pISSN 2234-8999 / eISSN 2288-2243

CLINICAL ARTICLE
Korean J Neurotrauma 2016;12(2):47-54 https://doi.org/10.13004/kjnt.2016.12.2.47

Clinical Outcome of Acute Epidural Hematoma in Korea:

Preliminary Report of 285 Cases Registered in the Korean
Trauma Data Bank System
Young Ha Jeong, MD, Ji Woong Oh, MD, Sungmin Cho, MD, PhD;
and the Korean Trauma Data Bank System Committee
Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea

Objective: The aim of this preliminary collaborative study was to assess the clinical characteristics, management, and out-
come of epidural hematoma (EDH) based on the data collected and registered in the Korean Trauma Data Bank System
(KTDBS).
Methods: Of 2,698 patients registered in the KTDBS between September 2010 and March 2014, 285 patients with EDH
were analyzed. Twenty-three trauma centers participated in the study voluntarily to collect data. We subcategorized the
patients into two groups with good and poor outcomes. Various clinical characteristics and the time intervals with regard to
treatment course were investigated to determine the relationship between these parameters and the functional outcome.
Results: Of multiple parameters for this analysis, older age (p=0.0003), higher degree of brain injury (p＜0.0001), cases of
surgical EDH (p＜0.0001), time interval from trauma to hospital before 6 hours, and the decreasing pattern of Glasgow
Coma Scale (GCS) between and initial and final GCS were strongly associated with poor outcome. Use of prophylactic an-
ticonvulsant did not affect the functional outcome. There was an interesting difference in the use of mannitol in treating
EDH between the urban and rural regions (p＜0.0001).
Conclusion: This is the first multi-center analysis of etiology of injury, pre-hospital care, treatment, and functional outcome
of EDH in Korea. The degree of brain injury and the GCS difference were notable factors that were significant in determin-
ing the functional outcome of EDH.
(Korean J Neurotrauma 2016;12(2):47-54)

KEY WORDS: Hematoma, epidural, cranial ㆍRepublic of Korea ㆍ Glasgow Coma Scale.

Introduction known for a long time. Yet, the pathological dynamics of

EDH is not fully understood. Its heterogeneous responses
Epidural hematomas (EDH) comprise 2% of total trau- to the treatment in the different subgroups of populations
matic brain injury (TBI) but its mortality rate is as high as require further international attention and investigation.11,15)
33%.18) This particular neurosurgical emergency has been Korea has recently attempted to collect a large cohort of
data relating to multiple aspects of TBI for the past few
Received: September 30, 2016 / Revised: October 16, 2016 years. Fatality of EDH has also partly urged the actions to
Accepted: October 20, 2016 emphasize the importance of epidemiological monitoring
Address for correspondence: Sungmin Cho
Department of Neurosurgery, Wonju Severance Christian Hospi-
for prevention, revisiting the safety laws, and the upgrad-
tal, Yonsei University, 20 Ilsan-ro, Wonju 26426, Korea ing trauma centers to ultimately improve the facilities and
Tel: +82-33-741-1342, Fax: +82-33-746-2287 systems for better functional outcomes. The evolving na-
E-mail: ns1287@hanmail.net
cc This is an Open Access article distributed under the terms of Cre-
ture of EDH is especially observed dynamically at the acute
ative Attributions Non-Commercial License (http://creativecommons. settings of different types of trauma; hence, the authors
org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original work
thought that this specific disease deserves a spot light for
is properly cited. national investigation. To our knowledge, though it is pre-

Copyright © 2016 Korean Neurotraumatology Society 47

Epidural Hematoma and Korean Trauma Data Bank System

liminary, this is the first report to attempt in evaluating the performed the two-sample t-test or chi-square test (Fisher’s
multi-center data registered in the Korean Trauma Data Bank exact test) as appropriate. Logistic regression analysis was
System (KTDBS) to unravel the patterns of clinical course of used to identify the factors to predict the poor outcome and
EDH in Korea and to identify the significant parameters the result were expressed as odds ratio (OR) with 95% con-
in determining the outcomes of EDH. fidence interval (CI). A p-value less than 0.05 was consid-
ered statistically significant and all statistical analyses were
Materials and Methods conducted using SAS 9.4 version (SAS Inc., Cary, NC, USA).

