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

Abstract

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.

Causes and risk factors of an unplanned second craniotomy in patients with traumatic brain injury

“…The early evacuation of EDH adjacent to the big cerebral vessels and effective prevention and treatment of subdural effusion after DC could avoid the occurrence of ipsilateral massive cerebral infarction. Lin et al [ 12 ] had established an early-warning scoring model for massive cerebral infarction after acute EDH evacuation, which enabled decision-making regarding additional DC to prevent the occurrence of massive cerebral infarction. Wan et al [ 13 ] suggested that early cranioplasty was the most effective method for preventing or treating contralateral intractable subdural effusion.…”

Comparative effectiveness of different surgical procedures for traumatic acute epidural haematoma: study protocol for Prospective, Observational Real-world Treatments of AEDH in Large-scale Surgical Cases (PORTALS-AEDH)

“…There is controversy concerning the initial neurosurgical management of AEDH 4 22 23. Neurosurgeons are confronted by the decision to evacuate the haematoma with or without a DC in some cases, especially for patients with brain herniation 24 25. More interestingly, for possible delayed haematoma development, in addition to surgery, MMA endovascular coil embolisation has the potential role 26–28.…”

Prospective Randomized Evaluation of Decompressive Ipsilateral Craniectomy for Traumatic Acute Epidural Hematoma (PREDICT-AEDH): study protocol for a randomized controlled trial

“…There is controversy with regard to the initial neurosurgical management of AEDH [4,12,13]. Neurosurgeons are confronted by the decision to evacuate the hematoma with or without a DC in some cases, especially for patients with brain herniation [6,14]. The BTF recommends that all patients with an EDH volume of greater than 30 cm 3 should undergo surgical evacuation of hematoma regardless of Glasgow Coma Scale [3].…”