Clinical Outcome and Prognostic Factors of Surgically Treated Acute Epidural Hematoma, A 32-Month Prospective Observational Study

Abstract

Introduction

Traumatic brain injury (TBI) is a leading cause of death and disability in young individuals, with acute epidural hematoma (AEDH) being a critical neurosurgical emergency. Advances in CT imaging and surgical techniques have reduced mortality from 86 to 5 to 12%.

Objective

To assess the socio-demographic characteristics, clinical outcomes, and factors influencing prognosis in patients surgically treated for traumatic AEDH.

Methods

A prospective cross-sectional study was conducted on 132 patients treated for AEDH between February 2020 and September 2022 at Tikur Anbessa Specialized Hospital and ALERT Trauma Center. Data were collected through interviews, chart reviews, and CT scans, and analyzed using SPSS version 25.

Results

Of the 132 patients, 92.4% were male, with a mean age of 30.8 years. Assault (59.1%) and road traffic accidents (25.8%) were the leading causes. Most hematomas (98.5%) were supratentorial and unilateral (91.6%), with the parietal region most commonly affected (61.4%). Preoperative Glasgow Coma Scale (GCS) scores of 14 to 15 were observed in 48.5% of cases, and 89.75% of patients had normal pupillary reactions. The mortality rate was 3%, with 6.8% discharged in a vegetative state and 75% achieving good recovery (GODS: 7–8). Poor outcomes were significantly associated with low postresuscitation GCS (p = 0.004), effacement of basal cisterns (p = 0.043), hemiparesis (p < 0.001), low oxygen saturation (p = 0.007), and abnormal pupillary reactions (p = 0.014).

Conclusion

This study reports a low mortality rate in AEDH patients. However, key prognostic factors such as low GCS and pupillary abnormalities stress the need for rapid diagnosis and intervention to optimize outcomes.

Keywords

acute epidural hematoma - basal cistern - pupillary reaction - hemiparesis

Introduction

Traumatic brain injury (TBI), often referred to as a “silent epidemic,” is a leading cause of death and disability worldwide, particularly among young individuals. The incidence of TBI continues to rise globally, especially in low- and middle-income countries (LMICs), due to increased motor vehicle usage and high-risk behaviors.[1] Acute epidural hematoma (AEDH), a serious complication of TBI, accounts for 1 to 3% of head injuries and affects approximately 9% of comatose patients, with a peak incidence in the second decade of life.[2] AEDH occurs from bleeding between the skull and the dura mater, usually due to trauma disrupting the middle meningeal artery. Traditionally, AEDH was associated with delayed deterioration caused by arterial bleeding; however, recent hypotheses suggest that dura detachment may precede hemorrhage, potentially influencing the timing and nature of surgical interventions.[3] If left untreated, AEDH can rapidly progress from a transient loss of consciousness to coma and death.[2]

The primary risk factors for AEDH include male gender, ages 20 to 30, and high-risk activities such as road traffic accidents (RTAs) and physical assaults.[1] [4] [5] Studies emphasize the importance of prompt surgical intervention to improve outcomes, with mortality rates ranging from 41% in patients with a Glasgow Coma Scale (GCS) score of 8 or less to 0% in alert patients.[5] [6] [7] Despite advancements in diagnostic imaging and emergency care, mortality rates for AEDH still vary widely, from 10 to 40%, depending on the healthcare infrastructure available in different regions.[8] [9] [10] [11] [12]

Statement of the Problem

In Ethiopia, traumatic injuries, including TBI, represent a major cause of morbidity and mortality, primarily affecting the economically active population. RTAs remain the leading cause of trauma-related injuries.[13] [14] Limited access to emergency medical care, especially in rural areas, and a lack of neurosurgical infrastructure exacerbate poor outcomes for AEDH patients.[15] The disparity in healthcare between hospitals and regions in Ethiopia highlights systemic challenges, such as insufficient trauma systems, lack of equipment, and inadequate prehospital care.[14] [16] These factors underscore the need for improved regulatory frameworks, public health education, and rapid emergency treatment protocols to mitigate injury-related mortality.