The KTDBS Results

The aim of this project was to conduct an epidemiologic
research on the epidemiology of TBI in Korea. The data were In order to identify the clinical factors associated with
voluntarily submitted by 23 trauma centers of all levels of poor outcome, the study population was divided into two
designation. The data sheet of the KTDBS was composed subgroups of good and poor outcome. The parameters of
of 392 items, containing information regarding the charac- clinical characteristics were compared between these two
teristics and etiology of the injury, diagnosis, treatment, and groups. According to the demographic statistics of the pa-
complications with respect to the outcome of patients. Two tients, older age (p=0.0003), more severe the degree of brain
thousand six hundred ninety-eight patients were added to injury (p＜0.0001), cases of surgical EDH with craniectomy
the database over its duration of the project. (p＜0.0001), shorter time interval from trauma to hospital
before 6 hours, shorter time interval from trauma to initial
Patient population CT (p=0.0078) and the decreasing pattern of GCS between
Of 2,698 cases of TBI patients, 377 case of EDH were re- and initial and final GCS (p=0.0374) were strong predict-
trieved from the database. Patients younger than 16 years ing factors of poor outcome (Table 1). The injury mecha-
and patients with field cardiac arrest were excluded. Thus, nism of falls was more common in the patients with good
the final cases of 285 patients with EDH were evaluated for outcome (121/232, 52.16%), however, it was not statistical-
this study. We subcategorized the patients into two groups ly significant (p=0.0537). Use of mannitol for controlling
with good and poor outcome. The following clinical param- increased intracranial pressure (ICP) upon the arrival at
eters were compared with respect to the final outcome: age, emergency department was higher in the patients with
gender, presence of skull fracture, treatment plan, degree poor outcome (10/14, 71.43%). On the other hand, those with
of brain injury, time interval from trauma to hospital, types good outcome received no treatment of mannitol for EDH
of injury mechanisms, time interval from trauma to initial (29/60, 48.33%). Again, the use mannitol was neither sta-
computed tomography (CT), treatment plan after the ini- tistically significant (p=0.0504). According to the 1:1 uni-
tial CT, time interval from initial CT to follow-up CT, the variate analysis, the odds of poor outcome for older patients
reasons for follow-up CT, use of mannitol, prophylactic use were 1.03 times. Cases of surgical EDH showed the odd of
of prophylactic anticonvulsant, time taken to decide a sur- poor outcome 9.51 times higher than those of non-surgical
gical treatment, and types of surgery. The difference of EDH. Compared to the patients with mild brain injury, those
Glasgow Coma Scale (GCS) between the GCS upon arriv- with moderate brain injury showed the odds of poor out-
al of the hospital and the lowest GCS during the hospital come 7.04 times higher than those with mild brain injury
stay were also analyzed. All patients underwent CT scan- while those with severe brain injury showed the odds 39.6
ning during the course of treatment. Outcome of 6 months times higher than those with mild brain injury. Shorter time
following injury by the Glasgow Outcome Scale (GOS) in interval from trauma to hospital before 6 hours showed the
which ‘good outcome’ was defined as a good recovery or a odds of poor outcome 8.41 times higher compared to that
moderate disability, and ‘poor outcome’ was severe disabil- after 6 hours. Finally, the odds of poor outcome are shown
ity, vegetative state, or death.7) 1.46 times higher when the patients’ final GCS is lower
than the initial GCS.
Statistical analysis Clinical parameters associated with the poor outcome
Data are expressed according to the properties of the vari- on the univariate analysis were entered into the multivari-
able. Continuous variables are presented as mean and stan- ate model for further evaluation. The degree of brain inju-
dard deviation. Categorical variables are presented as fre- ry (OR of 9.36 in moderate injury; 95% CI, 1.68-52.23;
quency and percentage. In order to compare two groups, we and OR of 55.56 in severe injury; 95% CI, 7.49-412.35, re-

48 Korean J Neurotrauma 2016;12(2):47-54

 Young Ha Jeong, et al.

