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BioMed Research International

Volume 2016, Article ID 6507350, 8 pages
http://dx.doi.org/10.1155/2016/6507350

Research Article
Minimally Invasive Surgical Treatment of
Acute Epidural Hematoma: Case Series

Weijun Wang
Department of Neurosurgery, Qiannan People’s Hospital, Qiannan 558000, China

Correspondence should be addressed to Weijun Wang; 751829615@qq.com

Received 6 January 2016; Revised 9 March 2016; Accepted 17 March 2016

Academic Editor: Robert M. Starke

Copyright © 2016 Weijun Wang. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background and Objective. Although minimally invasive surgical treatment of acute epidural hematoma attracts increasing
attention, no generalized indications for the surgery have been adopted. This study aimed to evaluate the effects of minimally
invasive surgery in acute epidural hematoma with various hematoma volumes. Methods. Minimally invasive puncture and
aspiration surgery were performed in 59 cases of acute epidural hematoma with various hematoma volumes (13–145 mL);
postoperative follow-up was 3 months. Clinical data, including surgical trauma, surgery time, complications, and outcome of
hematoma drainage, recovery, and Barthel index scores, were assessed, as well as treatment outcome. Results. Surgical trauma was
minimal and surgery time was short (10–20 minutes); no anesthesia accidents or surgical complications occurred. Two patients
died. Drainage was completed within 7 days in the remaining 57 cases. Barthel index scores of ADL were ≤40 (𝑛 = 1), 41–60
(𝑛 = 1), and >60 (𝑛 = 55); scores of 100 were obtained in 48 cases, with no dysfunctions. Conclusion. Satisfactory results can be
achieved with minimally invasive surgery in treating acute epidural hematoma with hematoma volumes ranging from 13 to 145 mL.
For patients with hematoma volume >50 mL and even cerebral herniation, flexible application of minimally invasive surgery would
help improve treatment efficacy.

1. Introduction H20) and progressively increasing; (4) consciousness dys-

function gradually worsening, even if bleeding amount does
Acute epidural hematoma is one of the most common not meet the surgical indication criteria. Traditionally, as
secondary brain neurosurgical skull injuries, accounting for long as patients have one of the abovementioned indica-
30% of intracranial hematomas. Bleeding is mainly due tions, hematoma clearance by craniotomy is performed. The
to ruptured meningeal middle artery [1] and partially to surgical outcome is acceptable. However, surgical trauma is
bleeding of dural arteriovenous fistulas and the baffle plate. relatively important, and general anesthesia carries inherent
Most patients mainly present with consciousness dysfunction risks; in addition, surgery cost is relatively high. Craniotomy
to some extent, headache, and vomiting [2]. If simple epidural has negative psychological effects on patients such as fear,
hematomas are treated immediately, a good prognosis is anxiety, and depression [5–7]. Most of the patients lacked
often achieved. However, if hematomas are accompanied with confidence to enter into marital relationships or perform
severe contusion and laceration brain injury or cerebral her- jobs and social activities due to perceived disability follow-
niation, prognosis is usually uncertain, and death rate could ing craniotomy. Application of minimally invasive surgery
reach 20% [3]. Currently, surgical indications for clearance attracts increasing attention from neurosurgeons and has
of epidural hematoma by craniotomy are as follows [4]: (1) been applied for the treatment of acute epidural hematoma
hematoma >40 mL and located at the supratentorial region [8–10]. Because minimally invasive surgery cannot com-
or hematoma >10 mL and located at the infratentorial region; pletely achieve one-off hematoma evacuation in short time
(2) obvious midline structure shift (>1 cm) and ventricle or and does stop bleeding under direct visualization, it has
cisterna pressure; (3) intracranial pressure >2.7 kPa (270 mm been proposed that hematomas >30–50 mL are unsuitable for
2 BioMed Research International

