Doing More with Less

Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma:
Endovascular Embolization Combined with Drainage Surgery and
Use of Urokinase
Yuhui Zhang1, Qiang Li2, Rui Zhao2, Zhigang Yang2, Yanan Li2, Weijie Min2, Zhijian Yue2, Jianmin Liu2

- BACKGROUND: Hematoma evacuation is regular treat- INTRODUCTION

ment for acute traumatic epidural hematoma (ATEDH) pa-
tients meeting with surgery indications. However, it is an
invasive approach performed under general anesthesia.
Here, a novel minimally invasive method of endovascular
E pidural hematomas (EDHs) occur in 1%e2% hospitalized
patients with traumatic brain injury and account for 5%e
15% of all fatal head injuries.1 About 70% hematomas
occur in the lateral hemisphere at the epicenter of pterion.
Arterial bleeding is responsible for 85% hematomas. The middle
embolization with subsequent drainage surgery and use of
urokinase was established to treat ATEDH under local meningeal artery (MMA) is the most common source of middle
fossa EDHs. Emergency surgery for hematoma evacuation is the
anesthesia.
standard therapy to prevent death or neurologic morbidity for
- METHODS: A novel minimally invasive method of endo- those without surgical contraindications. Although craniotomy
vascular embolization with subsequent drainage surgery and can provide a more complete hematoma evacuation, it is also a
use of urokinase was established to treat ATEDH under local more invasive approach2 and not suitable for those who cannot
anesthesia. Firstly, 23 ATEDH patients with hematomas in the be performed with general anesthesia. It is reported that
angiography followed by endovascular intervention can treat the
temporal area underwent digital subtraction angiography
epidural hematoma.3-5 Some studies have demonstrated that
detecting the bleeding point. Next, embolization was per-
burr hole evacuation followed by drainage is an effective method
formed. After embolization, drainage surgery was taken and for emergency management of traumatic EDHs.6-8
urokinase was injected into the hematoma cyst by drainage This article reports our experience with a combination of
tube to lyse hematoma twice per day. endovascular treatment and burr hole drainage with additional
urokinase to resolve the hematoma as a novel treatment strategy
- RESULTS: The results showed that the middle meningeal
for the management of EDHs, especially those with an obvious
artery was the bleeding source. Embolization immediately
occupying mass effect. It will provide an alternative approach for
ceased bleeding. Most clots were resolved and drained patients who are contraindicated for general anesthesia. To the
after treatment. No recurrence of hematoma or infection best of our knowledge, no published study has been reported
was observed. concerning such a combination treatment method.
- CONCLUSION: The findings suggest that the combined
treatments can be an alternative minimally invasive option METHODS
for ATEDHs, especially for elderly patients or those con-
traindicated for general anesthesia. Patients
A prospective review was made of 23 patients (14 men and 9
women; mean age 42 years, range 15e53 years) who were admitted

Key words From the 1Department of Spine Surgery, Renji Hospital, Medical School, Shanghai Jiaotong
- Drainage surgery University, Shanghai; and 2Department of Neurosurgery, Changhai Hospital, Second Military
- Embolization Medical University, Shanghai, China
- Endovascular treatment To whom correspondence should be addressed: Jianmin Liu, M.D.
- Epidural hematoma [E-mail: liu_jm_cn@126.com]
Zhijian Yue and Jianmin Liu contributed equally to this work.
Abbreviations and Acronyms
CT: Computed tomography Citation: World Neurosurg. (2018) 110:206-209.
EDH: Epidural hematomas https://doi.org/10.1016/j.wneu.2017.11.047
GCS: Glasgow Coma Scale Journal homepage: www.WORLDNEUROSURGERY.org
MMA: Middle meningeal artery Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

206 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.11.047

 DOING MORE WITH LESS
YUHUI ZHANG ET AL. TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA

to our emergency department between 1 January, 2015 and 31 surgery and after removal of the drain tube, GCS score at the time
December, 2016. The traumatogenic factors were classified as of admission and discharge, and Glasgow Outcome Scalee
traffic accidents in 13 cases, accidental falls in 4 cases, and impact Extended score at the time of discharge and at 6-month follow-up.
by falling subjects in 6 cases. The Glasgow Coma Scale (GCS) on
admission was higher than 12 in 11 patients and 8e12 in the RESULTS
remaining 12 patients. The most frequent symptoms were head-
The MMA was discovered as the corresponding meningeal artery
ache and vomiting. The mean time from trauma to patient
in all 23 patients in our series. After embolization, bleeding was
admission to our emergency center was <12
6 hours. The in-
stopped immediately without complications. The mean time for
terval time between the injury and surgery was <2 hours.
angiography and embolization was 42.3
8.2 minutes (range 25e
Computed tomography (CT) scan on admission showed the
50 minutes). The operation time for skull drilling and tube im-
following: the site of hematoma in the temporal area in 8 cases,
plantation was 26.5
7.6 minutes (range 20e35 minutes). The
frontotemporal area in 9 cases, and temporoparietal area in 6
mean time for hematoma drainage was 4.5
2.5 days (range 3e6
cases; the volume of hematoma ranging from 22e46 mL (mean
days). The mean volume of hematoma before tube removal was 5.5
32.5
15.1 mL); midline shift of the brain <10 mm in 18 patients;

4.2 mL (range 0e9 mL). Compared with the preoperative mean
10e15 mm in 5 patients; coexistence of linear fracture in 6 cases
volume of 32.5
15.1 mL, the hematoma volume before tube
and comminuted fracture in 5 patients; and no other additional
removal reduced by 83.1% (P ¼ 0.003).
intracranial lesion.
The consciousness status of the patients originally with
Our study was approved by the Institutional Review Board of the
conscious disturbances quickly improved within 3 days after sur-
hospital, and written informed consent was obtained from all
gery. The GCS score was significantly improved from 10
2 at
patients. There was no commercial involvement in the study
admission to 14
1 at discharge (P < 0.001, Figure 2A). The major
including design, conduct, or analysis.
symptoms, including headache and nausea or vomiting,
disappeared at the time of discharge. During the 6-month
Procedures
follow-up period, the Glasgow Outcome ScaleeExtended score
A quick head CT scan was performed on admission of each patient in
significantly improved to 5.6
1 versus 7.3
0.7 at discharge
the emergency department. Digital subtraction angiography was then
(P < 0.001, Figure 2B). No recurrence of EDHs was observed in
conducted under local anesthesia with sedation. High-resolution
any patient, nor were complications including cerebral infarction
digital fluoroscopy (Artis zee Biplane, Siemens AG, Germany) with
or dysfunction of cranial nerve observed after the embolization
biplane road-mapping capability was used. A 4-French angiocatheter
therapy. No surgery-related infection occurred.
with a 0.035-inch inner diameter was used when angiography began,
and it can also be used as a guiding catheter for the microcatheter.
Bilateral angiography was selectively performed including the com- DISCUSSION
mon, internal, and external carotid arteries. In all cases, angiography Urgent evacuation of hematoma is the standard treatment for trau-
demonstrated the active extravasation from the MMA, indicating the matic EDHs to prevent death or neurologic morbidity. In recent years,
presence of active bleeding from the MMA. The bleeding point was burr hole evacuation and drainage with/without urokinase was re-
embolized by advancing the catheter to the bleeding point with ported as a new minimally invasive strategy for the treatment of
Gelfoam particles (Hangzhou Alicon Pharm Sci&Tec, Linan, China; EDHs, especially those not suitable for general anesthesia.6,7 How-
diameter: 350e560 mm, Figure 1). Then a burr hole evacuation and ever, this method only reduced the volume without eliminating the
drainage surgery were performed in the operating room under local bleeding factor. Rebleeding is probably the most devastating
anesthesia. The burr hole was made in the center of the hematoma complication, which limits the application of the method to acute
guided by CT scanning images. The hematoma was sucked with a patients in the first 24 hours after injury. Arterial bleeding is
soft-tipped aspirator in all directions. A drainage tube was implan- responsible for about 85% of hematomas. Some reports showed that
ted into the hematoma cyst to aspirate some clots. Urokinase (20 ku angiography and possible embolization treatment could find and
resolved in 3-mL saline) was injected into the hematoma cyst through cease the bleeding point in EDH patients who do not require surgery
the tube with the tube kept closed for 3 hours before connecting it to for clot evacuation. Thus endovascular embolization in combination
the negative-pressure vacuum ball. The wound was closed in layers. with skull drilling and injection of urokinase can find and remove the
After completion of the operation, urokinase was repeatedly injected bleeding factor, thus decreasing the volume effect. Theoretically, it
into the hematoma cyst twice a day, and CT scan was performed 3 should be a safe and effective treatment for EDH patients. The data
days after injection of urokinase or according to changes of the obtained from our study have provided clinical evidence for safe and
clinical manifestations in individual patients. The drainage tube was effective use of this novel method.
removed when the drain fluid became yellow and most clots had Temporal regionerelated lesions were selected in our study,
disappeared as shown by CT scans. including the temporal area, frontotemporal area, and tempor-
Data about the procedural and clinical outcomes, procedure- oparietal area. Head CT showed more cases in the frontotemporal
related complications, and patient survival were obtained from area than those in the temporal area. The MMA has generally been
the medical records of the patients. considered the most common source of middle fossa EDHs.
Angiography in our study showed that MMA injury was the major
Statistical Analysis bleeding factor, and active extravasation from the MMA was the
Data were analyzed using the SPSS 13.0 edition. A Student’s t-test common bleeding point. Bleeding ceased immediately after
was performed to compares changes in hematoma volume before embolization in all our cases.

