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Acta Neurochir (Wien) (1994) 126:124-127

Springer-Verlag 1994 Printed in Austria

The CT Criteria for Conservative Treatment-but Under Close Clinical Observation- of Posterior Fossa Epidural Haematomas Ch.-W. Wong Division of Neurosurgery, Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College,, Taipei, Taiwan, Republic of China

Summary

tients u n d e r g o i n g

In order to assess whether the indications for conservative treatment of supratentorial epidural haematomas are applicable also to posterior fossa epidural haematomas (PFEDH), the author reviewed the records of 25 patients. With a PFEDH volume of no more than l 0 ml, a thickness of no more than 15 mm, a midline shift of no more than 5 mm, and in the absence of a significant intracranial haematoma elsewhere on computed tomography (CT) scans, the patients undergoing conservative treatment achieved the same excellent outcome as those undergoing early surgery. These CT criteria for conservative treatment of PFEDHs are similar to those of supratentorial epidural haematomas except the volume factor, namely, 10 ml in the former against 30ml in the latter. That means a PFEDH of 10ml or larger in the small posterior fossa may produce the same degree of midline shift and compression, and be as dangerous as an epidural haematoma of 30 ml or larger in the more capacious supratentorial compartment. But also for epidural haematomas of the posterior fossa, which initially are smaller than 10 ml, the general rule remains valid that they should be under close clinical supervision

treatment for their PFEDHs.

Keywords: Head injury; epidural haematoma; posterior fossa; conservative treatment.

Introduction While the traditional treatment of a posterior fossa e p i d u r a l h a e m a t o m a ( P F E D H ) is to h a v e it e v a c u a t e d s u r g i c a l l y a n d p r o m p t l y 1' 8, 9, 13, 24, 25, 29, 31 a n u m b e r o f p a t i e n t s w i t h a P F E D H h a v e b e e n successfully t r e a t e d w i t h o u t o p e r a t i o n 4' 7, 17, 20, 28, in a w a y s i m i l a r t o t h o s e

either early surgery or expectant

Patients and Methods From April, 1985 to April, 1993, 27 patients with a diagnosis of PFEDH were admitted to Chang Gung Memorial Hospital at Keelung. Two deceased patients with an accompanying intracerebellar haematoma in addition to a PFEDH were excluded; one underwent surgery as soon as the diagnosis was made and the other received expectant treatment. Expectant treatment was defined as hourly monitoring of the vital signs, pupillary reflexes and Glasgow Coma Scale (GCS) of the patients in the observation unit by specially trained nurses for 1 to 2 days before these patients were transferred to the ward. The post-traumatic condition of the patients was assessed by specialist neurosurgeons at the clinic. All the CT studies were performed by the scanner: Synerview 1200 SX (Picker International, Cleveland, Ohio, USA). The thickness of CT slices was 1 cm. The volumes of the PFEDHs were estimated with the formula: 0.5 x height x length x width ~8. When the haematoma extended beyond the posterior fossa, the PFEDH was measured up to the CT slice 1 cm cephalad to the mastoid bone. A midline shift was determined by measuring the deviation of the centre of the 4th ventricle to the line between the occipital protuberance and the midpoint of the clivus, or the midpoint of the sphenoid sinus on CT scans. All the statistical analyses were performed according to the Chi-Square Test with Yates' correction.

Results T h e r e w e r e 25 p a t i e n t s . C a s e s 1 to 17 u n d e r w e n t

w i t h a s u p r a t e n t o r i a l e p i d u r a l h a e m a t o m a 2' 3, 5, 6, 10, 11,

surgical evacuation of the PFEDtts

17,19,21-23, 27. T h i s is m a d e p o s s i b l e b y t h e e a r l y d i a g n o s i s

f o r f u r t h e r d e t e r i o r a t i o n o f the n e u r o l o g i c a l c o n d i t i o n

of an intracranial haematoma by computed tomog r a p h y ( C T ) 12' 16, 26, 30. I n o r d e r to assess w h e t h e r the

ment and 3 of them had their PFEDH

without waiting

( T a b l e 1). C a s e s 18 to 25 u n d e r w e n t e x p e c t a n t t r e a t evacuated later

c r i t e r i a f o r c o n s e r v a t i v e t r e a t m e n t o f s u p r a t e n t o r i a l epid u r a l h a e m a t o m a s 17' 19, 23, 27 are s u i t a b l e f o r P F E D H s

o n ( T a b l e 2). A l l t h e 25 p a t i e n t s p r e s e n t e d w i t h i n 48

as well, the a u t h o r c o m p a r e d t h e o u t c o m e s o f 25 p a -

PFEDH

h o u r s a f t e r t h e i n j u r y e x c e p t cases 14 a n d 25 w h o s e w a s d i a g n o s e d at d a y 5 a n d d a y 7 r e s p e c t i v e l y .