this operation [9–11]. Moreover, at present, no generalized high intracranial pressure, clinical symptoms, and complete
standard indications have been adopted for this surgery, hematoma drainage.
which is still in its exploratory stage. Interestingly, most
minimally invasive surgeries for acute epidural hematoma 3. Results
were conducted in hematomas ranging from 20 to 50 mL,
with good outcomes [8–12]. Indeed, detailed reports assessing 3.1. Subjects. A total of 59 patients, including 52 males and 7
minimally invasive surgical treatment for cases with larger females, were included. They ranged from 4 to 68 years old,
with a median age of 32 years. Causes of hematomas included
bleeding amounts are scarce. Therefore, the present study
fall from height (𝑛 = 15), car accident (𝑛 = 35), and fighting
aimed to assess minimally invasive surgery for cases with
(𝑛 = 9). Hematomas with volumes ranging from 13 to 19 mL
hematomas >50 mL and even cerebral herniation, exploring
occurred in 34 cases; 25 cases had volumes of 50–145 mL;
its application value in treatment efficiency and surgical
median volume was 45 mL. Four cases had simple acute
trauma reduction.
epidural hematomas and 3 presented with multiple epidural
hematomas; forty-one cases had epidural hematomas accom-
2. Materials and Methods panied with skull fracture, contusion, and brain laceration;
eight cases had concomitant cerebral herniation (including
2.1. Patients. 59 patients with acute epidural hematoma one patient with diffuse axonal injury); one case also had
were recruited from Department of Neurosurgery, Qiannan spinal cord injury.
People’s Hospital, Guizhou (China), from November 2011
to March 2015. This study was approved by the Hospital’s
3.2. Surgical Procedures [13] and Results. Hematoma sites and
Ethics Committee; informed consent was obtained from
volumes were confirmed by stereotaxic head CT prior to
patients and their families; minimally invasive surgery was
surgery. The puncture point on the scalp was the thickest
used as surgical treatment. Inclusion criteria were as follows:
hematoma area, and puncture angle and depth were mea-
diagnosis of acute epidural hematoma confirmed by 64-slice
sured. Routine sterilization and draping were carried out,
head CT upon admission, no surgery contraindications on
and 2% lidocaine was injected for local anesthesia. Once
examination prior to surgery, and agreement by patients and
anesthesia was effective, 0.5–0.8 cm incision was made on
their families to receive minimally invasive surgery.
the scalp (Figure 1(a)). A manual skull driller was used to
drill through the scalp and skull (Figure 1(b)), and hematoma
2.2. Selection of Surgical Approaches. Patients with no overt was aspirated as much as possible using a brain puncture
intracranial hypertension, cerebral herniation, or surgical needle (Figure 1(c)). A 10 F drainage tube was inserted into
contraindications underwent minimally invasive surgery the hematoma cavity (Figure 1(d)); then, the tube core was
alone; in those with multiple epidural hematomas, drainage withdrawn and the drainage tube further inserted toward
tube numbers were decided based on hematoma amounts the hematoma for 1 cm. After tube suture and fixation, a
(Figures 4(a)–4(c)). Combination of rapid minimally invasive closed backflow prevention drainage device was connected.
surgery and clearance of hematoma by craniotomy was Surgery was completed within 10–20 minutes. 24 h after
selected in case of cerebral herniation. surgery, the hematoma was slowly rinsed with normal saline;
once the washing solution was clear, 20,000–40,000 units
2.3. Timing of the Surgery. For patients with clear conscious- of urokinase in 2-3 mL normal saline were injected into the
ness and not very high cranial hypertension, surgery was hematoma cavity (urokinase amounts were adjusted, accord-
performed as soon as possible, within 6 h of onset; in case ing to hematoma volumes); drainage was opened 2 h after
of consciousness dysfunction, severe cranial hypertension, tube closure, 1-2 times daily. For the 8 patients with cerebral
or cerebral herniation, immediate preoperation preparation herniation, hematoma was first partially aspirated under local
should be made, and bed-site hematoma aspiration by min- anesthesia, and complete hematoma clearance by craniotomy
imally invasive aspiration and drilling skull drainage were was immediately performed in the surgery room. Whether
performed. bone flap remained depended on contusion severity, brain
injury laceration, and intracranial pressure after surgery.
2.4. Follow-Up and Evaluation Parameters. Patients were Bone flap was kept in 2 cases, with decompression made
followed up once monthly by telephone and return visits to by removing bone flaps in 5 cases. After surgery, patients
the hospital, until June 2015. Head CT was conducted at the received routine care such as oxygen delivery, hemosta-
first return visit. The Barthel index score of daily activity sis, and dehydration for lowering intracranial pressure and
living (ADL) was evaluated three months after surgery, and antibiotics for bacterial infection prevention. The antibiotics
the scoring criteria were interpreted as follows: poor: severe were administered 30 min before surgery, and prophylactic
dysfunction, score ≤40; moderate: moderate dysfunction, treatment was administered 24 h after surgery if the proce-
score of 41–60; fine: mild dysfunction, score >60. Full score dure lasted longer than 3 h [14] and brain cell nutrition. All
was 100, when patients can fully take care of themselves. 59 patients underwent successful hematoma aspiration and
Other parameters assessed included surgical time, bleeding drainage tube placement. Intraoperative bleeding amounts
amount during surgery, adverse effects, hospitalization dura- were 5–10 mL. No surgical complications occurred, such as
tion, surgery safety, and success rate. The criteria of success increased hematoma volume or functional impair caused by
rate for minimally invasive surgery included remission of surgical trauma, anesthesia, or intracranial infection.
BioMed Research International 3

(a) (b)

(c) (d)

(e)

Figure 1: (a)–(e) Surgical procedures step by step. (a) Scalp incision with a length of 0.7 cm under local anesthesia. (b) Approximately 20 mL
of blood clot was aspirated during surgery. A manual Skull driller is shown. (c) Old blood clot aspirated during surgery. (d) Drainage tube
placed within the cavity of a hematoma during surgery, with old blood clot aspirated during surgery. (e) Healed incision on the scalp after
surgery.

