ACTA NEUROCHIRURGICA 9 by Springer-Verlag 1978
Aeta Neuroehirurgica 41, 223--231 (1978)
The Neurosurgical Department, UllevM Hospital, Oslo, Norway
Extradural Haematoma Report
o f 132 C a s e s By
T. L. K v a r n e s a n d J. H. T r u m p y ~Vith 3 Figures
Summary I n ~ consecutive unseleeted series of 132 cases of acute extradural h a e m a t o m a among 9,600 patients who sustained a head injury and were a d m i t t e d without delay to a regional neurosurgical department during the years 1964 to 1975 the overall m o r t a l i t y was 23 per cent. Associated intradural lesions, the relative infrequeney of the lucid interval, sustained loss of consciousness from the time of admission, lack of the classical pupillary changes, and the rapid rise in intracranial pressure in some patients are factors of importance for the prognosis. I t should be possible to improve the results and lower the m o r t a l i t y if due consideration is taken of these factors.
Introduction A l t h o u g h i t is w i d e l y a c c e p t e d t h a t e a r l y diagnosis a n d s u r g e r y are essential ill t h e m a n a g e m e n t of a c u t e e x t r a d u r a l h a e m a t o m a , m o s t a u t h o r s r e p o r t a m o r t a l i t y of 20 p e r cent or higher. I f ~he d e l a y before s u r g e r y is i m p o r t a n t , t h e results of t r e a t m e n t in neurosurgieal d e p a r t m e n t s will be influenced b y t h e size of t h e a r e a t h e y serve a n d t h e t i m e lost in t r a n s f e r r i n g p a t i e n t s . I n an a t t e m p t to a v o i d this factor, we are r e p o r t i n g t h e results of t h e m a n a g e m e n t of p a t i e n t s in a neurosurgieal d e p a r t m e n t m a i n l y serving t h e c i t y of 0slo, where t h e t i m e lost in transp o r t i n g p a t i e n t s r a r e l y exceeds 30 minutes. Since all cases of m a j o r h e a d i n j u r y are a d m i t t e d to this d e p a r t m e n t , even t h o u g h i n t r a e r a n i a l s u r g e r y m a y n o t be i n d i c a t e d , d e l a y in o t h e r h o s p i t a l s before a d m i s s i o n is also avoided.
Material The records of all patients with the diagnosis of acute extradural h a e m a t o m a a d m i t t e d to the neurosurgieal department of Ullevgl Hospital during the years 1964-1975 were examined. Among 9,600 patients a d m i t t e d
0001-6268/78/0041/0223/$01.80
224
T.L. Kvarnes and J. H. Trumpy:
following a h e a d i n j u r y , t h e r e were 132 w i t h a n a c u t e e x t r a d u r a l h a e m a t o m a (1.4 p e r cent). T h e c r i t e r i a for t h e diagnosis of a signi/icant e x t r a d u r a l h a e m a t o m a were : A n e x t r a d u r a l b l o o d clot t h i c k e r t h a n 1 c m w h i c h h a d s e p a r a t e d t h e d u r a f r o m t h e skull o v e r a n a r e a l a r g e r t h a n 3 b y 3 s q cm.
Annual Incidence and Mortality Rate o/ Extradural Haematoma With and Without Associated Intradural Lesions in 132 Patients
T a b l e 1.
Year
No. of cases
Cases without associated intradural lesions Per cent No. deaths
Cases with associated intradural lesions Per cent No. deaths
Total No. of deaths
1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
14 12 10 9 9 12 9 9 9 11 15 13
10 8 5 7 7 9 5 4 8 4 11 11
10 25 20 14 14 0 20 50 12 50 9 0
4 4 5 2 2 3 4 5 1 7 4 2
100 50 40 0 50 67 50 60 100 0 0 0
5 4 3 1 2 2 3 5 2 2 1 0
Total
132
89
14
43
39
30
Per cent deaths
23
I n a n a t t e m p t t o f i n d a n e x p l a n a t i o n for a m o r t a l i t y w h i c h u p t o t h e l a s t few y e a r s h a s b e e n p e r s i s t e n t l y high, p a r t i c u l a r a t t e n t i o n w a s p a i d to f a c t o r s s u c h as d e t e r i o r a t i o n i n t h e level of consciousness, lucid i n t e r v a l s , site of h a e m a t o m a , a s s o c i a t e d i n t r a d u r a l lesions ( s u b d u r a l h a e m a t o m a s , or c o n t u s i o n s ) , t h e r a d i o g r a p h i c d e m o n s t r a t i o n of f r a c t u r e s , t h e use of c e r e b r a l a n g i o g r a p h y , a n d t h e i n t e r v a l b e t w e e n i n j u r y a n d surgery.
