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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 16  |  Issue : 1  |  Page : 26-32

Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale


1 Department of Neurosurgery, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India
2 Department of Anaesthesia, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, Haryana, India

Date of Web Publication11-Mar-2019

Correspondence Address:
Arvinpreet Kour
Flat No 22, I Block, Maharishi Markandeshwar University Campus, Mullana, Ambala - 133 207, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_93_18

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  Abstract 


Aim and Objective: This study aims to evaluate the outcome of the patients operated for acute extradural hematoma (EDH). Patients and Methods: Sixty consecutive cases of acute EDH were treated at medical college hospital to assess the outcome of the patients based on their Glasgow Coma Scale (GCS), radiological assessment, and pupil size. The patients were monitored of their GCS, pupillary size, and vitals. The Glasgow outcome scale was used to evaluate patient outcome at the discharge from the hospital and after 3 months. Observation and Results: Sixty patients constituting 56 males and 4 females were the part of the study. The mean age of the patients was 23.21 years (range: 2–47 years). On an average, the patients were operated around 9.91 h after the trauma (ranging 2–24 h). Out of sixty patients, 25, 17, and 18 patients had GCS of mild, moderate, and severe groups. Prompt surgery with better care obtained us with mortality 1.6%, morbidity 21.7%, and complete recovery in 83% patients. Conclusion: We may conclude in our study that presurgical clinical findings such as sensorium of patient and pupillary status were an important indicator for surgical outcome. In most of the cases, the outcome was favorable with progressive recovery.

Keywords: Epidural hematoma, Glasgow Coma Scale, surgical outcome, traumatic brain injury


How to cite this article:
Singh A, Kour A, Bindra G S, Gehlot AK, Midha R, Nandra K. Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale. Apollo Med 2019;16:26-32

How to cite this URL:
Singh A, Kour A, Bindra G S, Gehlot AK, Midha R, Nandra K. Surgical outcome of 60 operated patients with acute extradural hematomas based on the preoperative glasgow coma scale. Apollo Med [serial online] 2019 [cited 2019 Aug 18];16:26-32. Available from: http://www.apollomedicine.org/text.asp?2019/16/1/26/253879




  Introduction Top


A road traffic accident with injury to the brain is more common in the underdeveloped and developing countries than the developed countries, where the high-velocity injuries with polytrauma are one of the leading causes with high mortality. The most common brain injuries are the concussions, contusions, acute subdural hematomas, and the extradural hematomas (EDHs).

EDH occurs as a result of bleeding between the inner table of the skull and the outer layer of the dura mater. It constitutes 1%–3%[1],[2] of all head injured patients.

EDH is a neurosurgical emergency if treated early can save the life and can have low morbidity. Its immediate threat to life was reported as early as the eighteenth century.[3],[4] The outcome of treatment was so poor at that time that Callender[5] wrote that all treatments of epidural hemorrhage were so hopeless that he advised against futile trephination of the skull. However, from the experience of Gross[6] during the battle of Shiloh, he advised immediate evacuation of EDH by trephination. With current application of the medical services, transportation, better ICU care, and availability of the neurosurgeon at the nearest hospitals, the outcome of head injured patients requiring surgical intervention has improved.[7] We at our institution tried to evaluate the outcome of the patients with EDHs by providing them the earliest treatment.

Sixty consecutive EDHs were treated at medical college hospital to assess the outcome of the patients based on their Glasgow Coma Scale (GCS),[8] radiological assessment, and pupillary size. The initial assessment was conducted in the emergency department at the time of arrival; others injuries were ruled out. The abdominal and long bone injuries patients were too included in the study, and assessed upon GCS. Cases with large contusions and with acute SDH were excluded from the study. The patients were monitored of their GCS,[9] pupillary size, and vitals.

The GCS is based on patient's response to verbal order or painful stimulus on 3 variables: eye opening (E), verbal (V), and motor (M) responses [Table 1].
Table 1: Glasgow coma scale

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In accordance to the GCS, grading of the patients was done: mild injury (GCS: 13–15), moderate injury (GCS: 9–12), and severe injury (GCS ≤8) [Table 2]. The GCS has some limitations, and that is why pediatric scoring GCS system is included for the children.
Table 2: Glasgow outcome score

