Analysis of Risk Factors for the Development of Post-Operative Epidural Hematoma after Intracranial Surgery

Won Mo Gu; Won Il Joo; Hyoung Kyun Rha; Hae Kwan Park; Chung Kee Chough; Kyung Jin Lee

doi:10.13004/kjnt.2012.08.0.79

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Analysis of Risk Factors for the Development of Post-Operative Epidural Hematoma after Intracranial Surgery

Original Article

Korean J Nutr 2012;8(2):79-86.

Published online: 19 January 2012

DOI: https://doi.org/10.13004/kjnt.2012.08.0.79

Analysis of Risk Factors for the Development of Post-Operative Epidural Hematoma after Intracranial Surgery

Won Mo Gu, MD, Won Il Joo, MD, Hyoung Kyun Rha, MD, Hae Kwan Park, MD, Chung Kee Chough, MD, Kyung Jin Lee, MD

Department of Neurosurgery, Yeouido St. Mary's Hospital Neuroscience Center, College of Medicine, The Catholic University of Korea, Seoul, Korea

Address for correspondence: Won Il Joo, MD Department of Neurosurgery, Yeouido St. Mary's Hospital Neuroscience Center, College of Medicine, The Catholic University of Korea, 62 Yeouido-dong, Yeongdeungpo-gu, Seoul 150-713, Korea Tel: +82-2-3779-2248, Fax: +82-2-786-5809, E-mail: jwi@catholic.ac.kr The statistical consultation was supported by Catholic Research Coordinating Center of the Korea Health 21 R&D Project (A070001), Ministry of Health & Welfare, Republic of Korea.

Received 20 June 2012 Revised 4 August 2012 Accepted 9 August 2012

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective:

Patients undergoing intracranial operations often suffer from post-operative epidural hematoma (EDH). The incidence and risk factors for with the occurrence of EDH after intracranial operations are not well described previously. The objective of this study was to identify the risk factors and the incidence of post-operative EDH adjacent and regional to the craniotomy.

Methods:

This was a retrospective study of 23 (2.4%) patients, between January 2005 and December 2011, who underwent epidural hematoma evacuation after primary intracranial during this period, 941 intracranial operations were performed. The control group (46 patients) and hematoma group (23 patients) were categorized on the basis of having undergone the same pre-operative diagnosis and treatment within 3 months of their operations. The ages of the hematoma and control group were individually matched to similar ages within 10 years of each other to minimize bias of age.

Results:

Univariate analysis showed that the significant pre-operative and intra-operative factors associated with postoperative EDH were a pre-operative Glasgow Coma Scale (GCS) scored ＜8 (crude odds ratio 8.295), prothrombin ratio ＞1.0 (p=0.014), prothrombin time (PT) ＞11.3 sec (p=0.008), intra-operative blood loss ＞650 mL (p=0.003) and craniotomy size ＞7,420 mm² (p=0.023). In multivariate analysis, intra-operative blood loss exceeding 650 mL (median of total patients) placed a patient at significantly increased risk for post-operative EDH.

Conclusion:

Recognizing the limitations of the study, large intra-operative blood loss, wide craniotomy area, prolonged PT and a pre-operative GCS ＜8 are presented implicated with an increased risk of post-operative EDH after intracranial surgery.

Keywords: Intracranial epidural hematoma, Post-operative hematoma, Craniotomy, Risk factor

REFERENCES

1). Altschuler E., Moosa H., Selker RG., Vertosick FT Jr. The risk and efficacy of anticoagulant therapy in the treatment of thromboembolic complications in patients with primary malignant brain tumors. Neurosurgery. 27:74–76. discussion 77. 1990.

2). Awad JN., Kebaish KM., Donigan J., Cohen DB., Kostuik JP. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. 87:1248–1252. 2005.

3). Ban SP., Son YJ., Yang HJ., Chung YS., Lee SH., Han DH. Analysis of complications following decompressive craniectomy for traumatic brain injury. J Korean Neurosurg Soc. 48:244–250. 2010.

4). Fukamachi A., Koizumi H., Nagaseki Y., Nukui H. Postoperative extradural hematomas: computed tomographic survey of 1105 intracranial operations. Neurosurgery. 19:589–593. 1986.