Results Mortality T a b l e 1 s h o w s t h a t t h e o v e r a l l m o r t a l i t y w a s 23 p e r c e n t , o r 14 p e r cent when the extradural haematoma was not associated with an intrad u r a l l e s i o n . T h e m o r t a l i t y r a t e w a s s l i g h t l y r e d u c e d b e t w e e n 1964 a n d 1975. D u r i n g t h e s e y e a r s t h e n e u r o s u r g i c a l , a n a e s t h e t h i c , a n d n e u r o radiological facilities did not change significantly. When the epidural h a e m a t o m a w a s a s s o c i a t e d w i t h i n t r a d u r a l l e s i o n s , s u c h as c e r e b r a l c o n t u s i o n s a n d i n t r a c e r e b r a l b l o o d clots, t h e m o r t a l i t y r a t e w a s 39 p e r
Extradural
225
Haematoma
cent. I t was impossible to assess the relative significance of the extradural haematomas and the intradurM lesions in the living patients, but autopsy findings in fatal cases usually showed intradural lesions which might have been the cause of death, and which were rarely amenable to surgery.
Age, Sex, and Aetiology Fig. 1 shows a maximum incidence in the fifth decade and a preponderance of males at all ages, explicable by the males greater liability to trauma at work and to road traffic accidents. An additional factor contributing to the preponderance of males was alcohol. Twenty-five per cent of the males and only 10 per cent of the females were considered to be under the influence of alcohol at the time of injury. Table 2. Cause o/Injury No. of cases
Traffic accidents FM1 from height Fall on the ground Direct trauma to the head Total
Per cent
46 35 36 15
35 27 27 11
132
100
The cause of the injury is seen in Table 2. The frequency of road traffic accidents in epidural haematomas was the same as in our total head injury series. Falls on the ground, usually the result of domestic accidents, accounted for 27 per cent of the cases. Direct trauma included industrial injury and criminal assault.
Clinical Course and Level o] Consciousness Table 3 shows the changes in the level of consciousness among the patients. Only 14 patients passed through the classical consecutive stages of loss of consciousness, wakefulnes and loss of consciousness. Only 24 others showed a clear deterioration from an initial fully conscious state. The remaining 94 patients did not, at any time, show a clear deterioration of the level of consciousness. Thus 74 remained either unconscious or drowsy from the time of admission, while 20 others recovered consciousness or remained awake prior to surgery. I n the latter patients the diagnosis was suspected from clinical signs such as 15
Acta Neurochirurgica, Vol. 41, Fasc. 1--3
226
T . L . Kvarnes and J. H. T r u m p y :
restlessness, headache, hemiparesis or spastieity. I n these 20 patients there was no mortality. Evidence of scalp injury related to the position of the extradural h a e m a t o m a was present in 95 patients (71 per cent). E x t e r n a l bleeding from the ear on the side of the lesion occurred in 30 patients. Dilatation of the homolateral pupil was observed in only 42 (33 per cent) of the 126 patients with supratentorial lesions. I n 14 patients ( l l per cent) the contralateral pupil was the first to dilate. However, the possibility can n o t be excluded t h a t in some of these cases the a p p a r e n t enlargement of the eontralateral pupil was due to an initial, transitory constriction of the homolateral pupil during the irritative phase of a 3rd cranial nerve lesion. Table 3. Changes o/ the Level o/ Consciousness in 132 Cases o] Epidural Haematoma No. of cases Unconscious --~Awake -+ Unconscious Awake -+ Unconscious Awake -~ Somnolent
14 12 12
38
Unconscious throughout the course Somnolent throughout the course Unconscious -~ Awake Awake throughout
53 21 10 10
94
Total
132
L u m b a r p u n c t u r e was performed in 68 patients. The cerebrospinal fluid was blood-stained in 42 patients. I n 24 of 52 patients in w h o m pressure recording was done, the pressure was above 400 m m of water. Although clinical deterioration was not noted during the l u m b a r puncture, a potential adverse effect u p o n the subsequent course cannot be excluded. Site o/Haematoma Fig. 2 shows the distribution of the haematomas, the m a j o r i t y being temporal and parietal. F o u r of the 15 frontal, 14 of the 77 ternporal, and 8 of the 33 parietal h a e m a t o m a s were fatal. Delay in diagnosis and surgery was more frequent with frontal h a e m a t o m a s t h a n with those in other supratentorial sites.
