OBJECTIVE: To analyze clinical and imaging characteristics of post-traumatic posterior fossa extradural hematoma (PFEDH).
METHODS: Between 2018 and 2022, 51 patients were admitted to our tertiary care trauma center with a diagnosis of PFEDH. The management decision was tailored by an individual consultant based on clinicoradiological findings. We did a prospective analysis of patient characteristics, radiology, clinical presentation, management, and outcome at discharge and onemonth follow-up.
RESULTS: Of the 51 patients diagnosed with a PFEDH, 45 (88.2%) were male, and six (11.8%) were female with a mean age of 31.2 years (range 2-77 years). Twenty-six patients needed surgical evacuation of the EDH, while the rest 25 patients were managed conservatively. There was one crossover patient from the conservative to the surgical arm. Road traffic accidents (RTA) were the most common cause of injury (n=35; 68.6%), followed by falls from height (n=16; 31.4%). Most patients presented with vomiting and loss of consciousness (LOC). At presentation, 30 patients (58.5%) had a GCS 15. Seven patients (13.7%) presented with a GCS of 9-14, and 14 patients (27.5%) with GCS ≤ 8. The mean EDH volume in conservatively and surgically managed patients was 14.1 and 25.1cc, respectively. Five patients (9.8%) had significant midline shift with obliteration of basal cisterns, 15 patients (29.4%) had effacement of the fourth ventricle, and 11 patients (21.5%) had the presence of hydrocephalus. All patients with features suggestive of tight posterior fossa (hydrocephalus, obliterated basal cisterns, and fourth ventricle compression) needed surgical intervention. Of the 25 conservatively managed patients, 24 (96%) had favorable GOS scores at discharge, while one (4%) had an unfavorable score. 16/26 (61.5%) surgically treated patients had a good outcome at discharge (GOS=4-5), while ten patients (38.4%) had adverse outcomes (GOS < 4). Initial EDH volume was inversely correlated with presenting GCS and GOS with a mean volume of 21.5 ± 8.5 cc in patients presenting with a GCS ?8. Patients with a GCS of 15 at presentation had a mean EDH volume of 16.1 ± 8.2 cc. Patients with smaller EDH had much higher GOS scores than patients with higher volume EDH (GOS 1 = 22.0 ± 9.83 cc vs. GOS 5 = 18.9 ± 12.2 cc). Outcomes mainly depended on factors like GCS at arrival and associated supratentorial, thoracic/ abdominal polytrauma.
CONCLUSIONS: In patients with a clot volume of < 15 cm3 and GCS of 15 at presentation with no mass effect and absence of tight posterior fossa, a conservative trial under strict clinicoradiological monitoring in a neuro-critical multidisciplinary setting can be offered with good results. In cases of altered GCS, findings of a TPF, or clinicoradiological deterioration, immediate surgery is warranted.

Preoperative clinical and imaging findings predict neurological outcomes in patients with traumatic brain injury (TBI). Similarly, intraoperative factors such as blood loss and hypotension can also affect outcomes. However, there is not much data regarding the influence of perioperative variables on clinical outcomes in patients with extradural hematoma (EDH). This study aimed to understand the effect of perioperative factors on short-term neurological outcomes in patients operated for acute traumatic EDH.
After obtaining institutional ethical approval, we collected data retrospectively from records of patients who underwent emergency surgery for acute traumatic EDH over a two-year period. Data regarding age, gender, preoperative Glasgow coma scale (GCS) score, clinical and imaging findings, surgical and anesthetic details, blood loss and transfusion, duration of hospital stay, and GCS score at discharge were collected. Patients with discharge GCS score of 14-15 were considered to have favorable outcome and <14 as unfavorable outcome. Regression analysis was performed to examine the association between predictors and outcomes. Odds ratios (OR) and 95 % confidence intervals (CI) were calculated.
Data of 501 patients were analyzed. Outcome was favorable in 343 (68.5 %) and unfavorable in 158 (31.5 %) patients. On multivariate logistic regression analysis (OR, 95 % CI, p value), age (1.03, 1.01-1.05, 0.01), preoperative GCS score (0.68, 0.61-0.76, <0.001), signs of basal skull fracture (1.9, 1.02-3.61, 0.043) and intraoperative blood loss (2.23, 1.2-4.16, 0.01) were independently associated with unfavorable outcome. Pneumonia, neurological deficits, inotrope use and duration of hospital stay was more in this group.
Older age, poor pre-operative GCS score, signs of basal skull fracture, and intraoperative blood loss were associated with lower discharge GCS score, increased neurological deficits and longer hospital stay in patients operated for acute traumatic EDH.

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients.
This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score.
Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups.
Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission.