3.3. Postoperative Outcomes. Hematomas in 8 cases with them had diffuse axonal injury and died the 3rd week from
epidural hematomas were completely cleared by craniotomy respiratory failure caused by pulmonary infection; the other
as shown by head CT at 1 day after surgery. No rebleeding had cerebral hernia and died from central respiratory and
occurred. Head CT was carried out anew to assess progres- circulatory failure. Barthel index scores of ADL were ≤40
sion of hematoma drainage in 51 cases treated with simple (𝑛 = 1), 41–60 (𝑛 = 1), and >60 (𝑛 = 55); scores of 100 were
minimally invasive surgery at 3, 5, and 7 days after surgery. obtained in 48 cases, with no dysfunctions.
Drainage tubes were withdrawn after hematoma clearance
through drainage in 3, 17, and 31 cases at 3, 5, and 7 days, 4. Discussion
respectively, after surgery. The success rate of minimally
invasive surgery was 100%. Median hospital stay was 10 days; The concept of minimally invasive surgery in neurosurgery
follow-up time was 3 months. Two patients died; one of is widely accepted; therefore, treatment approaches of acute
4 BioMed Research International

(a) (b)

(c) (d)

Figure 2: (a)–(d) Head CT images showing minimally invasive drainage treatment of acute epidural hematoma at the right temporal-parietal
region, prior to and after surgery. (a) Head CT scan image prior to surgery. Hematoma volume was approximately 80 mL, midline shift. (b)
Head CT scan image immediately after surgery; hematoma volume was markedly reduced with a residual amount of approximately 30 mL.
(c) At 3 days after surgery, most of the hematoma has been drained; arrow indicates a drainage tube. (d) Five days after surgery, hematoma
was almost cleared, and the drainage tube was pulled off.

epidural hematoma gradually develop from craniotomy to acute epidural hematoma in the infratentorial region (Figures
minimally invasive surgery [15]; indeed, reduced surgical 3(a)–3(c)); drainage became clear at 3 to 7 days after surgery,
trauma is obtained with minimally invasive surgery; low and the drainage tube was then pulled off. Barthel index
risk and rapid recovery alongside reduced cost are the other scores of ADL in these patients were 100 with complete
advantages. The patients understood that the procedure was recovery and without dysfunction, corroborating previous
associated with less neurological dysfunction, which reduced reports [8–12].
any negative physiological consequences. Multiple studies It was suggested that simple minimally invasive surgery
have assessed minimally invasive surgery for the treatment should not be conducted for hematomas of more than 50 mL
of acute epidural hematomas ranging from 20 to 50 mL [6, 8, 10]. In this study, among the 25 cases with hematomas
[8–12], with good outcomes achieved. In the present study, ranging from 50 to 145 mL, 17 underwent simple minimally
hematoma drainage with simple minimally invasive awl invasive surgery (with the largest hematoma up to 80 mL,
cranium drainage was performed in 34 of 59 cases, with Figure 2(a)); the hematomas were completely drained within
volumes ranging from 13 to 49 mL, including 2 patients with 7 days, and drainage tubes were pulled off. Barthel index
BioMed Research International 5

(a) (b)

(c)

Figure 3: (a)–(c) Head CT images showing acute epidural hematoma at the left occipital region prior to and after surgery. (a) Head CT
images prior to surgery; bleeding volume was approximately 13 mL. (b) Head CT images 3 days after surgery; hematoma volume was obviously
reduced. Arrows indicate the site of hematoma and drainage tube. (c) Head CT images 5 days after surgery; hematoma was almost cleared,
and the drainage tube was pulled off.