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  Patients and Methods Top


Sixty consecutive cases of acute EDH were treated at our medical college hospital to assess the outcome of the patients based on their Glasgow come scale, radiological assessment, and pupillary size. The initial assessment was conducted by resident and the neurosurgeon in the emergency room at the time of arrival, and other associated injuries were ruled out. The abdominal injury or the long bony injuries were included in the study; treatments of those were done in association with respective general surgery and the orthopedic departments. Cases of acute EDH with acute subdural hematomas were excluded from the present study. The patients were monitored of their GCS, pupil size, blood pressure, pulse, and other important vitals. The patients were classified as mild (GCS: 13–15), moderate (GCS: 9–12), and severe (GCS ≤8), based on the GCS score at the time of admission to the emergency. Any further neurological deterioration was also taken into consideration. The patients were further divided into noncomatosed (GCS: 9–15) and comatosed (GCS ≤8) groups. The Glasgow outcome scale (GOS) was used to evaluate patient's outcome at the time discharge from the hospital and after a period of 3 months at follow-up. The Chi-square tests were used for statistical analysis, and P < 0.05 with 95% confident interval was considered as statistically significant.


  Results Top


Sociodemographic data

Sixty patients constituting 56 males and 4 females were the part of this study. The mean age of the patients was 23.21 years (range: 2–47 years) [Table 3]. Ndoumbe, et al.[10] in their series reported mean age of 29.56 years and 63.04% of patients were between 21 and 30 years with predominant males (94%), and accident was the cause in 70% whereas our series had 90% road traffic accidental injury.
Table 3: The age and number of the patients

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Twenty-five 25 patients of traumatic brain injury (TBI) with GCS of 13–15 [mild] had good recovery with GOS of 5. Furthermore, seventeen patients of TBI with GCS of 9–12 [moderate] had shown good recovery with GOS of 5. Although five patients with GOS of 4 had moderate disability, they were independent; their GCS at the time of admission is 2 patients with GCS of 3 and one patient each of GCS 5, 6, and 9 respectively [Table 4]. Five patients were severely disabled and were dependent.
Table 4: Grouping of the patients according to the, mild, moderate, and severe

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Radiologically 3 patients had uncal herniation with GCS of 4, 7, and 8. Two patients had subfalcine herniation with GCS of 4 each. Two of the patients had GCS of 3 with fixed dilated pupils, one had subfalcine herniation with midline shift of 16 mm and the other had midline shift of 15 mm. The patient with 16 mm herniation was operated within 5 h of the admission and had good recovery. The other patient who had 15 mm midline shift was operated after 8 h and was only one patient who died. The average time duration between trauma and the surgery in our series was 9.91 h (range: 2–24 h); the delay in the surgery was attributed to the delay in the arrival and investigations. Whereas Ndoumbe et al.[10] operated with the mean time of 78 h. Babu et al.[11] have reported similar results.

Temporoparietal location was the most frequent in our series whereas Babu et al.[11] in their series reported temporal site in 43% followed by frontal in 30% and posterior fossa in just 2% cases. The outcome of the patients in our series was better than other groups.[12]

Timely surgery in the patients creates a significant differences in the outcome of the patients. In a study carried by Rivas et al.,[13] significant differences were seen. Nnadi et al.[14] similarly showed favorable functional outcome with 83.72% recovery and the mortality of 13.95%. Rehman et al.[1] in their study found favorable outcome in 83.33% and mortality of 10%. These are almost similar to our results [Table 5]. Many authors reported mortality between 10% and 20%.[15],[16],[17],[18]
Table 5: Outcome of the extradural hematoma patients with respect to glasgow coma scale

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Radiological evaluation

In our study, all patients who were operated had supratentorial EDH with mass effect and midline shift (100%), uncal herniation in 8/60 (13.3%) patients, and 12/60 (20%) patients had subfalcine herniation [Table 6]. [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7] shows acute and hyperacute EDH.
Table 6: The herniation of brain in the noncontrast computed tomography head

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Figure 1: Acute bifrontal extradural hematoma

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Figure 2: Acute right temporal extradural hematoma with midline shift and uncal herniation

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Figure 3: Acute right frontotemporal extradural hematoma

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Figure 4: Acute left parieto-occipital extradural hematoma with midline shift

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Figure 5: Hyperacute left frontal extradural hematoma with subfalcine herniation

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Figure 6: Large left parietal acute extradural hematoma

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Figure 7: Noncontrast computed tomography of the patient showing acute extradural hematoma with midline shift

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Five of the patients had midline shift of 16–20 mm and 47 patients had shift ranging from 1 to 10 mm evident in the [Table 7]. One of the important criteria that the GCS had missed in the evaluation of the patient's outcome or the prognosis is the pupil size. 18 patients with pupillary asymmetry belonged to comatosed group [Table 8].
Table 7: The radiological shift in terms of millimeters

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Table 8: The pupillary abnormality in relation to glasgow coma scale of patients

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Sheikh et al.[19] reported mortality of 3%. They observed a difference in pupil size in 20 (50%) patients. In our study, we had 42 (58.33%) patients with pupillary changes and all those patients had GCS ranging from 3 to 12 whereas patients with GCS of 13–15 had 0% pupillary changes. Prompt surgery with better care obtained us with mortality of 1.6% only and morbidity of 21.7%; similar results were shown by Ayub et al.[20] and O'Sullivan et al.[21] who have shown <10% mortality.