Extradural I-Iaematorna
227
---] women
264 24[
~en
22 2O 18 16 No of cases 14 12 lO 8 6 4 2 ) 0
20
40
60
80 Age
Fig. I.
Distribution according to age and sex in 132 cases of extradural haematoma
Fig. 2. Site of the extraduraI h a e m a t o m a in 132 cases
Associated Intradural Lesions I n 43 (or 32 per cent) of t h e 132 p a t i e n t s a subdural clot or cerebral contusion were found. H o w e v e r , th e d u r a r e m a i n e d u n o p e n e d in a few cases a n d for this reason a c o - e x is t e n t i n t r a d u r a l lesion m a y h a v e been overlooked. I n 8 of t h e cases t h e d u r a h a d r u p t u r e d as a result of t h e t r a u m a , a n d in t h e r e m a i n i n g 35 t h e i n t r a d u r a l lesion was n o t e d as t h e d u r a was o p e n e d for inspection. I n 25 of these cases a t e m p o r a l lobe contusion was n o t e d on t h e same side. 15*
228
T.L. Kvarnes and J. H. Trumpy :
Radiology Plain skull radiograms showed a fracture related to the site of the h a e m a t o m a in 86 per cent of the patients. Carotid angiography was performed in 72 per cent of the cases. I n the angiography group, the mortality rate was 16 per cent, compared with an overall mortality of 23 per cent. However, angiography was used only in cases in which a relatively slowly progressing clinical deterioration allowed the time required for the procedure. Such patients obviously had a lower mortality t h a n those whose deterioration was rapid. Nevertheless, angiography was of considerable value in the planning of surgery, and also in excluding the presence of an extradural h a e m a t o m a in m a n y patients, thus preventing unnecessary craniotomies.
Interval Between Injury and Operation Fig. 3 shows the relation between injury-to-operation interval and mortality. I n 54 patients undergoing craniotomy within 6 hours of the injury, the mortality approached 38 per cent. When between 6 and 12 hours had passed the mortality was 25 per cent, and thereafter it was reduced to 6 per cent. However, among the 54 patients operated on within 6 hours, 32 remained unconscious from the time of admission, and in 20 there was evidence of associated intradural lesions. Discussion
Previous authors 1--6, 8 have described the clinical course and management of extradural haematomas. The mortality in neurosurgical hands has varied from 155 to 436 per cent. An extensive survey of the older literature has been given in 1960 by Loew & Wustner 7. Inevitable in most series has been the element of selection b y variations in distance of the referring department to the neurosurgical centre, and diagnostic and operative skills of general surgeons prior to neurosurgieal referral. I t has been suggested 1, 2, s, 10 t h a t the relatively poor results in neurosurgical departments have been, at least in part, attributable to such factors. The prime purpose in reporting the present series was to examine critically the results in a neurosurgical department to which all but trivial head injuries from a specified area were admitted with a delay of less than 30 minutes, thereby avoiding significant factors of variation. Furthermore, throughout the hospital period, full neurosurgical intensive care and neuroradiological facilities were available at all hours. The results in terms of mortality were disappointing. The overall mortality was 23 per cent. I n cases without associated intradural lesions the
Extradural
Haematoma
229
mortality was 14 per cent. For unknown reasons we have had a marked improvement during 1974 and 1975. The overall mortality for cases with associated intradnral lesions was 39 per cent. With regard to the causes for the relatively high mortality rate, the part played by associated intradural lesions remains difficult to assess.