5). Garber ST., Sivakumar W., Schmidt RH. Neurosurgical complications of direct thrombin inhibitors—catastrophic hemorrhage after mild traumatic brain injury in a patient receiving dabigatran. J Neurosurg. 116:1093–1096. 2012.

6). Gentleman D., Johnston RA. Postoperative extradural hematoma associated with induced hypertension. Neurosurgery. 17:105–106. 1985.

7). Gerlach R., Raabe A., Zimmermann M., Siegemund A., Seifert V. Factor XIII deficiency and postoperative hemorrhage after neurosurgical procedures. Surg Neurol. 54:260–264. discussion 264-265. 2000.

8). Guangming Z., Huancong Z., Wenjing Z., Guoqiang C., Xiaosong W. Should epidural drain be recommended after supratentorial craniotomy for epileptic patients? Surg Neurol. 72:138–141. discussion 141. 2009.

9). Haft H., Liss H., Mount LA. Massive epidural hemorrhage as a complication of ventricular drainage. J Neurosurg. 17:49–54. 1960.

10). Holden MP. Dangers of aspirin before cardiac surgery. BMJ. 305:365–366. 1992.

11). Hussain SA., Selway R., Harding C., Polkey CE. The urgent postoperative CT scan: a critical appraisal of its impact. Br J Neurosurg. 15:116–118. 2001.

12). Institute SAS. The sas system for windows, version 9.2. Cary, NC: SAS Institute. 1996.

13). Jeon JS., Chang IB., Cho BM., Lee HK., Hong SK., Oh SM. Immediate postoperative epidural hematomas adjacent to the craniotomy site. J Korean Neurosurg Soc. 39:335–339. 2006.

14). Kalfas IH., Little JR. Postoperative hemorrhage: a survey of 4992 intracranial procedures. Neurosurgery. 23:343–347. 1988.

15). Le Roux AA., Nadvi SS. Acute extradural haematoma in the elderly. Br J Neurosurg. 21:16–20. 2007.

16). Manian FA., Meyer PL., Setzer J., Senkel D. Surgical site infections associated with methicillin-resistant Staphylococcus aureus: do postoperative factors play a role? Clin Infect Dis. 36:863–868. 2003.

17). Palmer JD., Sparrow OC., Iannotti F. Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery. 35:1061–1064. discussion 1064-1065. 1994.

18). Park JE., Kim SH., Yoon SH., Cho KG., Kim SH. Risk factors predicting unfavorable neurological outcome during the early period after traumatic brain injury. J Korean Neurosurg Soc. 45:90–95. 2009.

19). Rapanà A., Lamaida E., Pizza V. Multiple postoperative intracerebral haematomas remote from the site of craniotomy. Br J Neurosurg. 12:364–368. 1998.

20). Sinar EJ., Lindsay KW. Distant extradural haematoma complicating removal of frontal tumours. J Neurol Neurosurg Psychiatry. 49:442–444. 1986.

21). Soff GA. A new generation of oral direct anticoagulants. Arterioscler Thromb Vasc Biol. 32:569–574. 2012.

22). Sokolowski MJ., Garvey TA., Perl J 2nd., Sokolowski MS., Cho W., Mehbod AA, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine (Phila Pa 1976). 33:108–113. 2008.

23). Thiagarajah S. Postoperative care of neurosurgical patients. Int Anesthesiol Clin. 21:139–156. 1983.

24). Troupp H. Extradural hematoma during craniotomy. Report of five cases. J Neurosurg. 40:783–785. 1974.

25). Yacubian EM., de Andrade MM., Jorge CL., Valério RM. Cerebellar hemorrhage after supratentorial surgery for treatment of epilepsy: report of three cases. Neurosurgery. 45:159–162. 1999.

26). Yoshino Y., Aoki N., Oikawa A., Ohno K. Acute epidural hematoma developing during twist-drill craniostomy: a complication of percutaneous subdural tapping for the treatment of chronic subdural hematoma. Surg Neurol. 53:601–604. 2000.

FIGURE 1.

Results of computed tomography (CT) examinations. A: CT scan showing intracranial hematoma at right basal ganglia with midline shifting. B: Post-operative immediate brain CT scan showed almost completely removed intracerebral hemorrhage, and also showed large amount of epidural hematoma (EDH) with aggravated mass effect. C: After reoperation was performed to remove the EDH beneath the previous craniectomy site, brain CT scan showed no residual epidural hematoma. A marginal amount of intracerebral hemorrhage remained.

