Epidural Hematoma: Placing Burr Holes in the ED ================================================ First of all not all epidurals are associated with skull fractures. In one study 30/146 (21%) of extradurals did not have an associated skull fracture of any type (1). In another, 27% had negative skull films (2). Of course subdurals and ICH may also be associated with skull fracture (3), confounding the issue. In practice, when a patient presents with sudden neurological deterioration a skull film is rarely available (or desirable). So, unless they have an obvious depressed fracture on physical exam you, likely, would not even know it. H. Louzon MD (1) Ersahin Y, Mutluer S, Guzelbag E Extradural hematoma: analysis of 146 cases. Childs Nerv Syst 1993 Apr;9(2):96-9 One hundred forty-six consecutive patients operated on for extradural hematoma (EDH) from 1979 through 1991 were analyzed. This series included patients from both before and after the advent of computed tomography (CT). There were 102 boys and 44 girls, aged 1-16 years. All patients underwent plain skull X-radiography. CT scans were obtained in 72 cases and angiography was performed in 10. Thirty patients with EDH did not have skull fractures. Falls were predominant among the modes of injury. Thirty-seven percent of patients had a lucid interval. The overall mortality was 10%. The mortality rates in the CT and plain X-ray groups were 6% and 16% respectively. There was only one death in patients who did not have a lucid interval. The Glasgow Coma Scale scores of all patients who died in this series were less than 8. We concluded that mydriasis, comatose state at the time of operation, and a lucid interval are ominous signs in the prediction of outcome. (2) Mlay SM Epidural haematoma: a study of 71 cases. East Afr Med J 1989 Sep;66(9):598-602 A study of 71 patients with epidural haematoma (EDH) who were managed surgically at the Neurosurgical Centre Nijmegen, Netherlands is presented. The male/female ratio was 5:2. 73.2% of all patients were under the age of 40 years. Traffic motor accidents and falls accounted for 84.5% as causes of head injury. 74.6% were either unconscious throughout or were initially conscious and subsequently unconscious. Only 53.7% were initially suspected to have EDH and investigated; while 46.3% developed signs suggestive of haematoma sometime after the initial assessment. The major clinical signs which influenced the initial management policy included lack of verbal response; pupillary dilatation and hemiparesis. Skull fractures were observed in 73.2% of which 9..8% had depressed fractures. The presence of a linear fracture did not influence the initial management policy. (3) Macpherson BC, MacPherson P, Jennett B CT evidence of intracranial contusion and haematoma in relation to the presence, site and type of skull fracture. Clin Radiol 1990 Nov;42(5):321-6 The skull films and CT scans of 1383 patients with acute head injury transferred to a regional neurosurgical unit were reviewed. Of the 850 patients with a skull fracture, contusion and/or haematoma was found in 71%, compared with 46% of the 533 patients with no fracture. Thirty-nine per cent of patients had neither contusion nor haematoma, and 21% had neither skull fracture nor contusion/haematoma. Haematomas occurred more frequently in association with lateral and occipital fracture than with frontal fracture, but the incidence of contusion was similar for all fracture sites. Linear fractures were more often associated with extra- and subdural haematomas than were depressed fractures.. Intracranial damage associated with depressed fractures was localized more frequently than with linear fractures. Frontal fractures were rarely associated with posterior damage alone, but with occipital fractures anterior contusion was more frequent than posterior. Damage associated with lateral fracture was solely contralateral in 26%. Skull fracture was present in 77% of patients with contusion, 87% of those with an extradural, 72% with a subdural, and 66% with an intracerebral haematoma (70% of all those with an intracranial haematoma). Andrews BT, Pitts LH, Lovely MP, Bartkowski H Is computed tomographic scanning necessary in patients with tentorial herniation? Results of immediate surgical exploration without computed tomography in 100 patients. Neurosurgery 1986 Sep;19(3):408-14 Computed tomographic (CT) scans are performed on virtually all patients with severe head injury at the time of admission. Because of the time involved in obtaining these studies, the evacuation of significant intracranial mass lesions is delayed. To avoid such delays, the authors performed burr-hole exploration for the diagnosis of intracranial hematomas before CT scans were obtained in 100 consecutive head-injured patients with clinical signs of tentorial herniation or upper brain stem dysfunction upon admission to the emergency room. Patients in whom a hematoma was discovered had a craniotomy for evacuation of the clot; those in whom the exploration was negative had a CT brain scan immediately after operation. Burr-hole exploration revealed extracerebral mass lesions in 56 patients. In 38 patients, the exploration was negative, and postoperative CT scanning showed no significant hematoma. Of 6 patients in whom the CT scan demonstrated extraaxial hematomas requiring surgical evacuation, 4 had subdural hematomas that were missed because the exploration was incomplete; 1 patient had an epidural hematoma and 1 had a subdural hematoma contralateral to a craniotomy on the side of a positive initial burr-hole exploration. Our results indicate that the relatively small subgroup of head-injured patients with early tentorial herniation or upper brain stem compression have a high incidence of immediate extraaxial hematomas and a low incidence of intracerebral hematomas. This is particularly true of patients over 30 years of age and those who suffer low speed trauma, such as falls and vehicle-pedestrian accidents. Springer MF, Baker FJ Cranial burr hole decompression in the emergency department. Am J Emerg Med 1988 Nov;6(6):640-6 Presently virtually all patients with acute head trauma are computed tomography (CT) scanned and transferred to a neurosurgical operating room before any surgical intervention. The time required for this, especially if the patient is transferred to another institution, may lead to a significant delay in treatment. In a patient with an expanding intracranial hematoma and evidence of brainstem compromise this delay may produce a worse outcome. Cranial burr hole placement can rapidly, safely, and accurately find and partially decompress most extracerebral intracranial hematomas. A burr hole placed rapidly before CT and transfer could prevent further damage to the brain by an expanding hematoma. The case of a child with a preterminal epidural hematoma whose outcome was excellent because of a burr hole placed in the emergency department (ED) is presented. In light of this case and a complete literature review, it is suggested that more frequent attempts to decompress intracranial hematomas in the ED may be warranted.