N
55
Deaths
50 45 4O 35 3O No of cases 25 2O 15 10 5 0 0
6 12 24 48 hours
5 10 15 days
4
6
weeks
Fig. 3. Mortality in cases operated at different intervals after the trauma
Per-operative evaluation of the thickness and extent of a subdural haematoma observed through a small dural opening after evacuation of an extradural haematoma is notoriously difficult. If the dura does not remain slack, it is reasonable to assume the presence of an intradural lesion which is as likely to be cerebral contusion or oedema as a snbdural clot. Carotid angiography with oblique projections to determine the maximum thickness of the extracerebral fluid collection m a y give evidence of associated intradural lesions, particularly if the midline displacement is greater than the thickness of the extradural haematoma, as was repeatedly the case in the present, series. I n the presence of an associated intradural lesion, e.g. contusion with oedema, a relatively small extradural haematoma m a y be sufficient to increase the intracranial pressure to a critical level. The patients who
230
T.L. Kvarnes and J. H. Trumpy:
remain unconscious or drowsy without a lucid interval are likely to have such pathology, and in this group the indication for angiography and computerized t o m o g r a p h y is especially strong. Like several other authors 2, 5, 9, n we have noted t h a t the classical lucid interval is rather infrequent. Furthermore, only 38 patients showed definite deterioration in the level of consciousness, either from a lucid interval or from a state of drowsiness or somnolence. A delay in diagnosis in such cases contributed to a high mortality rate. Noteworthy in this series was the lack of a dilated and non-reactive pupil in 76 of the 126 patients with supratentorial lesions, an observation which should be emphasized in medical teaching% We regard lumbar puncture in patients with head traumas as a valuable investigation, giving information about the presence of brain damage, and to a certain extent about intracranial pressure. L u m b a r puncture should be done with a small needle and particular care must be exerted in patients with anisoeoria and rigidity of the neck. If there is clinical suspicion of impending herniation, spinal puncture is not done. Unselected early admission to the neurosurgical department revealed a striking relationship between timing of surgery and mortality. The high mortality rate (38 per cent) following surgery during the first 6 hours after injury was caused b y the rapid increase of intracranial pressure. I n these cases intradural lesions were usually present. The value of good quality plain skull radiographs has been clearly demonstrated in our series. An exploratory burr hole in experienced neurosurgical hands is a quicker procedure than a carotid angiogram. If the level of consciousness is deteriorating and a fracture is present, a burr hole craniotomy should not be deferred. However, with increasing availability of computerized axial t o m o g r a p h y the necessity for an exploratory burr hole will diminish. If due regard is taken of the various factors mentioned above, it should be possible to improve the operative results of this disease the mortality of which is still remarkably high. References
1. Heiskanen, O., Epidural hematoma. Surg. Neurol. g (1975), 23--26. 2. ttooper, R., Observations on extradural haemorrhage. Brit. J. Surg. 47 (1959), 71--84. 3. Iwakuma, T., Brunngraber, C.V., Chronic extradural hematomas. A study of 21 cases. J. Neurosurg. 38 (1973), 488 493. 4. Jamieson, K.G., Surgical lesions in head injuries: their relative incidence, morality rates and trends. Aust. N. Z. J. Surg. 46 (1974), 241--250. 5. - - Yelland, J. D. N., Extradural hematoma. J. Neurosurg. 29 (1968), 13--23.
Extradural Haematoma
231
6. Kristiansen, K., Tandon, P., Diagnosis and surgical treatment of severe cranioeerebral injuries. J. Oslo City Hosp. 10 (1960), 105--213. 7. Loew, F., Wfistner, F., Diagnose, Behandlung und Prognose der Traumatischen Hgmatome des Sch-~delinneren. Wien : Springer. 1960. 8. MeKissoek, W. et al., Extradural haematoma. Observation on 125 cases. Lancet 2 (1960), 167--172. 9. Svendsen, V., Epidurale h~matomer hos born. Ugeskr. L~eg. 133 (1971), I--3. 10. Tysv~r, A., Epiduralt hematom. T. norske L~egeforen. 94 (1974), 1397--1400. 11. Weinman, D., Samaratunga, K., Biparasagital extradural haematoma. J. roy. Coll. Surg. Edinb. 18 (1973), 308--311. 12. Whittaker, K., Extradural hematoma of the anterior fossa. J. l~eurosurg. 17 (1960), 1089--1092.