Significance of the Study

This study aims to evaluate the surgical outcomes of AEDH patients in Ethiopian hospitals using the extended Glasgow Outcome Score (GOSE) at discharge.[17] By examining socio-demographic characteristics and clinical factors, the study seeks to identify variables influencing patient outcomes in a resource-limited setting. The results are expected to guide patient stratification, inform treatment prioritization, and potentially influence the development of institution-based and national guidelines for AEDH management. Additionally, this study provides a foundation for future research aimed at improving care in LMICs, where barriers such as limited neurosurgical services, delayed transportation, and inadequate postoperative rehabilitation contribute to suboptimal outcomes.[18]

Patients and Methods

Study Design and Setting

A prospective cross-sectional study was conducted at Tikur Anibesa Specialized Hospital (TASH) and All African Leprosy Rehabilitation and Training (ALERT) Trauma Center, Addis Ababa, Ethiopia. The study focused on patients who underwent surgical intervention for acute traumatic epidural hematomas (AEDH) between February 1, 2020, and September 30, 2022.

Study Population

Inclusion criteria consisted of patients aged 12 years and older with CT-confirmed acute traumatic epidural hematomas requiring surgical intervention during the study period. Exclusion criteria included patients younger than 12 years, those managed conservatively, patients with spontaneous epidural hematomas, and individuals undergoing surgery for unrelated indications.

Variables

Dependent variable: Surgical outcome measured by the Extended GOSE at discharge.

Independent variables: Age, sex, distance from the city, mode of presentation, mechanism of injury, time from injury to presentation, presence of extracranial injuries, vital signs at presentation, postresuscitation GCS, pupillary abnormalities, CT scan findings (e.g., hematoma location, volume, and associated lesions), time from admission to operation, indication for surgery, source of bleeding, length of hospital stay, and postoperative complications.

Sampling and Sample Size

A convenience nonprobabilistic sampling method resulted in 132 patients who met the eligibility criteria.

Data Analysis

Data were analyzed using IBM SPSS version 25. Descriptive statistics were used to summarize baseline characteristics, and results were presented as percentages, means, and medians. Patients were classified into good (GOS: 7–8) and poor (GOS: 1–6) outcomes. Associations between independent variables and outcomes were assessed using chi-square tests for categorical variables and independent sample t-tests for continuous variables, with significance set at p-values ≤ 0.05 (see [Table 1]). Binary logistic regression was performed to identify predictors of poor outcomes, with results reported as odds ratios (OR) and 95% confidence intervals (CI; see [Table 2]).

Table 1 Cross-tabulation between dependent and independent variables, summary

Cross tabulation
Variables			GOS at discharge		Sig. (p-value)
			1 (Good response)	2 (Poor response)
Gender	M		77%	23%	0.43
	F		70%	30%
Hospital	Alert		74.2%	25.8%	0.244
	TASH		81.4%	18.6%
Address	Addis Ababa		72.7%	27.3%	0.682
	Oromia		83.7%	16.3%
	Amhara		75%	25%
	SNNPR		75%	25%
Mode of presentation	Direct		71%	29%	0.27
	Referral		78.2%	21.8%
Admission	Ward		85.2%	14.8%	0.000
	ICU		37.5%	62.5%
Reason for ICU admission	Monitoring		75%	25%	0.001
	MV support		11.8%	88.2%
MOI	RTA		82.4%	14.8%	0.345
	Assault		76.9%	23.1%
	Fall		65%	35%
RTA	Pedestrian		79.2%	20.8%	0.614
	Passenger in a car		100%	0.0%
	Driver of motorcycle		80%	20%
Fall	Height		61.1%	38.9%	0.521
	Standing point		100%	0.00%
Assault	Stick		77.8%	22.2%	0.77
	Stone		77.8%	22.2%
	Sharp objects		60%	40%
	Riffle/gun		100%	0.0%
ECI	Yes		44.4%	55.6%	0.115
	No		78.9%	21.1%
H/A	Yes		93%	7%	0.002
	No		68.5%	31.5%
Vomiting	Yes		81.8%	18.2%	0.051
	No		65.9%	34.1%
Altered sensorium	Yes		68.2%	31.8%	0.555
	No		91.5%	8.5%
Hemiparesis	Yes		38.9%	61.1%	0.000
	No		82.5%	17.5%
GCS	Mild		96.9%	3.1%	0.000
	Moderate		70%	30%
	Sever		22.2%	77.8%
Pupil	Rt.	Normal	81.7%	18.3%	0.000
		DNR	40%	60%
		Due to Assess	50%	50%
	Lt.	Normal	79.5%	20.5%	0.011
		DNR	40%	60%
DSF	Yes		84.2%	15.8%	0.257
	No		73.4%	26.6%
Volume	>30		68.9%	31.1%	0.037
	≤30		85.7%	14.3%
Medline shift	≥0.5		65.6%	34.4%	0.007
	<0.5		86.4%	13.6%
Status of basal cistern	Open		87.9%	12.1%	0.000
	Partially effaced		78%	22%
	Fully effaced		25%	75%
ASDH	Yes		57.1%	42.9%	0.35
	No		77.6%	22.4%

