Contrecoup epidural hematoma: a rare case report.

Epidural hematoma (EDH) is defined as a traumatic accretion of blood separating the dural membrane and the internal table of the skull that caused from contact bending or skull fracture. The cases of contrecoup EDH are as not common, and there are just 10 recorded cases on this. As a result of its uncommonness, we disclose one subject of a 33-year-old man having countrecoup EDH who suffered from a head trauma caused by falling from 4 meters high. The main symptoms were decreasing consciousness and vomiting. Clinical findings showed a Glasgow Coma Scale score of 9, laceration in the left parietal region with stable hemodynamic. Head Computed tomography showed a large EDH in the right frontal and temporal region with coronal suture diastasis. The patient immediately underwent surgery, and craniotomy with evacuation of extradural hematoma were performed. This case presents that a force, which creates an angle, can propagates and causes opposite coronal suture diastasis and makes contrecoup EDH.

Aggressive primary scalp lymphoma mimicking an acute epidural hematoma: Case report and review of the literature.

BACKGROUND: Cutaneous Central Follicular Lymphoma (CCFL) is a type B cutaneous lymphoma with a usually indolent course. Scalp localization of CCFL is extremely rare, we report a new case mimicking an epidural hematoma, and showing a rapid progression with aggressive infiltration of skin, calvaria, dura and brain parenchyma. CASE REPORT: A 58-year-old patient with an unlabeled polymalformative syndrome was admitted to the Emergency department following a head injury secondary to a self-resolving tonic-clonic epileptic seizure. The initial CT-scan was interpreted as a minor subcutaneous and epidural hematoma initially deemed for conservative management. Within 4 days, the patient showed a progressive neurological deterioration culminating into a stuporous status which prompted a constrast-enhanced brain MRI. The scan revealed a multilayered solid lesion, extending from the subgaleal compartment to the subdural space, threatening the integrity of overlying skin and causing infiltration of the brain parenchyma. Following emergency neurosurgical excision a definitive histology diagnosis of central follicular lymphoma was made. A focused chemotherapy with high-dose Methotrexate with R-CHOP protocol led to disease control until the latest follow up at 2 years. CONCLUSION: To our knowledge, this case represents the first CCFL invading the brain parenchyma and the second extending to the dura. Although such tumor is usually indolent the aggressive behavior herein reported extend the differential diagnosis to high-grade meningiomas, sarcomas, and metastases. Prognostication and appropriate adjuvant treatment require prompt surgical excision and histological confirmation.

Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data.

Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.

Traumatic epidural hematomas in the pediatric population: clinical characteristics and diagnostic pitfalls.

BACKGROUND/PURPOSE: The purpose of this study was to review the initial clinical presentation of EDH, identify potential clinical markers and highlight diagnostic pitfalls. METHODS: Retrospective review of all pediatric patients admitted to a Level I Trauma Center diagnosed with blunt traumatic EDH from 2008 to 2018. RESULTS: A total of 699 pediatric patients were identified with blunt traumatic brain injury (TBI); 106 with EDH made up the study population. A skull fracture was present in 84%. Overall, the most common clinical finding was a scalp hematoma (86%), followed by loss of consciousness (66%), emesis (34%), headache (27%), amnesia (18%), and seizures (12%). Importantly, 40% of patients with EDH presented with GCS 15. Four children (4%) had GCS 15 and were completely asymptomatic on admission. In three children (3%) the only symptom was a scalp hematoma. 50% of all EDH required craniotomy, and this was not significantly different if GCS was 15 on presentation (45%, p = 0.192). Mortality was 2%. Fourteen patients (13%) were discharged with cognitive/motor deficits. CONCLUSIONS: Pediatric EDH frequently present with subtle clinical signs, including a normal GCS half the time. Irrespective of asymptomatic presentation, threshold for CT scan or an observation period should be low after head injuries in children. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II/III.

Intravenous Tranexamic Acid for Subdural and Epidural Intracranial Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Recovery of patients with traumatic brain injury largely depends on the reduction in secondary brain damage. The present study aims at investigating the effect of Tranexamic Acid (TXA) administration within the first hours of brain trauma in the emergency department (ED). METHODS: This randomized, double-blind, placebo-controlled clinical trial was carried out in patients with subdural and epidural hemorrhage. Patients with any type of bleeding were assigned into two groups of TXA and 0.9% normal saline as placebo. The rate of intracranial hemorrhage after surgery was assessed by CT-scan and amount of hemoglobin (Hb) was measured immediately before surgery and after 6 hours of surgery. RESULTS: A total of 80 participants were randomly assigned into four groups of 20 people. There was a significant difference in the mean of intraoperative bleeding during surgery in patients receiving TXA and placebo in both SDH (Subdural hematoma) and EDH (Epidural Hemorrhage) groups (P= 0.012). The Hb drop amount had no significant difference with placebo (P< 0.0001). No complications were observed in any of the intervention and control groups during the study as well. CONCLUSION: The use of TXA may reduce bleeding, however, based on the results of this study, such effect was not statistically significant in controlling the epidural and subdural hemorrhage, but clinical trials with a higher sample size are suggested for further investigation in this regard.