Author's address: Dr. J . H . Trumpy, Department of Neurosurgery, Ulleval Hospital, Oslo 1, Norway.
Aeta Neuroehirurgica 41, 223--231 (1978)
The Neurosurgical Department, UllevM Hospital, Oslo, Norway
Extradural Haematoma Report
o f 132 C a s e s By
T. L. K v a r n e s a n d J. H. T r u m p y ~Vith 3 Figures
Summary I n ~ consecutive unseleeted series of 132 cases of acute extradural h a e m a t o m a among 9,600 patients who sustained a head injury and were a d m i t t e d without delay to a regional neurosurgical department during the years 1964 to 1975 the overall m o r t a l i t y was 23 per cent. Associated intradural lesions, the relative infrequeney of the lucid interval, sustained loss of consciousness from the time of admission, lack of the classical pupillary changes, and the rapid rise in intracranial pressure in some patients are factors of importance for the prognosis. I t should be possible to improve the results and lower the m o r t a l i t y if due consideration is taken of these factors.
Introduction A l t h o u g h i t is w i d e l y a c c e p t e d t h a t e a r l y diagnosis a n d s u r g e r y are essential ill t h e m a n a g e m e n t of a c u t e e x t r a d u r a l h a e m a t o m a , m o s t a u t h o r s r e p o r t a m o r t a l i t y of 20 p e r cent or higher. I f ~he d e l a y before s u r g e r y is i m p o r t a n t , t h e results of t r e a t m e n t in neurosurgieal d e p a r t m e n t s will be influenced b y t h e size of t h e a r e a t h e y serve a n d t h e t i m e lost in t r a n s f e r r i n g p a t i e n t s . I n an a t t e m p t to a v o i d this factor, we are r e p o r t i n g t h e results of t h e m a n a g e m e n t of p a t i e n t s in a neurosurgieal d e p a r t m e n t m a i n l y serving t h e c i t y of 0slo, where t h e t i m e lost in transp o r t i n g p a t i e n t s r a r e l y exceeds 30 minutes. Since all cases of m a j o r h e a d i n j u r y are a d m i t t e d to this d e p a r t m e n t , even t h o u g h i n t r a e r a n i a l s u r g e r y m a y n o t be i n d i c a t e d , d e l a y in o t h e r h o s p i t a l s before a d m i s s i o n is also avoided.
Material The records of all patients with the diagnosis of acute extradural h a e m a t o m a a d m i t t e d to the neurosurgieal department of Ullevgl Hospital during the years 1964-1975 were examined. Among 9,600 patients a d m i t t e d
0001-6268/78/0041/0223/$01.80
224
T.L. Kvarnes and J. H. Trumpy:
following a h e a d i n j u r y , t h e r e were 132 w i t h a n a c u t e e x t r a d u r a l h a e m a t o m a (1.4 p e r cent). T h e c r i t e r i a for t h e diagnosis of a signi/icant e x t r a d u r a l h a e m a t o m a were : A n e x t r a d u r a l b l o o d clot t h i c k e r t h a n 1 c m w h i c h h a d s e p a r a t e d t h e d u r a f r o m t h e skull o v e r a n a r e a l a r g e r t h a n 3 b y 3 s q cm.
Annual Incidence and Mortality Rate o/ Extradural Haematoma With and Without Associated Intradural Lesions in 132 Patients
T a b l e 1.
Year
No. of cases
Cases without associated intradural lesions Per cent No. deaths
Cases with associated intradural lesions Per cent No. deaths
Total No. of deaths
1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
14 12 10 9 9 12 9 9 9 11 15 13
10 8 5 7 7 9 5 4 8 4 11 11
10 25 20 14 14 0 20 50 12 50 9 0
4 4 5 2 2 3 4 5 1 7 4 2
100 50 40 0 50 67 50 60 100 0 0 0
5 4 3 1 2 2 3 5 2 2 1 0
Total
132
89
14
43
39
30
Per cent deaths
23
I n a n a t t e m p t t o f i n d a n e x p l a n a t i o n for a m o r t a l i t y w h i c h u p t o t h e l a s t few y e a r s h a s b e e n p e r s i s t e n t l y high, p a r t i c u l a r a t t e n t i o n w a s p a i d to f a c t o r s s u c h as d e t e r i o r a t i o n i n t h e level of consciousness, lucid i n t e r v a l s , site of h a e m a t o m a , a s s o c i a t e d i n t r a d u r a l lesions ( s u b d u r a l h a e m a t o m a s , or c o n t u s i o n s ) , t h e r a d i o g r a p h i c d e m o n s t r a t i o n of f r a c t u r e s , t h e use of c e r e b r a l a n g i o g r a p h y , a n d t h e i n t e r v a l b e t w e e n i n j u r y a n d surgery.
