Doing More with Less
Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma:
Endovascular Embolization Combined with Drainage Surgery and
Use of Urokinase
Yuhui Zhang1, Qiang Li2, Rui Zhao2, Zhigang Yang2, Yanan Li2, Weijie Min2, Zhijian Yue2, Jianmin Liu2
- BACKGROUND: Hematoma evacuation is regular treat-
ment for acute traumatic epidural hematoma (ATEDH) pa-
tients meeting with surgery indications. However, it is an
invasive approach performed under general anesthesia.
Here, a novel minimally invasive method of endovascular
embolization with subsequent drainage surgery and use of
urokinase was established to treat ATEDH under local
anesthesia.
- METHODS: A novel minimally invasive method of endo-
vascular embolization with subsequent drainage surgery and
use of urokinase was established to treat ATEDH under local
anesthesia. Firstly, 23 ATEDH patients with hematomas in the
temporal area underwent digital subtraction angiography
detecting the bleeding point. Next, embolization was per-
formed. After embolization, drainage surgery was taken and
urokinase was injected into the hematoma cyst by drainage
tube to lyse hematoma twice per day.
- RESULTS: The results showed that the middle meningeal
artery was the bleeding source. Embolization immediately
ceased bleeding. Most clots were resolved and drained
after treatment. No recurrence of hematoma or infection
was observed.
- CONCLUSION: The findings suggest that the combined
treatments can be an alternative minimally invasive option
for ATEDHs, especially for elderly patients or those con-
traindicated for general anesthesia.
Key words
- Drainage surgery
- Embolization
- Endovascular treatment
- Epidural hematoma
Abbreviations and Acronyms
CT: Computed tomography
EDH: Epidural hematomas
GCS: Glasgow Coma Scale
MMA: Middle meningeal artery
206 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.11.047
INTRODUCTION
E pidural hematomas (EDHs) occur in 1%e2% hospitalized
patients with traumatic brain injury and account for 5%e
15% of all fatal head injuries.1 About 70% hematomas
occur in the lateral hemisphere at the epicenter of pterion.
Arterial bleeding is responsible for 85% hematomas. The middle
meningeal artery (MMA) is the most common source of middle
fossa EDHs. Emergency surgery for hematoma evacuation is the
standard therapy to prevent death or neurologic morbidity for
those without surgical contraindications. Although craniotomy
can provide a more complete hematoma evacuation, it is also a
more invasive approach2 and not suitable for those who cannot
be performed with general anesthesia. It is reported that
angiography followed by endovascular intervention can treat the
epidural hematoma.3-5 Some studies have demonstrated that
burr hole evacuation followed by drainage is an effective method
for emergency management of traumatic EDHs.6-8
This article reports our experience with a combination of
endovascular treatment and burr hole drainage with additional
urokinase to resolve the hematoma as a novel treatment strategy
for the management of EDHs, especially those with an obvious
occupying mass effect. It will provide an alternative approach for
patients who are contraindicated for general anesthesia. To the
best of our knowledge, no published study has been reported
concerning such a combination treatment method.
METHODS
Patients
A prospective review was made of 23 patients (14 men and 9
women; mean age 42 years, range 15e53 years) who were admitted
From the 1Department of Spine Surgery, Renji Hospital, Medical School, Shanghai Jiaotong
University, Shanghai; and 2Department of Neurosurgery, Changhai Hospital, Second Military
Medical University, Shanghai, China
To whom correspondence should be addressed: Jianmin Liu, M.D.
[E-mail: liu_jm_cn@126.com]
Zhijian Yue and Jianmin Liu contributed equally to this work.
Citation: World Neurosurg. (2018) 110:206-209.
https://doi.org/10.1016/j.wneu.2017.11.047
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All rights reserved.

YUHUI ZHANG ET AL. TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA
to our emergency department between 1 January, 2015 and 31
December, 2016. The traumatogenic factors were classified as
traffic accidents in 13 cases, accidental falls in 4 cases, and impact
by falling subjects in 6 cases. The Glasgow Coma Scale (GCS) on
admission was higher than 12 in 11 patients and 8e12 in the
remaining 12 patients. The most frequent symptoms were head-
ache and vomiting. The mean time from trauma to patient
admission to our emergency center was <12
6 hours. The in-
terval time between the injury and surgery was <2 hours.
Computed tomography (CT) scan on admission showed the
following: the site of hematoma in the temporal area in 8 cases,
frontotemporal area in 9 cases, and temporoparietal area in 6
cases; the volume of hematoma ranging from 22e46 mL (mean
32.5
15.1 mL); midline shift of the brain <10 mm in 18 patients;
10e15 mm in 5 patients; coexistence of linear fracture in 6 cases
and comminuted fracture in 5 patients; and no other additional
intracranial lesion.