Plasmacytoma of the skull mimicking an epidural hematoma: A case report.

RATIONALE: Plasmacytoma as the 1st presentation of skull tumors is a rare disorder. When it is combined with brain trauma or dramatic changes in intracranial pressure, patients are more prone to misdiagnosis. PATIENT CONCERNS: A 67-year-old woman complaining of a headache presented with a history of head trauma for the past 1 hour. Emergency head computed tomography initially suggested an epidural hematoma. DIAGNOSIS: Emergency surgery was performed to remove the intracranial hematoma, but a tumor-like mass was found during surgery, and pathologic assessment confirmed plasmacytoma. Surgery was difficult because of bleeding. The tumor was radically removed. INTERVENTIONS AND OUTCOMES: The patient underwent whole-brain radiotherapy and chemotherapy. She died 40 months after the surgery. LESSONS: Epidural lesions found after a head injury may be assumed to be an epidural hematoma, leading to unnecessary surgery. Diseases such as hematomas, meningiomas, eosinophilic granulomas, bone metastases, and osteosarcomas must be considered.

Spontaneous resolution and complete recovery of spontaneous cervical epidural hematoma: Report of two cases and literature review.

OBJECTIVE: To present the natural course and treatment modalities of spontaneous cervical epidural hematoma (SCEH), by reporting two rare cases with spontaneous resolution in both clinical and radiologic findings without surgery. MATERIAL AND METHODS: One patient presenting with acute right side hemiparesis and another showing pure cervical radiculopathy were diagnosed with SCEH on magnetic resonance imaging (MRI). Both were both treated non-operatively. We also conducted a literature review of 19 cases of spontaneous spinal epidural hematoma (SSEH). RESULTS: These two patients achieved complete resolution in terms of both neurologic function and radiologic findings within 21 days after onset. In the literature review, 63.2% of cases experienced neurologic improvement in the first 24h, 78.9% achieved complete neurologic recovery within 1 month, and radiological images showed complete resolution of hematoma in the first month for 73.7% of patients. CONCLUSIONS: Atypical cervical SSEH can mimic cerebral stroke or a ruptured cervical disc. A high index of clinical suspicion followed by MRI examination is critical for diagnosis. Prompt surgical decompression and evacuation of the hematoma is generally regarded as first-line treatment. However, for patients without or with only slight neurologic symptoms, or showing early and sustained neurologic improvement, non-surgical therapy with close observation is a viable alternative. Both neurologic and radiologic resolution can be expected within the first month following onset in most cases of spontaneous resolution of SSEH.

Rare occurrence of a huge traumatic extradural haematoma in a patient with an ipsilateral sylvian arachnoid cyst.

A man, a teenage victim of an assault to the head, presented to the emergency department, in Baghdad, with a Glasgow Coma Score of 4/15 (E1 M2 V1) and total right-sided paralysis. CT of the brain revealed a large-left sided frontotemporoparietal extradural haematoma with the presence of an ipsilateral sylvian arachnoid cyst deep to the haematoma. Urgent surgical evacuation of the haematoma was performed, leaving the arachnoid cyst intact. The patient improved and gained full consciousness within 4 days.Three years after the initial trauma, the patient has remained well. This case required a thorough discussion of the surgical options, in particular whether to intervene with the associated cyst, and whether any intervention with the cyst should be performed in the same or future operations. This dilemma forms the basis of the discussion in the following report.

A rare case of deep cerebral venous thrombosis secondary to traumatic epidural hematoma: Case report.