FIGURE 2.

Data concerning craniotomy extent. Craniotomy extent was measured from plain lateral skull X-ray that is, from maximal perpendicular diameter (radius a and b) of the craniotomy. The resulting size of craniotomy was then approximated using the formular for a circle (size=π×ab).

TABLE 1.

Clinical characteristics of the control and hematoma groups

		Control group [n=46 (%, 66.7%)]	Hematoma group [n=23 (%, 33.3%)]	p-value
Gender	Male	30 (65.2)	13 (56.5)	0.482
	Female	16 (34.8)	10 (43.5)
Age	Mean±SD	50.2±12.5	50.4±14.0	0.948
Diabetes mellitus	No	44 (95.6)	21 (91.3)	0.596
	Yes	2 (4.4)	2 (8.7)
Hypertension	No	34 (73.9)	16 (69.6)	0.703
	Yes	12 (26.1)	7 (30.4)
Alcohol use	No	32 (69.6)	16 (69.6)	0.999
	Yes	14 (30.4)	7 (30.4)
Tobacco use	No	37 (80.4)	19 (82.6)	0.999
	Yes	9 (19.6)	4 (17.4)
Hemoglobin (g/dL)	Mean±SD	13.7±1.5	13.7±1.8	0.836
Hematocrit (%)	Mean±SD	40.7±4.4	40.6±5.4	0.904
Platelet count (×10⁹/L)	Mean±SD	215.5±55.5	227.6±76.1	0.458
Prothrombinratio (INR)	Mean±SD	1.0±0.1	1.0±0.1	0.290
Prothrombin time (sec)	Median (minimum-maximum)	11.1 (9.4-17.7)	11.6 (10.6-13.3)	0.002∗
Prothrombin percent (%)	Median (minimum-maximum)	99.9 (10.5-142.3)	97.9 (80.8-116.6)	0.390
aPTT	Mean±SD	25.7±3.8	25.3±3.7	0.657
Anti platelet and	No	42 (91.3)	23 (100.0)	0.293
anticoagulant use	Yes	4 (8.7)	0 (0.0)
GCS (pre-op)	Median (minimum-maximum)	15.0 (3.0-15.0)	12.0 (3.0-15.0)	0.095
GCS Category	A (13-15)	34 (74.0)	11 (47.8)	0.085
	B (9-12)	6 (13.0)	6 (26.1)
	C (3- 8)	6 (13.0)	6 (26.1)
Operation time (min)	Median (minimum-maximum)	222.5 (90.0-670.0)	240.0 (100.0-1,020.0)	0.259
Intra-op EBL (mL)	Median (minimum-maximum)	500.0 (10.0-2,000.0)	1,000.0 (70.0-8,000.0)	＜0.0001∗
Epidural drain	No	32 (69.6)	15 (65.2)	0.715
	Yes	14 (30.4)	8 (34.8)
Durotomy	No	9 (19.6)	3 (13.0)	0.738
	Yes	37 (80.4)	20 (87.0)
Craniotomy area (mm²)	Median (minimum-maximum)	8,265.1 (2,642.1-15,848.8)	5,729.6 (1,209.6-25,717.4)	0.018∗

∗probability values ＜0.05 were considered statistically significant. INR: international normalized ratio, aPTT: activated partial thromboplastin, GCS: Glasgow Outcome Scale, pre-op: pre-operative, intra-op: intra-operative, EBL: estimated blood loss, SD: standard deviation

TABLE 2.

Univariate conditional logistic regression analysis (pre-operative patient details)

		Control group (n=46)	Hematoma group (n=23)	Univariate
		No. (%)	No. (%)	Crude OR (95% CI)	p-value
Gender	Female	16 (34.8)	10 (43.5)	2.303 (0.433-12.236)	0.328
Age	≥65 years	5 (10.9)	5 (21.7)	2.195 (0.576- 8.362)	0.250
Diabetes mellitus	Yes	2 (4.3)	2 (8.7)	2.732 (0.226-33.004)	0.429
Hypertension	Yes	12 (26.1)	7 (30.4)	1.356 (0.356- 5.171)	0.656
Alcohol use	Yes	14 (30.4)	7 (30.4)	1.000 (0.329- 3.038)	0.999
Tobacco use	Yes	9 (19.6)	4 (17.4)	0.871 (0.243- 3.114)	0.831
Antiplatelet anticoagulant use	Yes	4 (8.7)	0 (0.0)	-	0.993
anticoagulant use GCS category	A	34 (73.9)	11 (47.8)	1.000	0.082
	B	6 (13.0)	6 (26.1)	5.107 (0.981-26.591)
	C	6 (13.0)	6 (26.1)	8.295 (1.027-67.032)∗

∗95% Confidence interval were excluded 1.0. GCS: Glasgow Outcome Scale, OR: odds ratio

TABLE 3.

