Outcomes of Evacuation Extradural Hematoma via Craniotomy under Local Anesthesia

Background: The EDH occurs due to the accumulation of bleeding between the inner table of the skull and the outer layer of the dura mater. It is said to account for 1% 3% of all head injured patients and 9% of those who are comatose. The only life-saving treatment of choice is evacuation of EDH via craniotomy. Methods: This was a prospective observational study, where 40 patients were in follow-up for determining the outcomes of evacuation via craniotomy. Results: Majority of the patients were young and males. The main outcome of the evacuation was favorable (recovered), but certain unfavorable outcomes were also accounted like mortality. Conclusion: The pre-surgery clinical findings like consciousness of patient were an important indicator for EDH evacuation outcome. In most of the cases, the outcome was favorable with progressive recovery.


Introduction
Head injury is a crucial health problem.The mortality due to head injury accounts for 1% of all deaths whereas it is 15% among young-aged people [1] [2].
One of the vital head injuries is Extradural hematoma (EDH).It occurs due to the accumulation of bleeding between the inner table of the skull and the outer layer of the dura mater.EDH is said to account for 1% -3% [3] [4]  injured patients and 9% of those who are comatose [5].In eighty five percent (85%) of patients, the source of bleeding is the middle meningeal artery while in the rest, it is from middle meningeal sinus and dural sinuses [6] [7].It is published in various reports that the deterioration of conscious level and developing focal neurological marks indicates a rapid growing (EDH) [2].In these cases, a serious computed tomography (CT) scan will reveal biconvex hyperdense EDH.
The only life-saving treatment of choice is evacuation of EDH via craniotomy [2].The present study aims to determine the outcomes of evacuation of EDH via craniotomy under local anesthesia.

Material and Methods
This was a prospective observational study, conducted in Department of Neurology, Services Hospital, Lahore hospital.The study period was of Jan-Dec, 2016.The study exclusion criteria include all the patients with facial trauma and neck injury whereas all the patients with traumatic EDH were included in this study.The patient's medical and demographic history was noted with the main focus on the EDH.Moreover the time, place and mode of injury, details of initial management were taken into account.Another important factor; the conscious level from time of injury to admission were also noted.Later under local anesthesia the EDH injury was managed via craniotomy (surgery).Proper treatment and follow-ups were maintained for a certain time to examine the outcome of evacuation of EDH.
The ethical approval was taken from the ethical committee of the hospital.
Statistical analysis: All the collected data was stored electronically & analyzed later by using SPSS version 20.Descriptive statistics were applied to calculate mean and standard deviation.Frequency distribution and percentages were calculated for qualitative variables like gender, outcomes of evacuation.Over all a P values less than 0.05 was considered statistically significant.

Results
The study constitutes 40 patients with EDH traumatic injury, managed via craniotomy at xyz hospital.Out of the total, 32 (80%) were males and 8 (20%) were females.5 (12.5%) belongs to below 20, 21 (52.5%) were with age of 21 -30, 10 (25%) were in age group of 31 -40 and 4 (10%) were above 40 years of age.We observed a difference in pupil size in 20 (50%) patients and the remaining 20 (50%) with equal pupil and reacting to the light at time of admission.9 (22.5%) of the patients were with varying degrees of hemispheres.The clinical findings in patients with EDH were given in Figure 1.
All the patients went under surgery, and the EDH was evacuated through craniotomy.The outcome of the evacuation of EDH was given in Table 1.

Discussion
It is assumed that the EDH has the greatest importance among hematomas, due to its easy diagnostic and treatment [8].The most of EDH results from blunt  meninges and skull trauma.The blood accumulation between the inner table of skull and the stripped of dural membrane termed as EDH [8] [9].Several studies indicate that this bleeding in the resulting pockets creates a hydraulic "water pressure" effect, progressively stripping the dura away from skull and thus increasing the size of EDH [10] [11].Generally, the Skull X-ray is very good tool to assess the head injury [12].The incidence of EDH among head injury accounts for 2% -3% [13] [14] [15] [16].Moreover, the male to female ratio of EDH is of greater importance.Obviously the males are more exposed to the social and environmental hazards, due to their occupations, they are more in number with EDH.Our findings are inline with many other published studies, showing higher proportions of male to female ration our result was within the range of many studies showing higher proportion of male to female ratios, 4:1 to 8:1 [17] [18] [19].We also observed in our study that the most effected patients were in younger age group (21 -30 years).Among industrial and exposed working environment a large number of employees are young.Other authors documented this factor as well [20].We report in our observations that the prognostic factors like consciousness were the major deteriorates along with delay in surgery [21].
Others includes vomiting and headache.After the invention of the CT scan, the mortality due to EDH had been controlled to 12%, which was before in between 29% to 33%.It is foresaid that a persistent headache and vomiting are the important indications for a CT scan after head trauma [2].The present study was conducted to examine the outcome of evacuation of EDH via craniotomy.The study findings reports that the evacuation via craniotomy was successful in major of cases, as maximum number of patients was recovered and few underwent re-operation.Our results were inline with other published studies where favorable functional outcome was 83.72% and the mortality was 13.95%.In Khan et al.
[22] study with favorable outcome was 79.2% with a mortality of 12.5%.Rehman et al. [3] in their study found favorable outcome in 83.33% and mortality of 10%.

Conclusion
We may conclude in our study that pre surgery clinical findings like consciousness of patient were an important indicator for EDH evacuation outcome.In most of the cases, the outcome was favorable with progressive recovery.

Table 1 .
Outcomes of evacuation of EDH via craniotomy.