RATIONALE: Deep cerebral venous thrombosis (DCVT) is a rare disease, but always results in poor prognosis. PATIENT CONCERNS: We reported a 79-year-old female with coma after traumatic brain injury (TBI). DIAGNOSIS: The epidural hematoma was first diagnosed on non-contrast computerized tomography (CT). The hypodense areas in bilateral thalami and basal ganglia on reexamination CT highly indicated the suspicion of DCVT. Finally, the appearance of thrombosis of the vein of Galen on the computed tomography venography (CTA) and digital subtraction angiography (DSA) confirmed the diagnosis. INTERVENTIONS: The patients received surgery to remove the epidural hematoma. After that, she was treated with oral anticoagulation agent (low molecular weight heparin (LMWH), 180 Axal U/kg 24 h) for 4 weeks, shifted by oral warfarin (2.5 mg qd) for 4 weeks. OUTCOMES: The hypodense areas in bilateral thalami and basal ganglia have been largely reversed. At the time of 6 months after surgery, the patient could take care of herself. LESSONS: If the CT shows hypodense areas in bilateral thalami and basal ganglia, a diagnosis of DCVT should be suspected once the patients could not recover from the treatment of primary diseases.

Acute spontaneous intracranial epidural haematoma and disseminated intravascular coagulation in a paediatric sickle cell patient.

An African American teenage boy during an acute sickle cell crisis spontaneously developed acute bifrontal epidural haematomas (EDHs) in addition to disseminated intravascular coagulation (DIC). The successfully evacuated EDH reaccumulated postoperatively. After multiple transfusions, the patient underwent repeat surgery. Subsequent maximal medical therapy was unable to significantly improve the patient's neurological status, and due to family wishes, care was withdrawn. EDH are the most common emergent neurosurgical complication of sickle cell disease (SCD). Twenty-two such cases have been previously reported. We present one further complicated by DIC leading to reaccumulation of the patient's EDH. An understanding of the mechanisms of EDH formation in SCD and their associated radiological findings could help clinicians identify when a patient is at high risk of EDH formation and thus offer the potential for early intervention prior to the development of an emergency.

Emergency bedside evacuation of a subset of large postoperative epidural hematomas after neurosurgical procedures.

Postoperative epidural hematoma (POEDH) is a known complication after neurosurgical procedures. Large POEDHs are life-threatening and require emergency evacuation, and open surgery is the mainstay of treatment. Most of POEDHs are hyperdense on computed tomography (CT). We herein report a subset of POEDHs requiring evacuation, which presented with isodense features on CT. The presenting symptoms of patients were severe headache accompanied by nausea and vomiting as well as unilateral limb weakness (n = 1) and consciousness disorder (n = 4). The Glasgow coma score of the patients was 8.4 ±â€Š3.5. All patients underwent emergency bedside burr hole evacuation through a tube, rather than open surgery. The meantime for the bedside procedures is 6.0 ±â€Š1.5 minutes. All 5 POEDHs were proven liquid and evacuated successfully. All patients recovered quickly with good outcomes. We concluded that the isodensity of the POEDHs on CT represent their liquid nature. Bedside burr hole evacuation through a tube may be a recommendable method for this subset of POEDHs requiring evacuation. Thus, an open surgery and general anesthesia may be avoided.

Synchronous Diagnosis of Intradiploic Epidermoid Cyst and Anatomically Close Associated Chronic Epidural Hematoma.

BACKGROUND: Intradiploic epidermoid cyst (IEC) concurrent with chronic epidural hematoma (CEDH) has never been reported in the literature. We report a unique case of IEC concurrent with anatomically close associated CEDH. CASE DESCRIPTION: A 54-year-old man presented with a 1-week history of headache, confusion, and drowsiness. Computed tomography exposed large, extraaxial, mixed-density lesions with bone destruction and substantial mass effect in the left frontotemporal region. Magnetic resonance imaging revealed 2 adjacent extraaxial lesions. The frontal lesion was predominantly hyperintense on both T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI), with an enhancement rim of the thickened dura mater. The frontotemporal lesion was mainly hyperintense on both TlWI and T2WI, with some areas of hypointensity on both T1WI and T2WI. No enhancement in the lesion was found. The patient underwent left frontotemporal craniotomy for resection of the lesion. At the time of the craniotomy, a copious amount of yellow liquid outflowed. After the bone flap was removed, an irregular tumor was found epidurally located and composed of fragile and laminated yellow materials. The tumor was totally removed. Histologic examination revealed an epidermoid cyst. Postoperative computed tomography showed mild bleeding in the operation area. His symptoms improved significantly after surgery, and he was discharged 1 week later. At 2 weeks' follow-up, the patient was well without neurologic deficits. CONCLUSIONS: Intradiploic epidermoid cyst concurrent with chronic epidural hematoma is extremely rare. We present the first case of intradiploic epidermoid cyst concurrent with anatomically close associated chronic epidural hematoma.

Posterior Fossa Epidural Hematomas: Rare but Serious Complication of Occipitocervical Fusion Surgery.

