Tag Archives: epidural

CNS

Epidural Hematoma Treated With Middle Meningeal Artery Embolization

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Epidural hematoma is a life-threatening condition that is typically associated with arterial bleeding outside of the dura. Most frequently, this is due to a skull fracture that extends across and lacerates the middle meningeal artery (MMA).

The standard treatment regimen is neurologic monitoring in patients who have a (nearly) normal GCS and do not change neurologically. That escalates to rapid craniectomy and evacuation in those with neurologic compromise.  Interestingly, there have been a few case reports over the last 10 years describing attempted management by embolization of the MMA.

Let’s look at this idea more critically. This seems like it should be a good idea. But remember, in medicine you’ve actually got to study it. There are too many examples of things that make sense that are worthless or actually cause harm.

The first report I found was a series of one in which the patient was found to have a large subdural hematoma. He was taken to surgery and the lesion was evacuated. However, there was persistent epidural bleeding intraop which was thought to be controlled. Repeat scan the next day showed a large epidural, so he was returned to the OR. Once again, there was persistent epidural oozing and the collection was removed. Followup CT showed yet another epidural. The patient was finally taken to interventional radiology for embolization of the MMA. This was successful, and the patient had no further recurrences.

This case provided proof of concept, although the bleeding was not due to known traumatic injury to the MMA. Last year, another case report was published that described an experience (of one again) with a young male who was found down. He awakened and then became obtunded again. CT showed bilateral epidural hematomas. He was taken to the OR for operative evacuation of the larger one. Postop CT showed expansion of the smaller one.

The patient was then taken to the endovascular suite and MMA embolization was carried out. The hematoma stabilized and the patient was later discharged without sequelae.

This case was trauma-related, but not for an acute bleed. Now, let’s look at a bigger case series to see how well this works. This one detailed the experience of a neurosurgery group in Sao Paulo, Brazil. All patients who underwent conservative management based on “standard criteria” were studied. Patients with large hematomas, midline shift, depressed skull fracture, coagulopathy, or incomplete data were excluded. One third of the injuries were due to falls, and the rest were due to other blunt mechanisms.

Here are the factoids:

  • 85% had an attendant skull fracture
  • About 82% had active extravasation from the MMA
  • All patients had followup CT scan 1-7 days after the procedure, and no increase in epidural size was noted
  • None of the patients had a change in GCS or needed operative intervention
  • The authors compared these results to historical controls from other published literature

Bottom line: Sounds impressive, right? But not so fast, there are a lot of loose ends here. First, these are supposedly all patients with epidural hematoma who were treated without operation. Decision to operate was based on criteria set out in a paper published 15 years ago. This strains the imagination a bit. There is usually no uniformity in the way individual neurosurgeons decide to operate, so it is likely there may be some significant selection bias here. It is very easy to believe that patients who were predicted to do well were the only ones enrolled in the study. This also explains why the authors had to use controls from other authors’ research for outcome comparison.

The results are too clean as well. No adverse events. No patients who ended up needing surgery. Followup scans were performed any time between postop day 1 and 7, but there is no frequency breakdown. If most of the repeat scans were performed near the beginning of the postop period, little change would be expected. MMA embolization is either a miracle cure or …

You know what they say, “if it seems to good to be true…” A single case series like this should never change one’s practice. Middle meningeal artery embolization sounds like common sense, but the devil is always in the details. This concept needs a lot more study before you should ever consider it in your patients. Or, you could start a real, IRB-approved study and make an excellent contribution to the neurosurgery literature.

References:

  1. Embolization of the Middle Meningeal Artery for the Treatment of Epidural Hematoma. J Neurosurg 110(6):1247-1249, 2009.
  2. Middle Meningeal Artery Embolization for the Treatment of an Expanding Epidural Hematoma. World Neurosurg 128:284-286,2019
  3. Endovascular Management of Acute Epidural Hematomas: Clinical Experience With 80 Cases. J Neurosurg 128(4):1044-1050, 2018.
General

Delayed Intracranial Hemorrhage In Patients On Anticoagulants

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A sizable portion of our population is taking one type of anticoagulant or another. Heck, even golf star Arnold Palmer and comedian Kevin Nealon are on Xarelto! Any trauma professional, and anyone who reads the package insert, knows that there is an increased risk of bleeding if they are injured while taking these drugs, whether it be warfarin or the new, novel anticoagulants.

But does the risk stop soon after injury? That is the presumption at many hospitals that initially treat these patients. They are seen in the ED, examined, scanned, and sent home if nothing is found. Is this a safe practice?

