“CLINICAL EVALUATION AND MANAGEMENT OUTCOME OF EXTRADURAL HAEMATOMA”
BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the Study:
Intracranial haematomas, as we describe it are hematomas anywhere in the cranial cavity depending on the various sites – extradural haematoma, subdural haematoma, subarachnoid bleed, intraparenchymal and intraventricular bleed due to different causes, most commonly due to trauma to head (RTA, assault, sports, fall), rupture of aneurysms, altered coagulation profile, hypertension, chronic drug abuse like aspirin.
Traumatic Brain Injury (TBI), affects 2% of the population per year, and constitutes the major cause of death and disability among young people. By far, the most important complication of TBI is development of intracranial haematoma, which complicates 25%-45% of severe TBI cases, 3-12% moderate TBI cases, and approximately 1 in 500 patients with mild TBI1.
Extradural haematomas (EDH) constitutes one of the most common intracranial hematomas where in the collection of blood is formed between inner table of skull and the dura mater. Usually the brain beneath it is not injured. The blood collection is most commonly due to injury of the middle meningeal artery, although it can also occurs due to injury of dural venous sinuses, diploic veins.
Patient history and clinical examination, time since the onset of bleeding is important as it determines the mode of management of the patient and to prevent the complications due to increasing size of haematoma due to its pressure effects. Accordingly grading of consciousness is assessed clinically by Glasgow coma scale as Mild-13 to 15, Moderate-9 to 12, Severe-3 to 8, taking eye movements(4) verbal response(5) and motor activity(6) into consideration.
Factors like patients age, time of presentation since injury or the onset of symptoms, initial neurological status and continued assessment of consciousness of the patient with GCS, and with the help of CT scan head showing size of hematoma, associated brain parenchymal injuries and other associated systemic condition, this study can give a comprehensive idea and approach towards the management of the patient if the patient requires surgical intervention or with the conservative treatment.
6.2 Review of Literature:
The peak incidence of EDH is in the second decade, and the mean age of the patients with EDH is between 20-30 years of age. EDH is a rare entity in patients older than 50-60 years of age due to adherent dura with the cranium and is less frequent in very young children and neonates due to pliable nature of skull which resists fracturing1,2.
EDH can result from injury of the middle meningeal artery, middle meningeal veins, diploic veins, or the venous sinuses. Historically, bleeding from middle meningeal artery had been considered the main source of EDH. In a recent report on EDH in 102 pediatric patients and 387 adults, arterial bleeding was identified as the source of EDH in 36% of adults and only in 18% of children. In 31% of pediatric patients, bleeding source could not be identified and venous bleeding was accounted in approximately 32% of patients of EDH in both the age groups.1
It presents more commonly in temporoparietal and temporal regions1 and infrontal2,3 regions, occipital region and posterior fossa according to decreasing order of frequency.
Although most number of patients present with no neurological deficit initially, the patient can present in altered sensorium with symptoms like head ache, vomiting, Lucid interval (initially patient in unconscious state, then wakes up and the patient progresses to secondary deterioration), altered pupil and corneal reflexes, seizures.
Eventhough GCS scale is the preferred scale in assessing the level of consciousness, conditions like hypotension, hypoxia, alcohol intake and drugs may lead to abnormal neurological examination and may lead to overjudjement of the severity of primary head injury4.
According to guidelines for initial conservative treatment5, patients with EDH are treated conservatively when,
In patients who are fully conscious.
When the extra axial mass lesion is the single dominant lesion, i.e. there should not be multiple contusions or potentially significant contralateral mass lesions (which may be preventing midline shift).
When there are no features of mass effect such as midline shift greater than 3mm, or basal cistern effacement (Bullock and Teasdale, 1991). Clot volume < 30cm3, maximum thickness <1.5 cm, and GCS score >8.6
Small EDH in frontal polar or temporal polar are also managed conservatively.
Indications for surgical removal are,1,5
Presence of a mass lesion >40 ml, more than 15mm thickness, more than 5mm of midline shift (MLS) and GCS score <8 .
in the conscious, communicating, non-ventilated patient:
– decline in conscious state;
– development of focal signs;
– severe and especially worsening headache, nausea
in the unconscious, non-communicating, ventilated patient:
Either of these developments should lead to an urgent CT scan.
increase in haematoma size on CT scan (Galbraith and Teasdale, 1981).
Following Marshall’s CT classification, CT criteria such as hematoma volume over 25cm3 considered as the “prevailing” indication for evacuation of posttraumatic hematomas7.
Repeated CT monitoring of conservatively managed patients with EDH for rehaemorrhage is utmost important and is most appropriately timed in the first 36 hours after injury, with most cases of EDH enlargement occurring by 8 hours after injury8.
Moreover, intubation and chemical paralysis seem to have protective effects against EDH enlargement, perhaps by the control of head movement, blood pressure,and possibly ICP. Finally, EDH rehaemorrhage does not appear to result in worse neurologic status at discharge in conservatively managed patients8.
Determinants of outcome in patients undergoing surgical evacuation of EDH are GCS, age, pupillary abnormalities, associated intracranial masses or lesions, time between neurological deterioration and surgery and intracranial pressure. This can be graded by Glasgow Outcome Scale (GOS).1
6.3 Objectives of the study: To evaluate the presentation of patients with extradural haematoma secondary to head injury.
To decide upon the management based on Glasgow Coma Scale, CT Scan findings.
To study the results of the management outcome.
To study the factors affecting morbidity and mortality.
MATERIALS AND METHODS:
7.1 Source Of Data :
Data will be collected through a prescribed proforma from among the patients admitted in Department of surgery, Chigateri district hospital and Bapuji hospital, Davangere with extradural haematoma during the period November 2012 to October 2014.
7.2 Method Of Collection Of Data (Including sampling procedure if any):
All the patients with head injury on CT scan diagnosed to have EDH were included in the study. These patients were admitted, complete clinical evaluation and repeat CT scanning is done if necessary.
The management includes conservative measures and/or surgical intervention.
The patient is followed for the results during the period of stay in hospital.
The present study includes 50 patients of EDH who completes the inclusion and exclusion criteria were evaluated for the outcome in Chigateri district hospital and Bapuji hospital, Davangere. The period of study is from November 2012 to October 2014.
Number of cases for the study: 50 cases.
Patients admitted with head injury following
road traffic accident,
fall from height.
Patients confirmed to have isolated EDH on CT scan.
Patients aged between 15-70 years.
Patients with EDH associated with
Intraparenchymal/ intraventricular haemorrhage.
Patients with abdominal/chest injuries and limb fractures.
Children are not included.
Statistical analysis :
The results will be subjected for appropriate statistical analysis. Categorical data will be analyzed by Chi-square test / Fisher’s exact test.
7.3 Does the study require any interventions or investigations to be conducted on patients? If so please describe briefly.