Univariate conditional logistic regression analysis (pre-operative laboratory data)

		Control group (n=46)	Hematoma group (n=23)	Univariate
		No. (%)	No. (%)	Crude OR (95% CI)	p-value
Hemoglobin (g/dL)	≥12	41 (89.1)	18 (78.3)	0.500 (0.145-1.727)	0.273
Hematocrit (%)	≥35	42 (91.3)	20 (87.0)	0.667 (0.149-2.979)	0.596
Platelet count (109/L)	≥150	39 (84.8)	19 (82.6)	0.863 (0.237-3.142)	0.823
Prothrombinratio (INR)	≥1.0	16 (34.8)	16 (69.6)	3.747 (1.304-10.765)	0.014∗
Prothrombintime (sec)	≥11.3	20 (43.5)	20 (87.0)	16.000 (2.064-124.045)	0.008∗
Prothrombinpercent (%)	≥120	4 (8.7)	0 (0.0)	-	0.993
aPTT	≥26.3	23 (50.0)	9 (39.1)	0.641 (0.231-1.780)	0.394

∗probability values ＜0.05 were considered statistically significant. INR: international normalized ratio, aPTT: activated partial thromboplastin, OR: odds ratio

TABLE 4.

Univariate conditional logistic regression analysis (intra-operative data)

		Control group (n=46)	Hematoma group (n=23)	Univariate
		No. (%)	No. (%)	Crude OR (95% CI)	p-value
Operation time (mins)	≥230	22 (47.8)	14 (60.9)	2.171 (0.614-7.673)	0.229
Intra-op EBL (mL)	≥650	16 (34.8)	19 (82.6)	9.862 (2.214-43.937)	0.003∗
Epidural drain	Yes	14 (30.4)	8 (34.8)	1.250 (0.409-3.821)	0.696
Durotomy	Yes	37 (80.4)	20 (87.0)	2.171 (0.364-12.944)	0.395
Craniomy size (mm²)	≥7,420	18 (39.1)	16 (69.6)	3.845 (1.202-12.302)	0.023∗

∗probability values ＜0.05 were considered statistically significant. intra-op: intra-operative, EBL: estimated blood loss, OR: odds ratio

TABLE 5.

Multivariate conditional logistic regression analysis

		Control group (n=46)	Hematoma group (n=23)	Multivariate
		No. (%)	No. (%)	Adjusted OR (95% CI)∗	Adj. p-value∗
Prothrombinratio (INR)	≥1.0	16 (34.8)	16 (69.6)	0.807 (0.091-7.181)	0.847
Prothrombintime	≥11.3	20 (43.5)	20 (87.0)	26.128 (0.727-939.032)	0.074
GCS category	A	34 (73.9)	11 (47.8)	1.000	0.744
	B	6 (13.0)	6 (26.1)	2.279 (0.252-20.614)
	C	6 (13.0)	6 (26.1)	2.142 (0.073-62.557)
Intra-op EBL (mL)	≥650	16 (34.8)	19 (82.6)	21.900 (1.616-296.750)	0.020∗
Craniotomysize (mm²)	≥7,420	18 (39.1)	16 (69.6)	3.689 (0.522-26.070)	0.191

∗probability values ＜0.05 were considered statistically significant. INR: international normalized ratio, GCS: Glasgow outcome scale, intra-op: intraoperative, EBL: estimated blood loss, OR: odds ratio

TABLE 6.

Correlation analysis of the parameters associated with coagulopathy and intraoperative blood loss exceeding 650 mL

	Estimated blood loss above 650 mL (n=35)
	Pearson's r	p-value
Prothrombinpercent (%)	0.140	0.424
Prothrombinratio (INR)	0.061	0.727
aPTT	-0.067	0.701
Platelet count (×10⁹/L)	0.045	0.798

INR: international normalized ratio, aPTT: activated partial thromboplastin

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