Ch.-W. Wong: Posterior Fossa Epidural Haematoma

125

Table 1. Patients Undergoing Early Surgery Cases Sex/Age

GCS PFEDH ThickMidline Other score (ml) ness (ram) shift (mm) haematoma

1~ 2 3 4 5 6 7 8 9 !0 11 12 13 14

M/28 M/44 M/48 M/36 M/32 M/20 F/66 F/54 F/33 F/22 F/17 F/30 F/21 F/4

7 15 8 8 2; 15 13 10 9 9 8 6 12 15

15

F/5

15

16 17

M/4 F/47

15 14

17 3 12 15 14 4 4 22 7 4 7 12 5 9 24 12 13

19 10 24 20 20 20 20 27 10 12 18 20 12 16 20 20 21

4.0 1.0 5.0 6.0 5.0 5.0 4.0 7.5 1.0 0 0 3.0 2.0 7.0 7.0 3.0 5.5

O, Fi* O, P O, P O, T O Fi* Fi, Ti* O O,P,T

O, T* O O O

a Deceased. * Haematoma contralateral to the PFEDH. Fi, Ti frontal and temporal intracerebral contusion haematoma respectively; O,P,T occipital, parietal, and temporal epidural haematomas respectively.

Table 2. Patients Undergoing Expectant Treatment Cases Sex/Age GCS PFEDH ThickMidline Other score (ml) ness (mm) shift (ram) haematoma 18~,b 19a,b 20" 21b 22 23 24 25

F/40 M/20 M/63 M/18 M/34 M/10 M/8 F/7

14 15 7 15 15 15 15 15

12 16 15 i6 4 4 3 4

20 23 30 21 10 14 11 13

3.0 5.5 5.0 5.0 2.0 4 3 4

Fi* Fi* Fi, Fi* O,P*,T* O O O

a Deceased. b Delayed surgery. * Haematoma contratateral to the PFEDH. Fi frontal intracerebral contusion haematoma; O,P, T occipital, parietal, and temporal epidural haematomas respectively.

Case 1 did not improve after the suboccipital craniect o m y and repeat C T scans before his death demonstrated a residual P F E D H . In the expectant group, cases 18, 19, and 21 underwent surgical evacuation o f the P F E D H s 5, 14, and 12 hours after the diagnosis was made when they manifested a G C S score o f 13 and 3, and bradycardia respectively. Case 20 died rap-

idly without surgery. Cases 22, 23, 24, and 25 survived the nonsurgical treatment and remained well at fellowup periods o f 2 years, 3, 12, and 2 weeks respectively. O f the 13 patients with a P F E D H o f m o r e than 10ml (Tables 1 and 2), 8 out o f 9 survived the early operation and one out o f 4 survived the expectant treatment ( p < 0.05). However, all the 12 patients with a P F E D H o f less than 10 ml m a d e a g o o d recovery, no matter whether undergoing early surgery or expectant treatment. W h e n the 17 patients with a P F E D H thickness o f more than 15 m m were studied, 12 early surgical patients survived and so did one expectantly treated patient (p < 0.01). In the remaining cases, 4 early surgical and 4 "expectant" patients whose P F E D H thickness was less than 15 ram, the survival rate was 100%. There were 6 patients who had a midline shift o f m o r e than 5 m m on the C T scans, 5 surviving the early surgery and none (case 19) the delayed operation (p < 0.05). O f the 19 patients with a midline shift o f no m o r e than 5 mm, 11 out o f 12 survived the early surgery and 5 out o f 7 survived the conservative treatment (p > 0.05). While most o f the occipital and parietal epidural h a e m a t o m a s a c c o m p a n y i n g the P F E D H s were evacuated at the same procedure, a separate temporo-parietal c r a n i o t o m y for the evacuation o f the other supratentorial h a e m a t o m a was performed in cases 7, 12, and 21. All the frontal intracerebral contusion haem a t o m a s were treated conservatively (cases 1, 6, 7, 18, 19, and 20). Regardless o f the m o d e o f treatment for the 25 P F E D H s in this series, 4 o f the 6 patients with a frontal intracerebral contusion h a e m a t o m a died, but no one died o f the 19 patients who did not have such h a e m a t o m a s (p < 0.001). Nearly all the survivors became a s y m p t o m a t i c 4 days after the evacuation o f the P F E D H and remained free o f neurological deficit related to the P F E D H for a follow-up period o f 1 week to 42 months. The other aspects o f the two groups of patients were similar. R o a d traffic accident was the cause o f injury in 13 o f the 17 early surgical patients and in 6 o f the 8 " e x p e c t a n t " ones. A n initial loss o f consciousness was d o c u m e n t e d in cases 1, 3, 4, 6, 9, 10, 11, 12, and 13 in the former g r o u p and in cases 20, 24, and 25 in the latter. Cases 1, 2, 3, 4, 8, and 12 developed anisocoria. Hemiparesis was present in cases 1, 4, 8, 12, and 22. A fracture o f the occipital bone was evident in 82% o f the early surgical patients and in 50% o f their counterparts. Ventriculomega~y was present in the

