"Degrees of Certainty" [Standards, Guidelines, Options] and "Classification of Evidence" [Class I to III] are defined at the end of the "Major Recommendations" field.
Note: All of the following recommendations are at the Option level supported only by Class III scientific evidence.
Recommendations
Indications for Surgery
- An epidural hematoma (EDH) greater than 30 cm3 should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score.
- An EDH less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift (MLS) in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic (CT) scanning and close neurological observation in a neurosurgical center.
Timing
- It is strongly recommended that patients with an acute EDH in coma (GCS score <9) with anisocoria undergo surgical evacuation as soon as possible
Methods
- There are insufficient data to support one surgical treatment method. However, craniotomy provides a more complete evacuation of the hematoma.
Summary
In patients with an acute EDH, clot thickness, hematoma volume, and MLS on the preoperative CT scan are related to outcome. In studies analyzing CT parameters that may be predictive for delayed surgery in patients undergoing initial nonoperative management, a hematoma volume greater than 30 cm3, an MLS greater than 5 mm, and a clot thickness greater than 15 mm on the initial CT scan emerged as significant. Therefore, patients who were not comatose, without focal neurological deficits, and with an acute EDH with a thickness of less than 15 mm, an MLS less than 5 mm, and a hematoma volume less than 30 cm3 may be managed nonoperatively with serial CT scanning and close neurological evaluation in a neurosurgical center (see Appendix II of the original guideline document for measurement techniques). The first follow-up CT scan in nonoperative patients should be obtained within 6 to 8 hours after traumatic brain injury (TBI). Temporal location of an EDH is associated with failure of nonoperative management and should lower the threshold for surgery. No studies are available comparing operative and nonoperative management in comatose patients. The literature supports the theory that patients with a GCS less than 9 and an EDH greater than 30 cm3 should undergo surgical evacuation of the lesion. Combined with the above recommendation, it follows that all patients, regardless of GCS, should undergo surgery if the volume of their EDH exceeds 30 cm3. Patients with an EDH less than 30 should be considered for surgery but may be managed successfully without surgery in selected cases.
Time from neurological deterioration, as defined by onset of coma, pupillary abnormalities, or neurological deterioration to surgery, is more important than time between trauma and surgery. In these patients, surgical evacuation should be performed as soon as possible because every hour delay in surgery is associated with progressively worse outcome.
Definitions:
Degrees of Certainty
Standards: Represent accepted principles of patient management that reflect a high degree of clinical certainty.
Guidelines: Represent a particular strategy or range of management strategies that reflect a moderate degree of clinical certainty.
Options: Are the remaining strategies for patient management for which there is unclear clinical certainty.
Classification of Evidence on Therapeutic Effectiveness
Class I: Evidence from one or more well-designed, randomized, controlled clinical trials, including overviews of such trials
Class II: Evidence from one or more well-designed comparative clinical studies, such as nonrandomized cohort studies, case-control studies, and other comparable studies
Class III: Evidence from case series, comparative studies with historical controls, case reports, and expert opinion