Table 2 Summary of bivariate and logistic regression

Variables		Bivariate analysis				Logistic regression
		Sig.	COR	95% CI		Sig.	AOR	95% CI
				Lower	Upper			Lower	Upper
Address	Addis Ababa	0.607	0.519	0.2	1.344	0.362	15.781	0.042	5,932.881
	Oromia	0.176	0.524	0.2	1.352	0.763	2.242	0.012	430.913
	Amhara	0.921	0.889	0.88	9.028	0.378	11.031	0.053	2,300.919
	SNNPR	0.891	0.889	0.166	4.755	0.483	10.21	0.000
Admission		0.000	9.583	3.589	25.591	0.321	2.782	0.369	20.986
Total GCS		0.000	0.551	0.445	0.682	0.004	0.403	0.216	0.751
ECI		0.029	0.214	0.054	0.856	0.329	4.095	0.241	69.638
H/A		0.005	6.12	1.744	21.483	0.960	0.935	0.066	13.273
Vomiting		0.045	2.328	1.019	5.316	0.062	0.178	0.029	1.088
Altered sensorium		0.005	0.2	0.65	0.613	0.772	1.364	0.168	11.094
Hemiparesis		0.000	0.135	0.47	0.392	0.000	66.918	6.441	695.204
Volume		0.029	2.706	1.105	6.628	0.400	0.357	0.032	3.942
Medline shift		0.007	0.301	0.126	0.721	0.320	0.248	0.016	3.873
Status of basal cistern	Open	0.00	0.243	0.000		0.083	0.00	0.00
	Partial effacement	0.16	2.045	0.754	5.542	0.860	1.235	0.118	12.912
	Full effacement	0.000	21.750	5.629	84.036	0.043	65.481	1.133	3,784.693
DSF		0.19	1.932	0.722	5.173	0.475	0.509	0.080	3.239
ASDH		0.229	0.385	0.081	1.822	0.496	0.413	0.032	5.263
Pupil		0.001	6.714	2.156	20.914	0.014	0.010	0.000	0.393
Total hospital stay		0.001	1.124	1.052	1.202	0.310	1.074	0.935	1.234
Oxygen saturation		0.018	0.86	0.76	0.975	0.007	0.666	0.496	0.896

Results

A total of 132 patients aged 12 and older were included, with a notable male predominance (92.4%) and a male-to-female ratio of 12:1. The median age was 28 years, and 75% of participants were between 23 and 35 years of age (see [Fig. 1]). Most patients (67.4%) received care at trauma centers, while the remaining patients were treated elsewhere. Geographically, 58.3% of patients were from the capital city, and the rest from surrounding regions. Referrals accounted for 76.5% of presentations, while 23.5% were direct admissions. The median time from injury to presentation was 6 hours, with 75% of patients presenting within 4 to 24 hours (see [Tables 3] [4] [5]).

Table 3 Gender

	Frequency	Percent	Valid percent	Cumulative percent
Male	122	92.4	92.4	92.4
Female	10	7.6	7.6	100.0
Total	132	100.0	100.0

Note: Socio-demographic characteristics of Patients with AEDH

Table 4 Age and distance from Addis Ababa

	Age of the patient	Distance from Addis Ababa
Median	28.00	84.00
Range	54	390
Minimum	13	10
Maximum	67	400

Note: Socio-demographic characteristics of patients with AEDH

Table 5 Mode of presentation, hospital, and address of the patient

Mode of presentation	Frequency	Percent	Valid percent	Cumulative percent
Direct	31	23.5	23.5	23.5
Referral	101	76.5	76.5	100.0
Total	132	100.0	100.0
Hospitals	Frequency	Percent	Valid percent	Cumulative percent
Alert	89	67.4	67.4	67.4
TASH	43	32.6	32.6	100.0
Total	132	100.0	100.0
Region	Frequency	Percent	Valid percent	Cumulative percent
AA	77	58.3	58.3	58.3
Oromia	43	32.6	32.6	90.9
Amhara	4	3.0	3.0	93.9
SNNPR	8	6.1	6.1	100.0
Total	132	100.0	100.0

Note: Socio-demographic characteristics of patients with AEDH

Fig. 1 Histogram of age distribution of patients.

The most common mechanism of injury was assault (59.1%), followed by RTAs (25.8%) and falls (15.2%). Among assaults, stick injuries were the most prevalent (34.1%), while 90% of fall cases involved heights (see [Table 6]). In RTAs, 70.6% of injuries were sustained by pedestrians. Common presenting symptoms included vomiting (37%), altered consciousness (35.7%), headache (18.1%), and weakness (7.6%; see [Table 7]). Abnormal pupillary light reactions were observed in 11.4% of patients on the right side and 7.6% on the left.