BACKGROUND: Posterior occipitocervical fusion surgery is a commonly used surgical method to treat various craniovertebral junction pathologies. Though it is an effective method, there also have been some reports about complications of occipitocervical fusion. However, there have been no reports about posterior fossa epidural hematomas after occipitocervical fusion. CASE DESCRIPTION: A 44-year-old female was referred to our hospital with a 6-month history of neck pain and numb limbs for 2 months. On the basis of the imaging findings of the patient, the diagnosis was basilar invagination with atlantoaxial dislocation associated with Klippel-Feil syndrome and O-C1 assimilation. According to the principle of treatment, occipitocervical fusion surgery was performed. The operation was completed successfully, and the patient awoke from anesthesia 10 minutes later and went back to the orthopedic intensive care ward. Twenty hours after surgery, her mental status had deteriorated to a stupor, and both her pupils had dilated to 5 mm. Acute posterior fossa epidural hematomas were revealed by emergent computed tomography of the brain. Emergency craniectomy decompression and epidural hematoma removal surgery were performed for her in a timely manner. However, her mental status still did not improve and she fell into a deep coma. Her pupillary reflex disappeared, and then she died. CONCLUSIONS: Posterior fossa epidural hematoma is a rare complication of occipitocervical fusion surgery. Once it happens, it can be serious and even lead to death. It is important for the surgeons to realize that posterior fossa epidural hematomas may occur after the occipitocervical fusion surgery.

Bilateral Temporal Extradural Hematoma on Top of Bilateral Temporal Arachnoid Cyst: First Case Report and Extensive Literature Review.

BACKGROUND: The traumatic complication of an arachnoid cyst (AC) with intracystic and subdural hematoma has been reported in many cases. However, a unilateral extradural hematoma (EDH) as a complication of AC is extremely rare. Most arachnoid cysts are unilateral and are located in the middle cranial fossa. Bilateral temporal AC alone is an extremely rare condition, and a bilateral EDH on top of a bilateral temporal AC has never been reported in the literature, to our knowledge. CASE DESCRIPTION: We report the case of a 25-year-old man with a known bilateral AC who was involved in a motor vehicle accident and developed a bilateral temporal EDH. The brain computed tomography scan also showed fractures in the skull on both temporal areas. The patient was treated conservatively. He was discharge with Glasgow Coma Scale score of 5. CONCLUSIONS: Bilateral temporal EDH in a bilateral temporal AC has never been reported in the literature. The presence of an AC may predispose a patient to complications because of the anatomic changes in the area. It is important to educate asymptomatic patients and their families about these cysts and the importance of avoiding head injury and not being involved in contact sports or military service.

Pediatric patients with traumatic epidural hematoma at low risk for deterioration and need for surgical treatment.

BACKGROUND: Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable. OBJECTIVES: Create a prediction rule to identify patients with EDH unlikely to fail hospital observation. METHODS: Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation. RESULTS: Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20). CONCLUSION: Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation. LEVEL OF EVIDENCE: Retrospective cohort level I.

Is the presence of linear fracture a predictor of delayed posterior fossa epidural hematoma?

BACKGROUND: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated. METHODS: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH). RESULTS: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05). CONCLUSION: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.

Retrospective analysis of 14 cases of remote epidural hematoma as a postoperative complication after intracranial tumor resection.

BACKGROUND: The occurrence of remote epidural hematoma as a postoperative complication after intracranial tumor resection is rare. This study reviewed experiences treating these hematomas and speculated on the causes of this disease. This study reviewed the treatment experience of 14 such cases. METHODS: The 14 patients included 10 males and 4 females, with an age range of 19 to 65 years old. Six cases of tumors occurred in the sellar region, two cases in the lateral ventricle, one case in the fourth ventricle, one case in a cerebellar hemisphere, and four cases in other sites. Among them, five cases were complicated with supratentorial hydrocephalus. The tumors included five cases of meningioma tumors, two cases of pituitary adenomas, three cases of ependymomas, two cases of craniopharyngiomas, one case of astrocytoma, and one case of tuberculosis tumor. For the cases complicated with hydrocephalus, ventricular drainage was provided if needed, and the tumor resection was then performed, with close observation for postoperative changes. If neurological symptoms and disturbance of consciousness occurred, computed tomography (CT) examination was immediately performed. If a remote epidural hematoma was found, the hematoma was evacuated by craniotomy. The patients were followed up after surgery. In the five cases complicated with hydrocephalus, ventricular drainage was first provided for three cases. RESULTS: All of the 14 cases underwent total tumor resection, and postoperative remote epidural hematoma occurred in all cases, including eight cases on the ipsilateral side and adjacent to the supratentorial operative field; two cases occurred on the contralateral side; two cases occurred on bilateral sides; and two cases occurred in distant areas (with infratentorial surgery, the hematoma occurred on the supratentorial area). Postoperative remote epidural hematoma usually occurred 0.5-5 h after the tumor resection, when the tentorial hernia had already occurred. Following tumor resection and epidural hematoma evacuation, 13 patients were discharged with good recovery, and one patient died. CONCLUSIONS: The reduced intracranial pressure due to the intracranial tumor resection may be the cause of this hematoma. This type of epidural hematoma is acute and often occurs before hernia. Thus, the risk of remote epidural hematoma after intracranial tumor resection needs to be made known. Aggressive hematoma evacuation can often result in satisfactory outcomes for patients.

