Aim: This paper has three aims: 1) to describe, and to illustrate using case reports, that traumatic epidural hematoma (EDH) may fatally complicate a seemingly trivial head injury; 2) to assess the effects of computerized tomography (CT) and management guidelines for lowering the mortality, and 3) the factors that influence the prognosis for patients with EDH.
Methods: Searches made in PubMed and specific databases for neurosurgical journals by combining the terms "traumatic head injury", "cranial epidural hematoma, traumatic", "outcome", "head computerized tomography", and "guidelines". My mentor (KFL) made available relevant non-English (German, French, Spanish) and old (pre-1950) literature.
Results: After World War 2, mortality from EDH has decreased. At present, the mortality is about 10%. In the CT era, i.e. since the mid-1970's, mortality has on the overall been lower than before CT was introduced. This paper includes a meta-analysis of 9 studies showing significantly lower mortality with CT. It is however not sure whether CT directly lowered the mortality rates, because the paramount impact factors influencing outcome from EDH are the patient’s neurological state and level of consciousness at the time of surgery. Arguably, CT contributes by reducing the interval from injury to operation: the diagnosis of an EDH is obtained quicker (as well as with less trauma and resource expenditure) from a CT scan than by other imaging techniques, e.g. intra-arterial angiography.
Originating from Norway, this paper emphasizes Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. Guidelines use the patient’s clinical features (such as their Glasgow Consciousness Score – GCS) and case history to help in clinical decision-making, e.g. who needs a CT-scan and who does not. These guidelines are not 100 % sensitive or specific for detecting intracranial hematoma. It should nevertheless be emphasized that studies show that more traumatic hematomas are being detected when guidelines are in clinical use than when guidelines are not being implemented.
Conclusions: CT and management guidelines both contribute to reducing mortality from EDH. Yet, at the end of the day, the most important factor in lowering mortality from EDH is that the attending medical personnel: 1) are acquainted with the pathophysiology, the symptoms, and the signs of EDH; 2) appreciate that the course of traumatic head injuries may be difficult to predict; and 3) understand that even in the 21st century, a seemingly trivial head trauma may trigger a life-threatening EDH.