TABLE 1. Comparison of clinical factors according to Glasgow Outcome Scale class

Poor outcome Good outcome
Variables p-value
n=35 (12.3%) n=250 (87.7%)
Age (years) 53.57±18.85 39.73±21.48 ＜0.0003†
Gender (male) 26 (74.29%) 200 (80%)00. ＜0.4345
Presence of skull fracture 20 (57.14%) 153 (61.2%)0 ＜0.6453
Treatment
No operation 8/33 (24.24%) 182/247 (73.68%) ＜0.0001†
Operation 23/33 (69.7%)0 55/247 (22.27%)
Delayed operation 2/33 (6.06%)0 10/247 (4.05%)0
Degree of brain injury
Mild 5/34 (14.71%) 176/247 (71.26%) ＜0.0001†
Moderate 11/34 (32.35%) 55/247 (22.27%)
Severe 18/34 (52.94%) 16/247 (6.48%)0
Time interval from trauma to hospital
＜6 hours 32/33 (96.97%) 194/245 (79.18%) ＜0.0139†
≥6 hours 1/33 (3.03%)0 51/245 (20.82%)
Mechanism of injury
Other unknown mechanisms 7/31 (22.58%) 33/232 (14.22%) ＜0.0537*
Falls 9/31 (29.03%) 121/232 (52.16%)
Motor vehicle accidents 15/31 (48.39%) 76/232 (32.76%)
Time interval from trauma to CT (minutes) 93.0±61.71 206.4±567.6 ＜0.0078
Treatment after initial CT
No operation 13/33 (39.39%) 184/232 (79.31%) ＜0.0001*†
Operation (early+delayed) 20/33 (60.61%) 48/232 (20.69%)
Time interval from initial CT to follow-up CT 4.73±3.40 9.77±16.57 ＜0.0004†
Reasons for follow-up CT
Follow-up for abnormal findings in the initial CT 21/25 (84%)00. 148/193 (76.68%) ＜0.0090*†
Neurological deterioration 4/25 (16%)00. 7/193 (3.63%)0
Routine follow-up due to individual institutional protocol 0/25 (0%)00.0 26/193 (13.47%)
Others 0/25 (0%)000. 12/193 (6.22%)0
Mannitol use
No use 2/14 (14.29%) 29/60 (48.33%) ＜0.0504
Use upon the arrival at ER 10/14 (71.43%) 27/60 (45%)00.
Use after operation to control ICP 1/14 (7.14%)0 2/60 (3.33%)0
Use in combination with other osmotic agent when required 1/14 (7.14%)0 2/60 (3.33%)0
Anti-convulsant use
Surgical operation 27/27 (100%)0. 184/201 (91.54%) ＜0.2333*
First option 15/18 (83.33%) 43/74 (58.11%) ＜0.0468
After medical treatment 3/18 (16.67%) 31/74 (41.89%)
Time of operation from trauma
＜24 hours 27/27 (100%)0. 53/64 (82.81%) ＜0.0298*†
≥24 hours 0/27 (0%)000. 11/64 (17.19%)
Types of surgery
Craniotomy 8/23 (34.78%) 41/47 (87.23%) ＜0.0001*†
Craniectomy 15/23 (65.22%) 4/47 (8.51%)0
Burr hole trephination 0/23 (0%)000. 2/47 (4.26%)0
GCS difference
Initial-final 00.8±4.19 -1.06±1.79- ＜0.0374*†
*Fisher’s exact test, †statistical significance based on two-sample t-test or chi-square test (p＜0.05). CT: computed tomogra-
phy, ER: emergency room, ICP: intracranial pressure, GCS: Glasgow Coma Scale