I have personally seen a patient who had an initially clean CT present within 12 hours after ED discharge with a catastrophic bleed and die. Yes, this is anecdotal, but I have talked to other trauma professionals with similar experiences. If this were just a minor complication, no big deal. But they died. Big problem for everyone involved.

So what does the literature say? Unfortunately, it consists of a collection of relatively small studies. Here are the collected factoids that I can glean from them:

  • Most are retrospective, observational studies 
  • Most are from a single hospital, which may miss readmissions to other facilities in the area
  • The delayed bleeding rate is about 0.5% to 1%
  • Some papers recommended discharging patients with a normal head CT and giving them instructions to return if new symptoms develop (this is what happened with my patient; what if they live alone or in a care center where these may not be recognized?!)
  • A few papers did identify patients needing neurosurgical intervention or who died
  • Immediate bleeds were more common with antiplatelet agents, delayed bleeds were more common with warfarin
  • I could find nothing that looked at this problem in patients taking novel anticoagulants like Pradaxa or Xarelto

Bottom line: The literature provides little guidance at this point. A good multi-institutional trial is needed to generate the numbers to tell us what to do. While we get around to this, I recommend that a selective brief observation (12 hrs) protocol be adopted. This protocol recognizes that subclinical bleeding may be present on initial presentation, and that a little more time is needed for it to declare itself.

Here is a link to our protocol. If the initial head CT is negative and the INR is less than 2.5, we will only discharge the patient if all of these criteria are true:

  • Age < 65
  • No skull fx
  • No new focal neurologic deficits
  • No soft tissue injury visible on CT (hematoma, laceration)
  • GCS = 15
  • No persistent vomiting
  • Brief TBI screen passed (Short Blessed Test, link here)

Most do not pass all of these, usually failing the age criterion. They are admitted for observation and neurologic monitoring for 12 hours, at which time the head CT is repeated. If it is still normal, then they can go home.

And although this protocol was designed with warfarin in mind, we apply it to patients taking novel anticoagulants like Pradaxa and Xarelto as well. We’ve had no epic fails yet, but I keep my fingers crossed!

Related posts:

References:

  • Management of minor head injury in patients receiving oral anticoagulant therapy: a prospective study of a 24-hour observation protocol. Ann Emerg Med 59(6):451-455, 2012.
  • Immediate and delayed traumatic intracranial hemorrhage in patients with head trauma and preinjury warfarin or clopidogrel use. Ann Emerg Med 59(6):460-468, 2012.
  • Delayed intracranial hemorrhage after blunt trauma: are patients on preinjury anticoagulants and prescription antiplatelet agents at risk? J Trauma 71(6):1600-1604, 2011.
  • Low risk of late intracranial complications in mild traumatic brain injury patients using oral anticoagulation after an initial normal brain computed tomography scan: education instead of hospitalization. Eur J Neurol 21(7):1021-1025, 2014.
  • Can anticoagulated patients be discharged home safely from the emergency department after minor head injury? J Emerg Med 46(3):410-417, 2014.
  • Patients with blunt head trauma on anticoagulation and antiplatelet medications: can they be safely discharged after a normal initial cranial computed tomography scan? Am Surg 80(6):610-613, 2014.
History

Trauma 20 Years Ago: Continuous Epidural Analgesia for Rib Fractures

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Rib fractures are painful, and lots of rib fractures not only hurt, but can lead to complications or death. We take for granted all the modalities we now have for pain relief with rib fractures:

  • IV narcotics
  • epidural analgesia
  • rib blocks
  • intrapleural analgesia
  • lidocaine patches
  • fracture fixation techniques
  • and more!

In April 1991, we were still trying to figure out if epidural analgesia was any better than IV narcotics. A small prospective study of 32 patients who were awake and alert and had at least 3 rib fractures were given either IV or epidural fentanyl. The drug was administered as an initial bolus, followed by a continuous infusion. A visual analog pain scale was used for titration.

Vital capacity increased significantly in both groups. Epidural analgesia also led to an improvement in maximum inspiratory pressure (which we now know as NIF). IV analgesia led to somewhat troubling increases in pCO2 and decreases in pO2, whereas epidural administration did not. Pain relief was better with the epidural, while side effects were similar.

The authors concluded that epidural analgesia offers several advantages over IV, and stated that it should be the preferred method for patients at high risk for complications following multiple rib fractures. This paper started us on the path to using the epidural for pain management with significant rib fractures.

Reference: Prospective evaluation of epidural and intravenous administration of fentanyl for pain control and restoration of ventilatory function following multiple rib fractures. J Trauma 31(4):443-451, 1991.