Results Mortality T a b l e 1 s h o w s t h a t t h e o v e r a l l m o r t a l i t y w a s 23 p e r c e n t , o r 14 p e r cent when the extradural haematoma was not associated with an intrad u r a l l e s i o n . T h e m o r t a l i t y r a t e w a s s l i g h t l y r e d u c e d b e t w e e n 1964 a n d 1975. D u r i n g t h e s e y e a r s t h e n e u r o s u r g i c a l , a n a e s t h e t h i c , a n d n e u r o radiological facilities did not change significantly. When the epidural h a e m a t o m a w a s a s s o c i a t e d w i t h i n t r a d u r a l l e s i o n s , s u c h as c e r e b r a l c o n t u s i o n s a n d i n t r a c e r e b r a l b l o o d clots, t h e m o r t a l i t y r a t e w a s 39 p e r
Extradural
225
Haematoma
cent. I t was impossible to assess the relative significance of the extradural haematomas and the intradurM lesions in the living patients, but autopsy findings in fatal cases usually showed intradural lesions which might have been the cause of death, and which were rarely amenable to surgery.
Age, Sex, and Aetiology Fig. 1 shows a maximum incidence in the fifth decade and a preponderance of males at all ages, explicable by the males greater liability to trauma at work and to road traffic accidents. An additional factor contributing to the preponderance of males was alcohol. Twenty-five per cent of the males and only 10 per cent of the females were considered to be under the influence of alcohol at the time of injury. Table 2. Cause o/Injury No. of cases
Traffic accidents FM1 from height Fall on the ground Direct trauma to the head Total
Per cent
46 35 36 15
35 27 27 11
132
100
The cause of the injury is seen in Table 2. The frequency of road traffic accidents in epidural haematomas was the same as in our total head injury series. Falls on the ground, usually the result of domestic accidents, accounted for 27 per cent of the cases. Direct trauma included industrial injury and criminal assault.
Clinical Course and Level o] Consciousness Table 3 shows the changes in the level of consciousness among the patients. Only 14 patients passed through the classical consecutive stages of loss of consciousness, wakefulnes and loss of consciousness. Only 24 others showed a clear deterioration from an initial fully conscious state. The remaining 94 patients did not, at any time, show a clear deterioration of the level of consciousness. Thus 74 remained either unconscious or drowsy from the time of admission, while 20 others recovered consciousness or remained awake prior to surgery. I n the latter patients the diagnosis was suspected from clinical signs such as 15
Acta Neurochirurgica, Vol. 41, Fasc. 1--3
226
T . L . Kvarnes and J. H. T r u m p y :
restlessness, headache, hemiparesis or spastieity. I n these 20 patients there was no mortality. Evidence of scalp injury related to the position of the extradural h a e m a t o m a was present in 95 patients (71 per cent). E x t e r n a l bleeding from the ear on the side of the lesion occurred in 30 patients. Dilatation of the homolateral pupil was observed in only 42 (33 per cent) of the 126 patients with supratentorial lesions. I n 14 patients ( l l per cent) the contralateral pupil was the first to dilate. However, the possibility can n o t be excluded t h a t in some of these cases the a p p a r e n t enlargement of the eontralateral pupil was due to an initial, transitory constriction of the homolateral pupil during the irritative phase of a 3rd cranial nerve lesion. Table 3. Changes o/ the Level o/ Consciousness in 132 Cases o] Epidural Haematoma No. of cases Unconscious --~Awake -+ Unconscious Awake -+ Unconscious Awake -~ Somnolent
14 12 12
38
Unconscious throughout the course Somnolent throughout the course Unconscious -~ Awake Awake throughout
53 21 10 10
94
Total
132
L u m b a r p u n c t u r e was performed in 68 patients. The cerebrospinal fluid was blood-stained in 42 patients. I n 24 of 52 patients in w h o m pressure recording was done, the pressure was above 400 m m of water. Although clinical deterioration was not noted during the l u m b a r puncture, a potential adverse effect u p o n the subsequent course cannot be excluded. Site o/Haematoma Fig. 2 shows the distribution of the haematomas, the m a j o r i t y being temporal and parietal. F o u r of the 15 frontal, 14 of the 77 ternporal, and 8 of the 33 parietal h a e m a t o m a s were fatal. Delay in diagnosis and surgery was more frequent with frontal h a e m a t o m a s t h a n with those in other supratentorial sites.