http://www.kjnt.org 49
Epidural Hematoma and Korean Trauma Data Bank System

TABLE 2. Odds ratio (95% confidence interval) according to outcome

Univariate analysis Multivariate analysis
Variables
OR (95% CI) p-value OR (95% CI) p-value
Age (years) 01.03 (1.01-1.05)000 0.0006 1.02 (0.99-1.06)00 0.2248
Treatment
No operation 1 (reference) ＜0.0001 1 (reference) 0.6303
Operation 9.51 (4.03-22.46)00 3.07 (0.27-34.48)0
Delayed operation 4.55 (0.85-24.30)00 0.97 (0.08-11.92)0
Degree of brain injury
Mild 1 (reference) ＜0.0001 1 (reference) 0.0004*
Moderate 7.04 (2.34-21.14)00 9.36 (1.68-52.23)0
Severe 39.6 (21.98-120.78) 55.56 (7.49-412.35)
Time interval from trauma to hospital
＜6 hours 8.41 (1.12-63.04)00 0.0382 4.27 (0.46-39.28)0 0.2004
≥6 hours 1 (reference) 1 (reference)
Time interval from trauma to CT (minutes) 0.996 (0.99-1.002)00 0.1455 - -
Treatment after initial CT
No operation 1 (reference) ＜0.0001 1 (reference) 0.8811
Operation (early+delayed) 5.90 (2.74-12.7)000 0.85 (0.10-7.28)00
GCS difference
Initial-final 1.46 (1.17-1.83)000 0.0009 1.39 (1.06-1.81)00 0.0180*
*statistical significance based on logistic regression analysis (p＜0.05). OR: odds ratio, CI: confidence interval, CT: computed
tomography, GCS: Glasgow Coma Scale

TABLE 3. The association between seizure events and the use a diverse traumatic environment. In addition, different types
of prophylactic anti-convulsant
of brain injuries result in multiple subdivisions of incon-
Use of Seizure
stant consequences.5)
anti-convulsant Yes No p-value
Yes 4 (100%) 195 (98.48%) 1.000
Age
No 0 (0%) 003 (1.52%)
As the population ages with longer life expectancy, trends
of injury have also been changing with more injuries in the
spectively; p=0.0004) and the GCS differences between geriatric population.6,15,24) As well as we have already wit-
the initial and final GCS (OR of 1.39; 95% CI, 1.06-1.81; nessed in the analysis of our database, age is a major deter-
p=0.0180) showed a statistically significant result as strong minant of functional outcome.15,24) For example, an injury
determining factors related to poor outcome (Table 2). Of mechanism of falls from heights is one of the leading causes
note, prophylactic use of anticonvulsant did not affect the of TBI in the elderly older than 65 years with a high risk of
functional outcome (Table 3). death.22) Even ground-level falls are risks to the elderly when
There was an interesting difference in the use of manni- it is generally and easily known to be a low risk in the young-
tol in treating EDH between the urban and rural regions er population.19) Our data on EDH from KTDBS showed
[22/27 (81.48%) and 15/47 (31.91%), respectively; p＜0.0001] that falls are associated with good outcome of EDH (though
(Table 4). There was 63.83% (30/47) of patients who re- it was not statistically significant). Nevertheless, this alarms
ceived no mannitol treatment in the rural hospitals. This us to collect more systematized data to confirm the differ-
was a statistically significant difference between the two ence, if there is any, in the domestic and international epi-
regions. demiology of EDH. The results may even different in the
types of brain injury other than EDH as well. It is impera-
Discussion tive to be aware of the new injury types in the geriatric pop-
ulation.
EDH is a complex entity of trauma in which the neuro-
logic damage evolves after the impact.2,18,28) Different mech- Degree of brain injury
anisms of injury with EDH are usually involved to create As far as the degree of brain injury is concerned, one will

50 Korean J Neurotrauma 2016;12(2):47-54

 Young Ha Jeong, et al.