Traumatic acute extradural haematoma - Indications for surgery revisited.

Extradural haematomas (EDH) occur in approximately 2% of all head injuries but account for a significant proportion of fatal head injuries with mortality rates ranging from 1.2 to 33%. The expeditious surgical evacuation of EDH is associated with an excellent prognosis and is considered the most cost-effective operation performed by neurosurgeons. The Brain Trauma Foundation (BTF) has produced informative guidance on the management of EDH. The criteria laid out for conservative management comprises non-comatose patients with EDH less than 30 cm in volume, less than 15 mm thick and causing less than 5 mm midline shift. The BTF recommends that all patients with an EDH volume of greater than 30 cm(3) should undergo surgical evacuation regardless of Glasgow Coma Scale. 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 mind, we believe the indications for surgical evacuation of EDH merit renewed consideration.

Novel Clinical Scale for Evaluating Pre-Operative Risk of Cerebral Herniation from Traumatic Epidural Hematoma.

Secondary massive cerebral infarction (MCI) is the predominant prognostic factor for cerebral herniation from epidural hematoma (EDH) and determines the need for decompressive craniectomy. In this study, we tested the clinical feasibility and reliability of a novel pre-operative risk scoring system, the EDH-MCI scale, to guide surgical decision making. It is comprised of six risk factors, including hematoma location and volume, duration and extent of cerebral herniation, Glasgow Coma Scale score, and presence of preoperative shock, with a total score ranging from 0 to 18 points. Application of the EDH-MCI scale to guide surgical modalities for initial hematoma evacuation surgery for 65 patients (prospective cohort, 2012.02-2014.01) showed a significant improvement in the accuracy of the selected modality (95.38% vs. 77.95%; p = 0.002) relative to the results for an independent set of 126 patients (retrospective cohort, 2007.01-2012.01) for whom surgical modalities were decided empirically. Results suggested that simple hematoma evacuation craniotomy was sufficient for patients with low risk scores (≤9 points), whereas decompressive craniectomy in combination with duraplasty were necessary only for those with high risk scores (≥13 points). In patients with borderline risk scores (10-12 points), those having unstable vital signs, coexistence of severe secondary brainstem injury, and unresponsive dilated pupils after emergent burr hole hematoma drainage had a significantly increased incidence of post-traumatic MCI and necessity of radical surgical treatments. In conclusion, the novel pre-operative risk EDH-MCI evaluation scale has a satisfactory predictive and discriminative performance for patients who are at risk for the development of secondary MCI and therefore require decompressive craniectomy.

Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature.

BACKGROUND: Trauma is the leading cause of death in people younger than 45 years and head injury is the main cause of trauma mortality. Although epidural hematomas are relatively uncommon (less than 1% of all patients with head injuries and fewer than 10% of those who are comatose), they should always be considered in evaluation of a serious head injury. Patients with epidural hematomas who meet surgical criteria and receive prompt surgical intervention can have an excellent prognosis, presumably owing to limited underlying primary brain damage from the traumatic event. The decision to perform a surgery in a patient with a traumatic extraaxial hematoma is 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. CASE REPORT: A 30-year old man arrived at our Emergency Department after a traumatic brain injury. General examination revealed severe headache, no motor or sensory disturbances, and no clinical signs of intracranial hypertension. A CT scan documented a significant left fronto-parietal epidural hematoma, which was considered suitable for surgical evacuation. The patient refused surgery. Following CT scan revealed a minimal increase in the size of the hematoma and of midline shift. The neurologic examination maintained stable and the patient continued to refuse the surgical treatment. Next follow up CT scans demonstrated a progressive resorption of hematoma. CONCLUSIONS: We report an unusual case of a remarkable epidural hematoma managed conservatively with a favorable clinical outcome. This case report is intended to rather add to the growing knowledge regarding the best management for this serious and acute pathology.