Table 6 Mechanism of injury in patients with AEDH

		Frequency	Percent	Valid percent	Cumulative percent
Valid	RTA	34	25.8	25.8	25.8
	Assault	78	59.1	59.1	84.8
	Fall	20	15.2	15.2	100.0
	Total	132	100.0	100.0
Fall down accident
Valid	Fall from height	18	13.6	90.0	90.0
	Fall from standing point	2	1.5	10.0	100.0
	Total	20	15.2	100.0
Missing	System	112	84.8
Total		132	100.0
Assault
Valid	Stick injury	45	34.1	57.7	57.7
	Stone injury	27	20.5	34.6	92.3
	Sharp object	5	3.8	6.4	98.7
	Rifle/gunshot	1	0.8	1.3	100.0
	Total	78	59.1	100.0
Missing	System	54	40.9
Total		132	100.0
RTA
Valid	Pedestrian run over by a car	24	18.2	70.6	70.6
	Passenger in a car	5	3.8	14.7	85.3
	Driver of motorcycle	5	3.8	14.7	100.0
	Total	34	25.8	100.0
Missing	System	98	74.2
Total		132	100.0

Table 7 Clinical presentation of Patients with AEDH

		Responses		Percent of cases
		n	Percent
Signs and symptoms during presentation	Headache	43	18.1%	32.6%
	Vomiting	88	37.0%	66.7%
	Seizer	3	1.3%	2.3%
	Altered sensorium	85	35.7%	64.4%
	Hemiparesis/plegia	18	7.6%	13.6%
	Cranial nerve palsy	1	0.4%	0.8%
Total		238	100.0%	180.3%

Note: Presenting symptoms.

Postresuscitation GCS scores were 14 to 15 in 48.5% of patients, 9 to 13 in 37.9%, and less than 8 in 13.6% (see [Table 8]).

Table 8 GCS and pupillary status of patients with AEDH

		Frequency	Percent	Valid percent	Cumulative percent
Valid	Mild (14,15)	64	48.5	48.5	48.5
	Moderate (9–13)	50	37.9	37.9	86.4
	Sever (<8)	18	13.6	13.6	100.0
	Total	132	100.0	100.0
Right pupil
Valid	Normal	115	87.1	87.1	87.1
	DNR	15	11.4	11.4	98.5
	Difficult to Assess	2	1.5	1.5	100.0
	Total	132	100.0	100.0
Left pupil
Valid	Normal	122	92.4	92.4	92.4
	DNR	10	7.6	7.6	100.0
	Total	132	100.0	100.0

Note: GCS summary and pupil size and light reaction.

Cranial CT scans revealed unilateral AEDH in 91.6% of cases, with the parietal region being the most affected (61.4%). Hematoma thickness exceeded 1.5 cm in 80% of patients, and volume was greater than 30 cc in 56.9%. Midline shift was less than 0.5 cm in 50.8% of cases. Associated CT findings included linear skull fractures in 50% of patients and brain contusions in 27.3% (see [Table 9]).

Table 9 Radiological characteristics of AEDH patients

Side of hematoma		Frequency	Percent	Valid percent	Cumulative percent
Valid	Right	56	42.4	42.4	42.4
	Left	65	49.2	49.2	91.7
	Bilateral	3	2.3	2.3	93.9
	Medline	8	6.1	6.1	100.0
	Total	132	100.0	100.0
Location
Valid	ST	130	98.5	98.5	98.5
	IT	2	1.5	1.5	100.0
	Total	132	100.0	100.0
Thickness
Valid	≥1.5	104	78.8	80.0	80.0
	<1.5	26	19.7	20.0	100.0
	Total	130	98.5	100.0
Missing	System	2	1.5
Total		132	100.0
Status of basal cistern
Valid	Open	66	50.0	50.0	50.0
	Partially effaced	50	37.9	37.9	87.9
	Fully effaced	16	12.1	12.1	100.0
	Total	132	100.0	100.0
Side and other findings		n	Percent	Percent of cases
CT scan finding	CT	132	21.1%	100.0%
	Linear	66	10.5%	50.0%
	DSF	38	6.1%	28.8%
	Contusion/ICH	36	5.7%	27.3%
	ASDH	7	1.1%	5.3%
	DAI_BE	1	0.2%	0.8%
	BSF	11	1.8%	8.3%
	Pneumocephalus	5	0.8%	3.8%
	Location	130	20.7%	98.5%
	Frontal	59	9.4%	44.7%
	Temporal	59	9.4%	44.7%
	Parietal	81	12.9%	61.4%
	Occipital	2	0.3%	1.5%
Total		627	100.0%	475.0%

