Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma

Abstract

Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.

Factors affecting the surgical outcome of patients with cerebral contusions

“…Lobato RD et al in their study found a mortality of 28.1%. 10 In the present study it is seen that age more than 30 years, severe GCS and midline shift of more than 5 mm were the important predictors of mortality after surgery for cerebral contusions. The risk of death was 3.8 times more for those who were more than 30 years of age and this was found to be statistically significant (p < 0.05).…”

The surgical outcome of traumatic extraaxial hematomas causing brain herniation

“…Initial GCS scores have been reported to be a good predictor of outcome for patients both with EDH (4,5,15,20,22,23,43,45) and with SDH (6,7,29,33,42). In our study, almost all patients with herniated extraaxial hematoma were comatose and had GCS scores equal to or lower than 9.…”

Traumatic Extradural Hematoma Overview, Clinical Study and Management

“…Associated intracranial lesions such as SDH intracerebral hematoma, cerebral contusion have a detrimental effect on outcome and result in a mortality rate four times greater than in patients without such lesions. Increased age, poor neurological condition, large hematoma volume, delay in operative evacuation, large midline shift, and postoperative elevation in ICP are all associated with poor outcome (Phonprsert et al, 1980;Lobato et al, 1988;Ali et al, 1984).…”