TABLE 4. Comparison of clinical factors according to region

Urban region Rural region
Variables p-value
n=168 (59.2%) n=116 (40.8%)
Age 41.54±20.73 41.28±23.04 ＜0.9193
Gender (male) 136 (80.95%) 89 (76.72%) ＜0.3879
Time interval from trauma to hospital
＜6 hours 134 (79.76%) 91/109 (83.49%) ＜0.4381
≥6 hours 34 (20.24%) 18/109 (16.51%)
Mechanism of injury
Other unknown mechanisms 25/151 (16.56%) 9/111 (8.11%)0 ＜0.1453*
Falls 71/151 (47.02%) 58/111 (52.25%)
Motor vehicle accidents 49/151 (32.45%) 42/111 (37.84%)
Leisure activities 6/151 (3.97%)0 2/111 (1.80%)0
Time interval from trauma to CT (minutes) 163.1±246.1 231.0±750.5 ＜0.3853
Mannitol use
No use 1/27 (3.7%)00 30/47 (63.83%) ＜0.0001*†
Use upon the arrival at ER 22/27 (81.48%) 15/47 (31.91%)
Use after operation to control ICP 2/27 (7.41%)0 1/47 (2.13%)0
Use in combination with other osmotic agent when required 2/27 (7.41%)0 1/47 (2.13%)0
GOS class
Poor outcome 23 (13.69%) 12 (10.34%) ＜0.3992
Good outcome 145 (86.31%) 104 (89.66%)
*Fisher’s exact test, †statistical significance based on two-sample t-test or chi-square test (p＜0.05). CT: computed tomogra-
phy, ER: emergency room, ICP: intracranial pressure, GOS: Glasgow Outcome Scale

immediately think of the pathological mechanism of early the emergency department due to lack of professional pre-
events of TBI, which is still much less understood though hospital management, will be as critical as the impact of ir-
there is a great effort of basic research undertaken inter- reversible primary damage of neuronal pathways of con-
nationally to uncurtain the injury mechanisms at the cel- sciousness at the first place.10)
lular levels.8,27) However, macroscopically, the severity, du-
ration of impact, duration without treatment, and nature of Golden time for CT scans
injuries determine the degree of brain injury. Degree of A clinical deterioration of a patient with EDH is related
brain injury is often characterized by severe brain swell- with the size of EDH and its time-dependent enlargement.
ing, combination with traumatic subarachnoid hemorrhage, There was an analytical study reported that a CT scan per-
cerebral vasospasm, and delayed cerebral infarction after formed less than 6 hours after the onset of trauma had an
trauma.1,8,26) EDH with additional intracranial injuries would increased risk of hematoma enlargement.2,5) Our analysis
act together in a simultaneous manner implicating to wors- of EDH data from KTDBS also confirms that the time in-
en the patients’ condition. The accumulative damage will terval from trauma to the initial CT scan before 6 hours is
add on to escalate the extent of brain injury, which will even- associated with a poor functional outcome. It is also report-
tually affect the functional outcome as we have already dem- ed that a series of CT scans in non-operative EDH patients
onstrated in the analysis of our data. In the end, patients should be obtained within 6 to 8 hours after the initial inju-
with severe GCS and the management of ICP determines ry for better outcomes with prompt decision of treatment.20)
the final outcome in patients with EDH as the response of Moreover, Ding et al.3) reported that the non-surgical pa-
recovery is dependent on the treatment effects during the tients with routine repeat CT scans have a better outcome
clinical course and possibly on the patients’ predisposing than those with non-routine repeat CT. However, the same
co-morbidity.5) authors also mentioned that routine follow-up CT scans 48
One must also bear in mind that there are also extrinsic hours after trauma may not also be required.3,16)
factors which can potentially threaten the patients outside
the hospital. Namely, the secondary injury by such as hy- Timing and indications of hematoma evacuation
poxia or hypotension occurred, before the patient entered According to the guidelines of the Brain Trauma Founda-

