Introduction

Extradural Hematoma (EDH) forms 0.5% of all head injuries.₁ Conventionally urgent evacuation is the accepted mode of management .₂ With the routine use of Computer Tomogram(CT) for management of head injury patients , nonoperative management is being used more often in selected patients .₁₂₃₄ Five cases of EDH which were managed conservatively and discharged without neurological sequele, are reported here. The common factors amongst these cases have also been enumerated.

Materials and method

Patients having a traumatic EDH with a Glasgow coma Score (GCS) of 15/15 were included in the study. Other inclusion criteria were – Volume less than 25mL (as calculated by Peterson and Esperson equation), ₅ absence of midline shift or mass effect and no other lesion on CT scan. Infratentorial EDH was excluded. All patients were monitored in a neurosurgical Intensive care unit. Specifically GCS, pulse, blood pressure, pupils were observed. The study did not interfere with the set neurosurgical protocols for head injury management.

Results

Out of 6 patients included one patient became drowsy and had to be operated. Five patients were successfully managed conservatively. Mode of injury was road traffic accident in all cases .A summary of the cases is shown in table 1 .All patients were males in the age group 18-30 years (mean age 23.4 years), Location was in the parietal region in 3 cases; frontal in two, The volume of EDH ranged from 9mL – 23mL (mean 17.3mL).At no point of time did any of the five case show any signs of raised intracranial pressure. Immediate neurosurgical care was available at all times.

Figure 1

Table 1: Summary of cases

Discussion

Patients with EDH who are conscious have a mortality of almost nil.₁ Non operative management of EDH is well documented. Patient selection is of utmost importance in conservative management of EDH. Various factors have been found to influence the management strategy.

Volume : Dubey etal₃ and Bezircioglu etal ₆have recommended a volume of EDH less than 30mL for conservative management ,Bullock etal₇ found 12 -38mL suitable ,whereas Giordano etal₈ have managed patients with a volume upto 55mL ,without surgery.

Location: Most studies have taken only supratentorial hematomas into consideration.₃₄₅₆ Wong₉ reports a posterior fossa EDH volume less than 10mL to be favorably managed conservatively. Temporal EDH is unlikely to be managed conservatively₃₆ as compared to frontal or parietal.

GCS: a lower GCS has been associated with a worse outcome in most studies ₁₃₁₀₁₁

Others factors like a thickness > 15mm and a midline shift > 5mm have also been found to unfavorably influence the outcome.₁₂

Another important consideration is the timing of repeat CT scan.Sullivan etal₁₃ have shown that EDH enlargement occurs within 36 hours and a repeat CT is useful at this time .EDH enlargement occurred in 23% of patient and mean time to enlargement was 8 hours of injury.₁₃

Conclusions

Non operative management of EDH can be a safe option in carefully selected patients, where close monitoring is available.