Extradural I-Iaematorna
227
---] women
264 24[
~en
22 2O 18 16 No of cases 14 12 lO 8 6 4 2 ) 0
20
40
60
80 Age
Fig. I.
Distribution according to age and sex in 132 cases of extradural haematoma
Fig. 2. Site of the extraduraI h a e m a t o m a in 132 cases
Associated Intradural Lesions I n 43 (or 32 per cent) of t h e 132 p a t i e n t s a subdural clot or cerebral contusion were found. H o w e v e r , th e d u r a r e m a i n e d u n o p e n e d in a few cases a n d for this reason a c o - e x is t e n t i n t r a d u r a l lesion m a y h a v e been overlooked. I n 8 of t h e cases t h e d u r a h a d r u p t u r e d as a result of t h e t r a u m a , a n d in t h e r e m a i n i n g 35 t h e i n t r a d u r a l lesion was n o t e d as t h e d u r a was o p e n e d for inspection. I n 25 of these cases a t e m p o r a l lobe contusion was n o t e d on t h e same side. 15*
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Radiology Plain skull radiograms showed a fracture related to the site of the h a e m a t o m a in 86 per cent of the patients. Carotid angiography was performed in 72 per cent of the cases. I n the angiography group, the mortality rate was 16 per cent, compared with an overall mortality of 23 per cent. However, angiography was used only in cases in which a relatively slowly progressing clinical deterioration allowed the time required for the procedure. Such patients obviously had a lower mortality t h a n those whose deterioration was rapid. Nevertheless, angiography was of considerable value in the planning of surgery, and also in excluding the presence of an extradural h a e m a t o m a in m a n y patients, thus preventing unnecessary craniotomies.
Interval Between Injury and Operation Fig. 3 shows the relation between injury-to-operation interval and mortality. I n 54 patients undergoing craniotomy within 6 hours of the injury, the mortality approached 38 per cent. When between 6 and 12 hours had passed the mortality was 25 per cent, and thereafter it was reduced to 6 per cent. However, among the 54 patients operated on within 6 hours, 32 remained unconscious from the time of admission, and in 20 there was evidence of associated intradural lesions. Discussion
Previous authors 1--6, 8 have described the clinical course and management of extradural haematomas. The mortality in neurosurgical hands has varied from 155 to 436 per cent. An extensive survey of the older literature has been given in 1960 by Loew & Wustner 7. Inevitable in most series has been the element of selection b y variations in distance of the referring department to the neurosurgical centre, and diagnostic and operative skills of general surgeons prior to neurosurgieal referral. I t has been suggested 1, 2, s, 10 t h a t the relatively poor results in neurosurgical departments have been, at least in part, attributable to such factors. The prime purpose in reporting the present series was to examine critically the results in a neurosurgical department to which all but trivial head injuries from a specified area were admitted with a delay of less than 30 minutes, thereby avoiding significant factors of variation. Furthermore, throughout the hospital period, full neurosurgical intensive care and neuroradiological facilities were available at all hours. The results in terms of mortality were disappointing. The overall mortality was 23 per cent. I n cases without associated intradural lesions the
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mortality was 14 per cent. For unknown reasons we have had a marked improvement during 1974 and 1975. The overall mortality for cases with associated intradnral lesions was 39 per cent. With regard to the causes for the relatively high mortality rate, the part played by associated intradural lesions remains difficult to assess.