In terms of surgical management, all patients underwent craniotomy and hematoma evacuation. Eighty-one point eight percent of patients were admitted to wards, while 18.2% required ICU care, primarily for mechanical ventilation (58.6%). The mean hospital stay was 6.23 days, and the mean ICU stay was 5.32 days (see [Table 10]). The overall mortality rate was 3%, with 75% of patients achieving good recovery and 22% experiencing poor recovery (see [Table 11] and [Fig. 2]).

Fig. 2 Pie chart on the surgical outcome of patients with AEDH.

Table 10 Surgical management and hospital course of patients

Place of admission		Frequency	Percent	Valid percent	Cumulative percent
Valid	Ward	108	81.8	81.8	81.8
	ICU	24	18.2	18.2	100.0
	Total	132	100.0	100.0
Reason for ICU admission
Valid	Monitoring	12	9.1	41.4	41.4
	Ventilator support	17	12.9	58.6	100.0
	Total	29	22.0	100.0
Missing	System	103	78.0
Total		132	100.0
Surgical indication
Valid	Imaging	89	67.4	67.4	67.4
	FND	11	8.3	8.3	75.8
	GCS < 8	16	12.1	12.1	87.9
	Hematoma expansion CT	2	1.5	1.5	89.4
	PND	14	10.6	10.6	100.0
Bleeding source
Valid	MMA	61	46.2	46.6	46.6
	Venous sinus	19	14.4	14.5	61.1
	Fractured bone	43	32.6	32.8	93.9
	Not specified	8	6.1	6.1	100.0
	Total	131	99.2	100.0
Missing	System	1	.8
Total		132	100.0
Postop complications
Valid	Yes	7	5.3	5.3	5.3
	No	125	94.7	94.7	100.0
	Total	132	100.0	100.0
Complication type
Valid	Chest infection	7	5.3	100.0	100.0
Missing	System	125	94.7
Total		132	100.0
	Total	132	100.0	100.0
		Total stay in Hospital	ICU stay	Time between accident and presentation	Time between presentation and surgery
n	Valid	132	28	132	132
	Missing	0	104	0	0
Mean		6.23	5.32	25.73	4.91
Median		4.00	3.50	6.00	3.00
SD		7.033	5.578	36.773	9.444
Range		43	22	215	71
Minimum		2	1	1	1
Maximum		45	23	216	72
Percentiles	25	3.00	2.00	4.00	2.00
	50	4.00	3.50	6.00	3.00
	75	6.00	5.75	24.00	4.00

Table 11 Outcome of patients with AEDH

EGOS		Frequency	Percent	Valid percent	Cumulative percent
Valid	Death	4	3.0	3.0	3.0
	Vegetative state	9	6.8	6.8	9.8
	Lower SD	2	1.5	1.5	11.4
	Upper SD	10	7.6	7.6	18.9
	Lower MD	1	0.8	0.8	19.7
	Upper MD	7	5.3	5.3	25.0
	Lower GR	38	28.8	28.8	53.8
	Upper GR	61	46.2	46.2	100.0
	Total	132	100.0	100.0

Note: Summary of outcome of study participants at discharge.

Discussion

This study evaluated 132 patients with acute traumatic epidural hematomas (AEDH) who underwent surgical intervention. The cohort demonstrated significant male predominance, consistent with global trends in trauma epidemiology.[12] [16] [19] [20] The majority of injuries were due to assaults, particularly in the context of interpersonal violence. The mortality rate of 3% aligns with international benchmarks,[21] [22] underscoring the efficacy of current treatment protocols.

Timeliness of intervention is critical in AEDH management. While the median time from injury to surgery was 6 hours, this did not significantly impact outcomes in our study. Instead, factors such as postresuscitation GCS, pupillary abnormalities, oxygen saturation, and basal cistern effacement emerged as key predictors of recovery, emphasizing the need for comprehensive patient assessments.

Conclusion

This study underscores the importance of early surgical intervention in patients with acute traumatic epidural hematomas, favorable recovery reflects effective management strategies, but disability remains a concern for some patients. Improving early detection and treatment, particularly in resource-limited settings, may further enhance outcomes.

Conflict of Interest

None declared.

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Publication History

Received: 25 February 2025

Accepted: 05 May 2025

Accepted Manuscript online:
08 May 2025

Article published online:
28 May 2025