scores were 100 in 12 cases at discharge, and 3 cases had scores complications. The Barthel index scores were <40 in one case
>60. Although hematoma volumes were >50 mL in these with concomitant cervical spinal injury; scores were 40–59 in
patients, consciousness dysfunctions were not severe, and one case, >60 in two cases, and 100 in two cases. For patients
no cerebral herniation occurred; the fluid within hematomas with acute epidural hematoma accompanied with cerebral
in some cases was not sticky and could be more aspirated hernia, it took 1.5–2 h from admission, presurgery discus-
during surgery (Figure 2(b)). Some residues were maintained sion, signature, presurgical preparation, general anesthesia by
inside the hematomas; therefore, intracranial pressure was endotracheal intubation, incision of scalp flap, drilling of the
obviously relieved. Some cases with hematoma in elderly skull, opening of bone flap, and clearance of hematoma to
people were accompanied with brain atrophy; there is certain intracranial pressure decompression. In traditional surgical
space with buffering capacity within the skull, and thus approaches for hematoma clearance by craniotomy, it takes at
minimally invasive surgery can be still applied for these cases. least 1.5–2 h to reduce cerebral hernia. According to intracra-
The other 8 cases with cerebral hernia underwent min- nial volume-pressure relationships, patients already with
imally invasive surgery in combination with craniotomy. cerebral hernia showed relatively high intracranial pressure;
Two cases had long-term coma after surgery and died from even hematoma was reduced by a small volume, likely leading
6 BioMed Research International

(a) (b)

(c)

Figure 4: (a)–(c) Head CT images showing minimally invasive drainage treatment of acute multiple epidural hematoma at the right temporal-
parietal region prior to and after surgery. (a) Head CT scan image prior to surgery. (b) Head CT scan reexamined immediately after surgery;
hematoma volume at the parietal region was markedly reduced. Arrow indicates hematoma and drainage tube. (c) Five days after surgery,
hematoma was almost cleared and the drainage tube was pulled off.

to overtly reduced intracranial pressure. Based on this mech- hematoma by craniotomy. As shown in Figure 5(c), a part of
anism, minimally invasive surgery cannot completely clear aspirated hematoma was seen in the hematoma center; bone
hematomas at once and does not yield fully decompression; flap can be maintained if intracranial pressure is not high
nevertheless, it can help partly aspirate hematomas within during surgery (Figure 5(d)) [16]. During surgical treatment
short time to partially reduce high intracranial pressure. of patients with cerebral herniation, minimally invasive
Moreover, prerequisite for minimally invasive surgery is surgery can help partly aspirate hematomas during preop-
not high, and the surgery can be performed under local erative preparation for craniotomy, rapidly decompressing
anesthesia before preoperative preparation for craniotomy hematoma partially, saving time, and providing conditions
under general anesthesia. In addition, surgery time is only 10– for recovery.
20 minutes. In the present study, there were 8 hematoma cases Although this surgical approach is simple, cautions
accompanied with cerebral hernia, with the largest hematoma should be observed during operation; complications should
volume of 145 mL (Figure 5(a)); aspiration volume was 30– be avoided as much as possible. The thickest part of
40 mL with minimally invasive surgery, and patients were hematoma was chosen as the puncture site. Most epidural
immediately sent to surgery room for routine clearance of hematomas are accompanied with skull fracture. If the
BioMed Research International 7

(a) (b)

(c) (d)

Figure 5: (a)–(d) Head CT images showing a huge acute epidural hematoma with cerebral hernia at the right temporal-parietal region prior
to and after surgery. (a) Head CT scan image prior to surgery; hematoma volume was approximately 145 mL and midline shift 13 mm. (b)
Hematoma volume with rapid minimally invasive aspiration under local anesthesia was approximately 40 mL; drainage tube was placed.
(c) Skull bone flap was opened during surgery; an arrow indicates a partly aspirated hematoma in the hematoma center. (d) Head CT scan
reexamined the day after surgery; drainage of hematoma was almost complete, brain tissues were expanded again, midline shift was improved,
dilated pupil is recovered and light reflection was recovered.

thickest hematoma region is a fracture line, it should be During surgery, after successful skull drilling, if hematoma
avoided as much as possible to prevent aggravation of fracture is a thin liquid, a drainage tube will be directly inserted
injury by skull drilling, as well as the possibility of bleeding. for aspiration; in case of a thick liquid, because the silicone
If patients had comminuted fracture of the skull, the fracture drainage tube is soft, stronger aspiration might cause closure
site should be avoided as well; otherwise, it is possible to of the cavity, limiting the aspirated volume. It is better to
cause dislocation of fracture fragments or even collapse, use brain puncture needle for aspiration; during aspiration,
leading to bleeding again, or brain damage. Meanwhile, the direction is continuously changed, or the needle is rotated
pterional should be avoided in order to prevent damage of to aspirate as much as possible. With a large hematoma
the meningeal middle artery, which also causes bleeding. and limited aspiration volume, a drainage tube with double
8 BioMed Research International

holes is used for aspiration, which has advantage in speeding References

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Competing Interests 596–597, 2011.

The author declares that there is no conflict of interests

regarding the publication of this paper.
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