Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT

Small asymptomatic epidural hematomas (EDHs) are frequently managed nonoperatively with good neurologic outcome. Our goals were to determine the frequency and timing of enlargement of acute traumatic EDHs that are not immediately surgically evacuated as well as to identify factors associated with rehemorrhage.

Of 252 consecutive patients with acute traumatic EDH who were treated over a 5-year period, 160 were managed nonoperatively. Their CT scans, imaging reports, and medical records were reviewed retrospectively. Parameters analyzed as possible predictors of rehemorrhage during nonoperative management were size of the EDH, presence of an associated fracture, contralateral brain injury, midline shift, coagulopathy, and neurologic and physiological injury as measured by the Revised Trauma Score. We compared discharge discharge disposition as a proxy for neurologic condition at discharge.

The EDH enlarged in 37 (23%) of the 160 patients during conservative management. Mean enlargement was 7 mm, and the mean time to enlargement was 8 hours after injury and 5.3 hours after CT diagnostics. EDH enlargement occurred within 36 hours after injury in all cases. Of the parameters analyzed, only a high Revised Trauma Score correlated significantly with EDH rehemorrhage, suggesting that intubation and chemical paralysis may prevent rehemorrhage through the restriction of head movement and the control of blood pressure. The subgroup of patients with rehemorrhage experienced no difference in neurologic outcome despite a higher rate of clinical deterioration.

EDH enlargement occurs frequently, but early. Repeat imaging with CT is most appropriate within 36 hours after injury.