126 C T scans o f cases 5 a n d 8. Bleeding f r o m the transverse sinus was evident at the o p e r a t i o n o f all the p a t i e n t s except case 11 w h o h a d bleeding f r o m the f r a c t u r e d bone.

Discussion O u r d a t a s h o w e d t h a t u n d e r g o i n g " e x p e c t a n t ' treatment, the p a t i e n t s with P F E D H v o l u m e o f m o r e t h a n 10 ml, a thickness o f m o r e t h a n 15 m m , a n d a midline shift o f m o r e t h a n 5 r a m h a d a significantly higher m o r t a l i t y t h a n t h o s e u n d e r g o i n g e a r l y surgery. H o w ever, the higher m o r t a l i t y o f these p a t i e n t s m i g h t be related m o r e significantly to the a s s o c i a t e d f r o n t a l int r a c e r e b r a l c o n t u s i o n h a e m a t o m a s t h a n the P F E D H s a l t h o u g h the G C S scores o f cases 1, 18, 19, a n d 20 were n o t p a r t i c u l a r l y w o r s e t h a n those with o n l y epid u r a l h a e m a t o m a s (Tables 1 a n d 2). It is therefore difficult to d r a w a c o n c l u s i o n f r o m o u r d a t a u p o n the C T criteria for the early surgery o f P F E D H s . O n the o t h e r h a n d , for t h o s e w i t h a P F E D H v o l u m e o f no m o r e t h a n 10 ml, a thickness o f no m o r e t h a n 15 m m , a n d a m i d l i n e shift o f n o m o r e t h a n 5 m m , the survival rates were excellent in b o t h the early surgical a n d the c o n s e r v a t i v e l y t r e a t e d patients. This raises the q u e s t i o n w h e t h e r cases 10 a n d 13 c o u l d have d o n e well w i t h o u t the surgical e v a c u a t i o n o f their small P F E D H s as cases 22, 23, 24, a n d 25 did. W i t h the P F E D H s c o m p a r a b l e to those o f cases 10 a n d 13, cases 2 a n d 9 p r o b a b l y should, as they did, u n d e r g o early surgery n o t for the P F E D H s b u t for the a s s o c i a t e d s u p r a t e n torial e p i d u r a l h a e m a t o m a s . A l t h o u g h a b r u p t deterio r a t i o n a n d d e a t h h a v e been r e p o r t e d in p a t i e n t s with a P F E D H 13-1s' ~9, given the g o o d o u t c o m e o f cases 22 to 25, it m a y be w o r t h w h i l e to reserve " e x p e c t a n t " t r e a t m e n t for those with a P F E D H v o l u m e o f n o m o r e t h a n 10 ml, a thickness o f no m o r e t h a n 15 m m , a m i d line shift o f no m o r e t h a n 5 m m , a n d in the absence o f a significant i n t r a c r a n i a l h a e m a t o m a elsewhere on the C T scans. These C T i n d i c a t i o n s for c o n s e r v a t i v e treatm e n t for P F E D H s are similar to those for the s u p r a t e n t o r i a l e p i d u r a l h a e m a t o m a s except the v o l u m e factor, n a m e l y , 10 ml in the f o r m e r a n d 30 ml in the latter 6' 17, 19, 23, 27. This is n o t s u r p r i s i n g because a 10-mlP F E D H in the small p o s t e r i o r fossa m a y i n d u c e the s a m e degree o f m i d l i n e shift as a 3 0 - m l - e p i d u r a l haem a t o m a in the s u p r a t e n t o r i a l c o m p a r t m e n t .

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Correspondence: Cheuk-Wah Wong, M.D., Chang Gung Medical Community, 223-3/F, Kweishan, Taoyuan 33333, Taiwan~Republic of China.