Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study

Abstract

Background and objectives: Guideline recommendations for surgical management of traumatic epidural hematomas (EDHs) do not directly address EDHs that co-occur with other intracranial hematomas; the relative rates of isolated vs nonisolated EDHs and guideline adherence are unknown. We describe characteristics of a contemporary cohort of patients with EDHs and identify factors influencing acute surgery.

Methods: This research was conducted within the longitudinal, observational Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury cohort study which prospectively enrolled patients with traumatic brain injury from 65 hospitals in 18 European countries from 2014 to 2017. All patients with EDH on the first scan were included. We describe clinical, imaging, management, and outcome characteristics and assess associations between site and baseline characteristics and acute EDH surgery, using regression modeling.

Results: In 461 patients with EDH, median age was 41 years (IQR 24-56), 76% were male, and median EDH volume was 5 cm 3 (IQR 2-20). Concomitant acute subdural hematomas (ASDHs) and/or intraparenchymal hemorrhages were present in 328/461 patients (71%). Acute surgery was performed in 99/461 patients (21%), including 70/86 with EDH volume ≥30 cm 3 (81%). Larger EDH volumes (odds ratio [OR] 1.19 [95% CI 1.14-1.24] per cm 3 below 30 cm 3 ), smaller ASDH volumes (OR 0.93 [95% CI 0.88-0.97] per cm 3 ), and midline shift (OR 6.63 [95% CI 1.99-22.15]) were associated with acute surgery; between-site variation was observed (median OR 2.08 [95% CI 1.01-3.48]). Six-month Glasgow Outcome Scale-Extended scores ≥5 occurred in 289/389 patients (74%); 41/389 (11%) died.

Conclusion: Isolated EDHs are relatively infrequent, and two-thirds of patients harbor concomitant ASDHs and/or intraparenchymal hemorrhages. EDHs ≥30 cm 3 are generally evacuated early, adhering to Brain Trauma Foundation guidelines. For heterogeneous intracranial pathology, surgical decision-making is related to clinical status and overall lesion burden. Further research should examine the optimal surgical management of EDH with concomitant lesions in traumatic brain injury, to inform updated guidelines.

Trial registration: ClinicalTrials.gov NCT02210221.

FIGURE 1.

Concomitant radiologic findings on the first scan in participants with EDHs. The boxed area represents the subgroup we defined as isolated (133 participants), meaning no concomitant ASDHs and/or IPHs, which are space-occupying lesions that may warrant surgical intervention on their own. By this definition, isolated EDHs included cases with coexisting TSAH but also with other intracranial traumatic findings not represented here, such as intraventricular hemorrhage and traumatic axonal injury, meaning that radiologic “pure” EDHs are even more infrequent. Abbreviations: ASDH, acute subdural hematoma; EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; TSAH, traumatic subarachnoid hemorrhage.

FIGURE 2.

Surgical care pathways of participants with EDHs, by presence of concomitant acute subdural hematomas and/or IPHs on the first scan. A, Participants with isolated EDHs (n = 133). Most of the isolated EDHs had volumes <15 cm³ (103 participants, 77%), most of which were treated conservatively throughout the entire clinical course (96 participants, 93%). Participants with isolated EDHs between 15 and 30 cm³ received either initially conservative treatment (7 participants, range EDH volumes 16-28 cm³) or early targeted EDH evacuation (4 participants, range EDH volumes 15-19 cm³, motivated by mass effect on computed tomography, or clinical deterioration). Most participants with isolated EDHs ≥30 cm³ received early targeted EDH evacuation (15 participants, 79%). Early targeted EDH evacuation was used after the first scan in 22 participants with isolated EDH (17%), with a median EDH volume of 54 cm³, IQR 18 to 110. Seven participants with isolated EDH who were not operated directly after the first scan (motivated by guideline adherence, little/no mass effect, no surgical lesion, or acceptable/good neurologic condition) later received delayed targeted EDH evacuation. In these, repeat scanning revealed hematoma enlargement, with a median EDH volume of 26 cm³ on the first scan and 44 cm³ on the last follow-up scan before surgery. Two participants received EDH evacuation during surgery for another indication, one in the early phase, for depressed skull fracture elevation (3 cm³ EDH), and the other during evacuation of a delayed large contusion. B, Participants with nonisolated EDHs (n = 328) Most of the nonisolated EDHs had volumes <15 cm³ (225 participants, 69%), most of which were treated conservatively throughout the entire clinical course (169 participants, 75%). Participants with nonisolated EDHs between 15 and 30 cm³ received either initially conservative treatment (42%, median EDH volume 21 cm³, IQR 17-22), early targeted EDH evacuation (42%, median EDH volume 23 cm³, IQR 21-26), or surgery for another main indication. Most participants with nonisolated EDHs ≥30 cm³ received early targeted EDH evacuation (55 participants, 82%). In the early clinical course, after the first scan, a third of participants with nonisolated EDH received a surgical intervention. Early targeted EDH evacuation was used in 77 participants (23%), with a median EDH volume of 46 cm³, IQR 29 to 78. Early nontargeted EDH evacuation was performed in 11 participants, during surgery for another main indication: ipsilateral ASDH evacuation or DC, elevation of adjacent depressed skull fracture. Early craniotomies/DCs for other indications, during which the EDH was not evacuated, were performed in 23 participants, who received contralateral ASDH evacuation/DC, supratentorial ASDH evacuation/DC (in participants with posterior fossa EDHs), ipsilateral ASDH evacuation/DC (EDH outside craniotomy window). Various delayed surgical interventions were used in 33 participants with nonisolated EDHs who initially received conservative management. Delayed targeted EDH evacuation was used in 21 participants, with a median EDH volume of 18 cm³ on the first scan and 44 cm³ on the last follow-up scan before surgery. ASDH, acute subdural hematoma; DC, decompressive craniectomy; EDH, epidural hematoma; IPH, intraparenchymal hemorrhage. Targeted EDH evacuation: EDH evacuation was the main surgical indication; Nontargeted EDH evacuation: EDH evacuation performed, but was not the main surgical indication; Craniotomy/DC, no EDH evacuation: craniotomy or DC for ASDH and/or IPH evacuation/decompression, during which the EDH was not evacuated; Initially conservative: initial nonsurgical management strategy after the first scan; Conservative: no major intracranial surgery throughout the entire clinical course.