There is an ongoing debate whether a surgical drainage is beneficial to prevent local accumulation of hematoma and to reduce the rate of wound infections, and neurological deficits. Data from the German Spine Society (DWG) registry were filtered for surgically treated spine tumor cases between 2017 and 2021. Cases were categorized into with (Group I) and without (Group II) placement of a surgical drainage. Subgroups were compared for demographic data, type of surgery, experience of the surgeon and postoperative surgical complications. 10,029 cases were included into final analysis (Group I: 3007; Group II: 7022). There was no significant difference between both groups regarding age or gender distribution. Average morbidity of patients was significantly elevated in Group I (p < 0.05) and the rates of invasive surgery were significantly increased in this group (p < 0.001). Overall complication rates were reported with 12.0% (Group I) and 8.5% (Group II). There were significantly more epidural hematoma (p < 0.001) and motor dysfunction (p = 0.049) as well as deep wound infections (p < 0.001) and implant failures (p = 0.02) in Group I. A surgical wound drainage cannot prevent epidural hematoma.

Epidural Hematoma (EDH) is a common condition of traumatic brain injury. It has a good prognosis if prompt surgical intervention is conducted. There is a dearth of studies on neuropsychological assessment of executive functioning exclusively in post-operative EDH patients. Moreover, age as a variable in determining executive functions in patients post-head injury, has been studied mostly in the older adults. This cross-sectional case-control study assessed Executive Functions (EF) in 62 post-surgery patients with EDH and compared 57 healthy controls (HC) using standardized assessment tools of sustained attention, speed, working memory, fluency, set-shifting, perseveration, planning, and response inhibition. Further, executive functions in two phases of adulthood, viz. Early Adulthood (20-39 years) and Middle Adulthood (40-60 years) were compared in the EDH group (E-EDH and M-EDH) and HC (E-HC and M-HC). A two-way Analysis of Variance (ANOVA) and correlational analysis was conducted. Results showed a trend where the M-EDH group performed significantly poorer on executive function tests (viz a viz., time taken, errors, and correct responses), followed by E-EDH, M-HC, and E-HC. The main effect of age was found significant on Digit Symbol, Color Trail 1, N-Back 2, Animal Naming, and Stroop Effect (p < 0.01 level) while N-Back 1, WCST-PE, and Tower of London (p < 0.05 level). The findings have significant clinical and therapeutic implications. In addition, it gives guidance regarding planning specific neuropsychological tests and rehabilitation targeting specific areas of executive functions decline due to age in EDH post-surgery patients.

Controversy and variation exist in surgical management for acute epidural haematoma (AEDH). Although craniotomy for AEDH is conventionally employed, no specific evaluation on the necessity of decompressive craniectomy (DC) followed by AEDH evacuation has been performed.
This is a multicentre prospective, phase III observational study that evaluates different surgical managements for the AEDH. Patients of both genders, aged 18-65 years, presenting to the emergency room with a clinical and radiological diagnosis of AEDH, complying with other inclusion and exclusion criteria, are enrolled. Clinical information, including diagnosis of AEDH, radiological information, treatment procedures and follow-up data of 1, 3 and 6 months post-injury, is collected on 2000 eligible patients among 263 hospitals in China. Recruitment for the study started in April 2021, and inclusion will be continued until the sample size is obtained, expected is an inclusion period of 24 months. The interventions of concern are surgical treatments for AEDH, including craniotomy and DC. The primary outcome is the Glasgow Outcome Score-Extended 6 months post-injury. Secondary outcomes include the incidence of postoperative cerebral infarction, the incidence of additional craniocerebral surgery and other evaluation indicators within 6 months post-injury.
The study protocol has been approved by the ethics committee and institutional review board of Renji Hospital, School of Medicine, Shanghai Jiao Tong University. All study investigators strictly follow the Declaration of Helsinki and Human Biomedical Research Ethical Issues. Signed written informed consent will be obtained from all enrolled patients. The trial results will be disseminated through academic conferences and published in peer-reviewed journals.
NCT04229966.

A number of patients who sustain a traumatic brain injury (TBI) require surgical intervention due to acute intracranial bleeding. The aim of this retrospective study was to assess the national trends of acute craniotomies following TBI in the Finnish adult population.
The data were collected retrospectively from the Finnish Care Register for Health Care (1997-2018). The study cohort covered all first-time registered craniotomies following TBI in patients aged 18 years or older. A total of 7627 patients (median age = 59 years, men = 72%) were identified.
The total annual incidence of acute trauma craniotomies decreased by 33%, from 8.6/100,000 in 1997 to 5.7/100,000 in 2018. The decrease was seen in both genders and all age groups, as well as all operation subgroups (subdural hematoma, SDH; epidural hematoma, EDH; intracerebral hematoma, ICH). The greatest incidence rate of 15.4/100,000 was found in patients 70 years or older requiring an acute trauma craniotomy. The majority of surgeries were due to an acute SDH and the patients were more often men. The difference between genders decreased with age (18-39 years = 84% men, 40-69 = 78% men, 70 + years = 55% men). The median age of the patients increased from 58 to 65 years during the 22-year study period.
The number of trauma craniotomies is gradually decreasing; nonetheless, the incidence of TBI-related craniotomies remains high among geriatric patients. Further studies are needed to determine the indications and derive evidence-based guidelines for the neurosurgical care of older adults with TBIs to meet the challenges of the growing elderly population.