  Discussion Top


Preoperative state of the patient is one of the most crucial factors for the outcome. All the patients operated in our series were operated as soon as reached hospital after required urgent investigations. Only the patients having GCS of 14/15 and 15/15 with no neurodeficit was delayed. Khan et al.[22] in their study revealed favorable outcome with 79.2% and a mortality of 12.5% and pointed that the final outcome was significantly related to GCS before surgery. Whereas from our study [Table 9], we evaluated that outcome of the patient is multifactorial and depends on preoperative GCS, pupillary abnormalities, time lapse between trauma and operative procedure, age, clot size, mass effect, herniation, mechanism of the injury, associated disease (e.g., hypertension and diabetes mellitus) and patients on anticoagulants and antiplatelet. Promptness in the referral and diagnosis remained the main weapon for the excellent outcome all the patients of the EDH; 78.3% of the patients had good recovery with no neurological deficit. Nearly, 6% of the patient had moderate disability, 8.3% had severe disability but still manages to walk with support, one patient each, i.e., 1.6% remained in permanent vegetative state, and 1 patient was unfortunate who succumbed to injuries.
Table 9: Details of the patients

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  Conclusion Top


We may conclude in our study that presurgery clinical status and the rapidity of transfer to the territory center are the hallmarks for the outcome of the patients with EDH evacuation outcome. In most of the cases, the outcome was favorable with progressive recovery.

Informed consent

Obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Ndoumbe A, Ekeme MV, Jemea B, Simeu C, Takongmo S. Epidemiological analysis of surgically treated acute traumatic epidural hematoma. Open J Mod Neurosurg 2016;6:89-97.  Back to cited text no. 10
    
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Lobato RD, Rivas JJ, Cordobes F, Alted E, Perez C, Sarabia R, et al. Acute epidural hematoma: An analysis of factors influencing the outcome of patients undergoing surgery in coma. J Neurosurg 1988;68:48-57.  Back to cited text no. 12
    
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Rivas JJ, Lobato RD, Sarabia R, Cordobés F, Cabrera A, Gomez P, et al. Extradural hematoma: Analysis of factors influencing the courses of 161 patients. Neurosurgery 1988;23:44-51.  Back to cited text no. 13
    
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Nnadi MO, Bankole OB, Fente BG. Outcome of surgically treated traumatic extradural hematoma. Br J Med Med Res 2016;12:1-9.  Back to cited text no. 14
    
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Kalkan E, Cander B, Gul M, Girisgin S, Karabagli H, Sahin B, et al. Prediction of prognosis in patients with epidural hematoma by a new stereological method. Tohoku J Exp Med 2007;211:235-42.  Back to cited text no. 16
    
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Marshall LF, Gautille T, Klauber MR, Eisenberg HM, Jane JA, Luerssen TG, et al. The outcome of severe closed head injury. J Neurosurg 1991;75:S28-36.  Back to cited text no. 18
    
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Sheikh MW, Shahnawaz I, Abdullah M, Kamal O, Naheed R, Bushra A, et al. Outcomes of evacuation extradural hematomaz via craniotomy under local anesthesia. Neurosci Med 2017;8:41-5.  Back to cited text no. 19
    
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Ayub S, Ali M, Llyas M. Acute extradural haematoma: Factors affecting the outcome. J Postgrad Med Inst 2005;19:208-11.  Back to cited text no. 20
    
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O'Sullivan MG, Gray WP, Buckley TF. Extradural haematoma in the Irish republic: An analysis of 82 cases with emphasis on 'delay'. Br J Surg 1990;77:1391-4.  Back to cited text no. 21
    
22.
Khan MB, Riaz M, Javed G, Hashmi FA, Sanaullah M, Ahmed SI, et al. Surgical management of traumatic extra dural hematoma in children: Experiences and analysis from 24 consecutively treated patients in a developing country. Surg Neurol Int 2013;4:103.  Back to cited text no. 22
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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