Outcome of traumatic extradural haematoma in Hong Kong

Summary

Aim

Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong.

Patients and methods

Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001–2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined.

Results

Two thousand and two hundred and eight patients were in the trauma registry for 2001–2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13–15, 9 (10%) GCS 9–12 and 18 (20%) GCS 3–8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS < 8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days.

Conclusion

Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.

Introduction

Traumatic extradural haematoma (EDH) has been recognised for more than 140 years.⁵ 100 years ago, the mortality rate of EDH was as much as 86%⁶ and traumatic EDH remains a true neurosurgical emergency. Until the late 1970s, when angiography was used for diagnosis [the era before computed tomography (CT)], the mortality rate was 30% or higher.³

With the introduction and wide availability of cranial CT, early diagnosis and timely surgical intervention for EDH is an attainable gold standard. Indeed, the treatable nature of EDH has led some authors to suggest that “toward zero mortality” is an achievable target with respect to this condition.¹ Studies examining the incidence and outcome of EDH have been performed around the world¹¹ including previous reports from Hong Kong.1, 9, 11

The aim of this prospective observational study was to determine the incidence, mortality and functional outcome [measured by Glasgow Outcome Scale (GOS)]⁷ of all consecutive patients with traumatic EDH who were admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH) in Hong Kong over the 4 year period from 2001 to 2004 inclusive.