologic outcome

The purpose of this study was to present MRI characteristics of traumatic spinal epidural hematomas (TSEHs) and to evaluate their effect on neurologic outcome. A retrospective analysis was performed of all 74 cases in which patients underwent emergent spinal MRI in the setting of acute trauma at our institution's Emergency Department between June 2002 and January 2003. MRI studies were evaluated for the presence of a TSEH. CT studies were evaluated for the presence of osseous trauma. Patient data were collected from medical records on the initial neurologic status at admission and at 6 months after injury. Twenty-seven of 74 patients had a spinal fracture and a TSEH. Twenty-five of 74 patients had a spinal fracture with no TSEH. Twenty-two of 74 patients had normal imaging studies. Six-month follow-up of neurologic status demonstrated no statistically significant difference in neurologic outcome between patients with spinal fractures and TSEH and those with spinal fractures but no TSEH. If a spinal fracture and abnormal neurologic exam are present, the neurologic outcome at 6 months is not worsened by the presence of a TSEH.

Lesión mesencefálica contralateral por hernia cerebral. Imagen en Resonancia Magnética de la Hendidura de Kernohan (Kernohan‘s Notch)

We report a case of a traumatic epidural hematoma with ipsilateral hemiparesis, due to the so-called Kernohan's notch. We document the injury with axial and coronal magnetic resonance imaging.

Traumatic epidural haematoma of the posterior fossa in childhood: 16 new cases and a review of the literature

A series of 16 children (nine males, seven females) with traumatic epidural haematoma of the posterior fossa (TEHPF) is presented. All patients had a history of mild to moderate trauma to the occiput. The causes were falls in 15 and traffic accident in one case. Four of the 16 cases had depressed fractures of the occipital bone. Surgical intervention was performed in all cases. In 14 patients the outcome was good, one patient had moderate disability and one died. Our study revealed that early diagnosis and urgent surgical intervention may give the patient a chance of total recovery and craniotomy with haematoma evacuation is an appropriate surgical technique as in the case of supratentorial extradural hematoma.