http://www.kjnt.org 51
Epidural Hematoma and Korean Trauma Data Bank System

tion (BTF), the volume of EDH and the initial GCS are de- Use of mannitol
terminants of surgical indication of EDH. Not all patients Sufficient cerebral perfusion and prevention of increased
benefit from the operation of EDH.2,12,18) Our data showed ICP is a crucial tactic in managing TBI.23) Protocols of ICP
that the poor outcomes are more associated with the cases management vary inevitably due to different experiences,
of surgical EDH. Furthermore, the cases of decompressive and they vary even among neurosurgeons within the same
craniectomy with hematoma evacuation of EDH are also institution. According to our data, mannitol seems to be sit-
associated with a poor outcome (p＜0.0001). It is rather ting in the middle of controversy in the context of ICP man-
ironic that the act of surgery is not guaranteeing the func- agement of EDH patients. Although mannitol was not di-
tional outcome of the patients while the neurosurgeons have rectly associated with final outcome (Table 1), the individual
put so much effort and time to open the skull to relieve the institutional protocols in treating EDH and the time of man-
increased ICP. Oppositely speaking, the patients undergo- nitol given during the course of disease progression have
ing the operation to decompress the ICP would have been not yet met a consensus in Korea (Table 4). If this is true, the
already in a life-threatening condition due to severe brain effect of mannitol on the outcome of the patients with EDH
injury that the surgery is the last resource for their survival. must be scrutinized carefully in the near future. Implemen-
The surgery within 24 hours is indicative of a fast progres- tation of evidence-based recommendations by BTF is re-
sion of the disease. Whereas the surgery 24 hours after lated with the improvements in mortality in TBI.9) Adoption
trauma somewhat suggests a slow nature in the develop- and integration of the basic guideline to individual institu-
ment of hematoma enlargement, henceforth, this is clini- tional protocols is a step forward to treating a diverse pool
cally associated with good outcome in our data analysis. of patients with EDH.4,21)
Park et al.14) also reported that the ultra-early decompres-
sive craniectomy for TBI did not improve the patient out- Development of national prognostic model of EDH
come after all. Surgery should not be the only solution of In hoping to be of some contribution for building a Ko-
treating EDH.2,12,18) At the same time, surgery should not rean prognostic model of EDH, we attempted to classify
be mandatory robotically even if the guidelines of BTF say the clinical parameters in association with the functional
so. There are number of clinical articles on the management outcomes by the analysis of data based on the KTDBS. By
of non-surgical EDH in the selected patients, such as elder- sharing the trauma data nation-wide and adopting the prog-
ly patients.2,12,18) These data should be heavily considered nostic models, this national study will soon activate the im-
in establishing more systematic and tailored protocols for provement in the quality of neurosurgical care of EDH.25)
treating EDH.12,14,18)
Limitations
GCS difference This study is a retrospective review of collected data from
GCS is a static measurement of consciousness of neuro- only 23 trauma centers in Korea, thus, these results may not
logical patients. It may fluctuate from time to time and it yet reflect the whole EDH population in Korea. Non-oper-
may change dramatically early after injury. The proper as- ative groups of patients may be biased if the patient’s fam-
sessment of initial GCS should be carried out ideally after ily disagreed on the surgical treatment. A new prospective
hemodynamic and respiratory resuscitation of TBI pa- database needs to be more specified with more informa-
tients. Nevertheless, under the same name of EDH, some tion and details regarding the decision making of treat-
patients would exhibit neurological deterioration mean- ments in the clinical practice. This data set did not include
while others would improve as time passes by. BTF men- the predisposing co-morbidities and medical conditions of
tions the importance of initial GCS at presentation. How- patients, thus, this will underestimate the differences in the
ever, because of the unreliability of initial GCS in a certain course of coagulopathy of the individuals with EDH to a
group of patients, we retrieved the data from the KTDBS certain extent.17) This study has defined the clinical out-
and attempted to calculate the difference between the ini- come as a functional outcome, not mortality, and this was
tial and the final GCS in order to assess the functional out- assessed with the GOS. We may have to differentiate the
come. As a result, we found that the larger the difference severe EDH from mild EDH as the survival factors will be
of GCS from the initial to the final GCS in a decreasing more relevant for severe EDH. The quality of health care
manner, the poorer the functional outcome of the patients. systems have to be taken account in the analysis as it pos-
sibly determines the long-term outcome of the patients.25) In
order to elucidate the variability of responses to EDH, a

52 Korean J Neurotrauma 2016;12(2):47-54

 Young Ha Jeong, et al.

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