OBJECTIVE: The main objectives of this study were to describe the epidemiological characteristics, the associated factors and outcomes of extra-axial hematoma (EAH) in patients of traumatic brain injury (TBI) due to road traffic accident (RTA) and to assess their survival probability after 6 and 12 months to RTA.
METHODS: This was a retrospective record-based study. A total of 520 patients diagnosed with EAH due to RTA-related TBI were studied. This study covered ten years from January 1, 2010, to December 31, 2019. Descriptive statistics, including frequencies, percentages, mean, standard deviation, median and range were used. To test for significance in the difference between proportions, a chi-square test was applied and adjusted standardized residual to confirm the differences between groups. The Kaplan-Meier curve was plotted, and mean survival rates were calculated for each type of EAH. A two-sided p-value less than 0.05 (5%) at 95% CI was considered to be statistically significant.
RESULTS: EAH occurred in 42.1% of RTA-related TBI. Subdural hematoma (SDH) was the most common RTA-related EAH. Age and sex differences exist in the type of EAH with male preponderance and a significantly higher rate of SDH in patients aged 55 years or above. The total EHA mortality was 18.7%, and most occurred within the first month of the incident. Traumatic subarachnoid hemorrhage (tSAH) was associated with poorer outcome in terms of mortality. Epidural hematoma (EDH) has the best prognosis and survival probability at six months and one year from the accident.
CONCLUSIONS: Extra-axial hematomas are very common in RTA-related TBIs and have high mortality. SDH is the most common, tSAH had the highest mortality, while EDH has the best survival. Aggressive efforts are compulsory to reduce RTA-related TBI.

To date, there is no evidence concerning the emergency surgical management of severe trauma patients (STP) with severe traumatic brain injury (STBI) presenting a life-threatening intracranial hematoma and a concomitant extra-cranial noncompressible active bleeding. Current guidelines recommend stopping the extra-cranial bleeding first. Nevertheless, the long-term outcome of STP with STBI mainly depends from intracranial lesions. Thus, we propose a combined damage-control surgical strategy aiming to reduce the time spent with intracranial hypertension and to hasten the admission in the intensive care unit. The main objective of the study is to evaluate the benefits of combined cranial and extra-cranial surgery of STP on the long-term outcome.
We retrospectively searched through the database of STBI of a level 1 trauma center facility (Sainte-Anne Military Teaching Hospital, Toulon, France) from 2007 until 2021 looking for patients who benefited from combined cranial and extra-cranial surgery in an acute setting.
The research yielded 8 patients. The mean age was 35 years old (±14) and the male to female sex ratio was 1.7/1. The trauma mechanism was a fall in 50% of the cases and a traffic accident in 50% of the cases. The median Glasgow coma scale score was 8 (IQR 4) before intubation. The median Injury Severity Score was 41 (IQR 16). Seven patients (88%) presented hypovolemic shock upon admission. Six patients (75%) benefited from damage-control laparotomy among, whom 4 (67%) underwent hemostatic splenectomy. One patient benefited from drainage of tension pneumothorax, and one patient benefited from external fixator of multiple limb fractures. Seven patients (88%) benefited from decompressive craniectomy for acute subdural hematoma (5 patients) or major brain contusion (2 patients). One patient (12%) benefited from craniotomy for epidural hematoma. Three patients presented intraoperative profound hypovolemic shock. Six patients (75%) presented a favorable neurologic outcome with minor complications from extra-cranial surgeries and 2 patients died (25%).
Performing combined life-saving cranial and extra-cranial surgery is feasible and safe as long as the trauma teams are trained according to the principles of damage control. It may be beneficial for the neurologic prognostic of STP with STBI requiring cranial and extra-cranial surgery.

BACKGROUND: The expeditious surgical evacuation of acute epidural hematoma (AEDH) is an attainable gold standard and is often expected to have a good clinical outcome for patients with surgical indications. However, controversy exists on the optimal surgical options for AEDH, especially for patients with brain herniation. Neurosurgeons are confronted with the decision to evacuate the hematoma with decompressive craniectomy (DC) or craniotomy.
METHODS: Patients of both sexes, age between 18 and 65 years, who presented to the emergency room with a clinical and radiological diagnosis of AEDH with herniation, were assessed against the inclusion and exclusion criteria to be enrolled in the study. Clinical and radiological information, including diagnosis of AEDH, treatment procedures, and follow-up data at 1, 3, and 6 months after injury, was collected from 120 eligible patients in 51 centers. The patients were randomized into groups of DC versus craniotomy in a 1:1 ratio. The primary outcome was the Glasgow Outcome Score-Extended (GOSE) at 6 months post-injury. Secondary outcomes included incidence of postoperative cerebral infarction, incidence of additional craniocerebral surgery, and other evaluation indicators within 6 months post-injury.
CONCLUSIONS: This study is expected to support neurosurgeons in their decision to evacuate the epidural hematoma with or without a DC, especially in patients with brain herniation, and provide additional evidence to improve the knowledge in clinical practice.
BACKGROUND: ClinicalTrials.gov NCT04261673 . Registered on 04 February 2020.