WORLD NEUROSURGERY 110: 206-209, FEBRUARY 2018 www.WORLDNEUROSURGERY.org 207

 DOING MORE WITH LESS
YUHUI ZHANG ET AL. TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA

Figure 1. A patient with acute traumatic epidural hematoma was treated the middle meningeal artery. (D) The middle meningeal artery stops
with endovascular embolization and microinvasive surgery. (A and B) bleeding completely after embolization with polyvinyl alcohol particles.
Preoperative cranial computed tomography scan shows a right epidural (E and F) The hematoma disappeared 2 weeks after surgery.
hematoma. (C) Digital subtraction angiography reveals a bleeding lesion in

Gelfoam particles (diameter: 350e560 mm) were selected for 5 and reached the peak on day 14.9 In our study, CT showed that
embolization in our study, knowing that Gelfoam can be absor- the volume of hematoma ranged from 22e46 mL (mean 32.5

bed. The affected artery was reanalyzed about a week later after 15.1 mL). It took 4.5
2.5 days to drain the hematoma. After
embolization, which should be long enough to prevent rebleeding. drainage, the volume of hematoma was reduced to 5.5
4.2 mL
As there were some dangerous extracranialeintracranial anasto- by about 83.1% as compared with the hematoma volume before
moses with the external carotid artery (ECA) and the mean drainage, indicating that the new method can prevent expansion
diameter of these anastomoses was >100 mm, we chose Gelfoam of the hematoma effectively.
particles of 350e560 mm in diameter so that they would not be Narayan et al10 reported in 1985 that urokinase was safe and
irrigated into the intracranial system through anastomoses, thus effective for lysis of intracranial hematomas in their animal
reducing possible complications of the brain or nerve infarction. model in that it could lyse and reabsorb clots effectively without
No cerebral infarction or dysfunction of cranial nerve was noticed producing neurotoxicity or recurrent bleeding. Other studies
after embolization in our patient group. further reported good results concerning the clinical use of
Postembolization drainage operation was performed in cases urokinase for lysis of hematomas.11-15 However, early use of uro-
with mass effect of hematoma. It usually took 4e12 weeks before kinase may lead to a higher rate of rebleeding in 7%e15% of
the hematoma was fully reabsorbed after injury. The expansion of intracerebral hematoma patients as reported by Montes et al.15 In
the hematoma always appeared during the reabsorption phase due our study, the bleeding vessel was embolized before the use of
to fibrinolytic activity. The expansion may be predominant in urokinase to prevent rebleeding, and no rebleeding case was
some cases, and the volume of the hematoma increased from day observed.

208 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.11.047

 DOING MORE WITH LESS
YUHUI ZHANG ET AL. TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA

***
***
15

Glascow Outcoma Scale-Extended

8
13 7

Glascow Coma Scale 11 6

5
9
4
7
3
5 2

3 1
at admission at discharge at discharge at 6-month follow-up
A B
Figure 2. Plots show the improvement in the Glasgow GOSE score was also significantly improved on
Coma Scale (GCS) and Glasgow Outcome discharge compared with that at the 6-month follow-up
Scale-Extended (GOSE) of the patients. (A) The GCS (P < 0.001). ***P value < 0.001 considered very
score on admission was significantly improved significant.
compared with that on discharge (P < 0.001). (B) The

CONCLUSIONS The combination of the 2 treatments can be a viable minimally

Endovascular embolization of the MMA can prevent rebleeding invasive option for the treatment of EDHs, especially in
from the MMA. Further drainage surgery with the use of uro- elderly patients or those who are contraindicated for general
kinase can resolve and remove the mass effect of hematoma. anesthesia.

hole evacuation and drainage. A preliminary spontaneous intracerebral hematomas. Neurosurg

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