Intracranial epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome 1).
The decision to perform a surgery in a patient with a traumatic intracranial epidural hematoma can dependent on several factors (neurological status, size of hematoma, age of patients, CT findings) but also may depend on the judgement of the treating neurosurgeon 2).
The Brain Trauma Foundation (BTF) produced informative guidance on the management of EDH:
An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score. An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center.
It is strongly recommended that patients with an acute EDH in coma (GCS score < 9) with anisocoria undergo surgical evacuation as soon as possible.
This recommendation was based upon early case series and cohort studies from two decades. Within an ageing population, we now see many older patients who may accommodate greater extra-axial blood volumes. With this in Soon et al., believe the indications for surgical evacuation of EDH merit renewed consideration 3).
The size of a traumatic intracranial haematoma at the moment of diagnosis can be impressive. Haematoma thickness is an inaccurate estimator of haematoma volume, and association with patient outcome is controversial. In a study computerized volumetry of offline digitized CT scans was used to relate haematoma volume with both patient characteristics on admission and at the six months outcome.
Ninety eight patients operated upon for an epidural haematoma and 91 patients operated upon for an acute subdural haematoma were analyzed. The relative importance of clinical data, CT scan parameters, and calculated haematoma volumes was determined by multivariate analysis. Volume of the haematoma did not correlate with preoperative neurological condition or the six months outcome in either group, and consequently is not of additional prognostic value 4).
Epidural hematomas presenting with an increase in size should be operated immediately. Delayed developing EDH imply worse outcome and make adequate surveillance of high-risk patients mandatory 5).
There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma 6).
Although rare, rapid spontaneous resolution of epidural hematomas in the pediatric population has even been reported, with only seven cases in the literature. Numerous theories have been proposed to explain the pathophysiology behind these cases, including egress of epidural collections through cranial discontinuities (fractures/open sutures), blood that originates in the subgaleal space, and bleeding from the cranial diploic cavity after a skull fracture that preferentially expands into the subgaleal space 7).
Erdogan et al. describe an 8-year-old boy who had been followed up conservatively for 10 days at a local hospital due to acute epidural hematoma. A new CT revealed an expansion of the former hematoma accompanied by a thick hyperdense layer. Because the patient presented with symptoms of elevated intracranial pressure, an immediate craniotomy was performed to evacuate the hematoma. The ossified layer, which was densely adhered to the dura mater, was also completely removed. Rapid ossification and/or calcification of an epidural hematoma appearing 10 days after a head injury have not been reported previously. Possible mechanisms of rapid ossification are also discussed in relation to the present report, and the relevant literature is reviewed 8).