N
55
Deaths
50 45 4O 35 3O No of cases 25 2O 15 10 5 0 0
6 12 24 48 hours
5 10 15 days
4
6
weeks
Fig. 3. Mortality in cases operated at different intervals after the trauma
Per-operative evaluation of the thickness and extent of a subdural haematoma observed through a small dural opening after evacuation of an extradural haematoma is notoriously difficult. If the dura does not remain slack, it is reasonable to assume the presence of an intradural lesion which is as likely to be cerebral contusion or oedema as a snbdural clot. Carotid angiography with oblique projections to determine the maximum thickness of the extracerebral fluid collection m a y give evidence of associated intradural lesions, particularly if the midline displacement is greater than the thickness of the extradural haematoma, as was repeatedly the case in the present, series. I n the presence of an associated intradural lesion, e.g. contusion with oedema, a relatively small extradural haematoma m a y be sufficient to increase the intracranial pressure to a critical level. The patients who
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remain unconscious or drowsy without a lucid interval are likely to have such pathology, and in this group the indication for angiography and computerized t o m o g r a p h y is especially strong. Like several other authors 2, 5, 9, n we have noted t h a t the classical lucid interval is rather infrequent. Furthermore, only 38 patients showed definite deterioration in the level of consciousness, either from a lucid interval or from a state of drowsiness or somnolence. A delay in diagnosis in such cases contributed to a high mortality rate. Noteworthy in this series was the lack of a dilated and non-reactive pupil in 76 of the 126 patients with supratentorial lesions, an observation which should be emphasized in medical teaching% We regard lumbar puncture in patients with head traumas as a valuable investigation, giving information about the presence of brain damage, and to a certain extent about intracranial pressure. L u m b a r puncture should be done with a small needle and particular care must be exerted in patients with anisoeoria and rigidity of the neck. If there is clinical suspicion of impending herniation, spinal puncture is not done. Unselected early admission to the neurosurgical department revealed a striking relationship between timing of surgery and mortality. The high mortality rate (38 per cent) following surgery during the first 6 hours after injury was caused b y the rapid increase of intracranial pressure. I n these cases intradural lesions were usually present. The value of good quality plain skull radiographs has been clearly demonstrated in our series. An exploratory burr hole in experienced neurosurgical hands is a quicker procedure than a carotid angiogram. If the level of consciousness is deteriorating and a fracture is present, a burr hole craniotomy should not be deferred. However, with increasing availability of computerized axial t o m o g r a p h y the necessity for an exploratory burr hole will diminish. If due regard is taken of the various factors mentioned above, it should be possible to improve the operative results of this disease the mortality of which is still remarkably high. References
1. Heiskanen, O., Epidural hematoma. Surg. Neurol. g (1975), 23--26. 2. ttooper, R., Observations on extradural haemorrhage. Brit. J. Surg. 47 (1959), 71--84. 3. Iwakuma, T., Brunngraber, C.V., Chronic extradural hematomas. A study of 21 cases. J. Neurosurg. 38 (1973), 488 493. 4. Jamieson, K.G., Surgical lesions in head injuries: their relative incidence, morality rates and trends. Aust. N. Z. J. Surg. 46 (1974), 241--250. 5. - - Yelland, J. D. N., Extradural hematoma. J. Neurosurg. 29 (1968), 13--23.
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6. Kristiansen, K., Tandon, P., Diagnosis and surgical treatment of severe cranioeerebral injuries. J. Oslo City Hosp. 10 (1960), 105--213. 7. Loew, F., Wfistner, F., Diagnose, Behandlung und Prognose der Traumatischen Hgmatome des Sch-~delinneren. Wien : Springer. 1960. 8. MeKissoek, W. et al., Extradural haematoma. Observation on 125 cases. Lancet 2 (1960), 167--172. 9. Svendsen, V., Epidurale h~matomer hos born. Ugeskr. L~eg. 133 (1971), I--3. 10. Tysv~r, A., Epiduralt hematom. T. norske L~egeforen. 94 (1974), 1397--1400. 11. Weinman, D., Samaratunga, K., Biparasagital extradural haematoma. J. roy. Coll. Surg. Edinb. 18 (1973), 308--311. 12. Whittaker, K., Extradural hematoma of the anterior fossa. J. l~eurosurg. 17 (1960), 1089--1092.
Author's address: Dr. J . H . Trumpy, Department of Neurosurgery, Ulleval Hospital, Oslo 1, Norway.