Our study was approved by the Institutional Review Board of the
hospital, and written informed consent was obtained from all
patients. There was no commercial involvement in the study
including design, conduct, or analysis.
Procedures
A quick head CT scan was performed on admission of each patient in
the emergency department. Digital subtraction angiography was then
conducted under local anesthesia with sedation. High-resolution
digital fluoroscopy (Artis zee Biplane, Siemens AG, Germany) with
biplane road-mapping capability was used. A 4-French angiocatheter
with a 0.035-inch inner diameter was used when angiography began,
and it can also be used as a guiding catheter for the microcatheter.
Bilateral angiography was selectively performed including the com-
mon, internal, and external carotid arteries. In all cases, angiography
demonstrated the active extravasation from the MMA, indicating the
presence of active bleeding from the MMA. The bleeding point was
embolized by advancing the catheter to the bleeding point with
Gelfoam particles (Hangzhou Alicon Pharm Sci&Tec, Linan, China;
diameter: 350e560 mm, Figure 1). Then a burr hole evacuation and
drainage surgery were performed in the operating room under local
anesthesia. The burr hole was made in the center of the hematoma
guided by CT scanning images. The hematoma was sucked with a
soft-tipped aspirator in all directions. A drainage tube was implan-
ted into the hematoma cyst to aspirate some clots. Urokinase (20 ku
resolved in 3-mL saline) was injected into the hematoma cyst through
the tube with the tube kept closed for 3 hours before connecting it to
the negative-pressure vacuum ball. The wound was closed in layers.
After completion of the operation, urokinase was repeatedly injected
into the hematoma cyst twice a day, and CT scan was performed 3
days after injection of urokinase or according to changes of the
clinical manifestations in individual patients. The drainage tube was
removed when the drain fluid became yellow and most clots had
disappeared as shown by CT scans.
Data about the procedural and clinical outcomes, procedure-
related complications, and patient survival were obtained from
the medical records of the patients.
Statistical Analysis
Data were analyzed using the SPSS 13.0 edition. A Student’s t-test
was performed to compares changes in hematoma volume before
WORLD NEUROSURGERY 110: 206-209, FEBRUARY 2018
DOING MORE WITH LESS
surgery and after removal of the drain tube, GCS score at the time
of admission and discharge, and Glasgow Outcome Scalee
Extended score at the time of discharge and at 6-month follow-up.
RESULTS
The MMA was discovered as the corresponding meningeal artery
in all 23 patients in our series. After embolization, bleeding was
stopped immediately without complications. The mean time for
angiography and embolization was 42.3
8.2 minutes (range 25e
50 minutes). The operation time for skull drilling and tube im-
plantation was 26.5
7.6 minutes (range 20e35 minutes). The
mean time for hematoma drainage was 4.5
2.5 days (range 3e6
days). The mean volume of hematoma before tube removal was 5.5

4.2 mL (range 0e9 mL). Compared with the preoperative mean
volume of 32.5
15.1 mL, the hematoma volume before tube
removal reduced by 83.1% (P ¼ 0.003).
The consciousness status of the patients originally with
conscious disturbances quickly improved within 3 days after sur-
gery. The GCS score was significantly improved from 10
2 at
admission to 14
1 at discharge (P < 0.001, Figure 2A). The major
symptoms, including headache and nausea or vomiting,
disappeared at the time of discharge. During the 6-month
follow-up period, the Glasgow Outcome ScaleeExtended score
significantly improved to 5.6
1 versus 7.3
0.7 at discharge
(P < 0.001, Figure 2B). No recurrence of EDHs was observed in
any patient, nor were complications including cerebral infarction
or dysfunction of cranial nerve observed after the embolization
therapy. No surgery-related infection occurred.
DISCUSSION
Urgent evacuation of hematoma is the standard treatment for trau-
matic EDHs to prevent death or neurologic morbidity. In recent years,
burr hole evacuation and drainage with/without urokinase was re-
ported as a new minimally invasive strategy for the treatment of
EDHs, especially those not suitable for general anesthesia.6,7 How-
ever, this method only reduced the volume without eliminating the
bleeding factor. Rebleeding is probably the most devastating
complication, which limits the application of the method to acute
patients in the first 24 hours after injury. Arterial bleeding is
responsible for about 85% of hematomas. Some reports showed that
angiography and possible embolization treatment could find and
cease the bleeding point in EDH patients who do not require surgery
for clot evacuation. Thus endovascular embolization in combination
with skull drilling and injection of urokinase can find and remove the
bleeding factor, thus decreasing the volume effect. Theoretically, it
should be a safe and effective treatment for EDH patients. The data
obtained from our study have provided clinical evidence for safe and
effective use of this novel method.
Temporal regionerelated lesions were selected in our study,
including the temporal area, frontotemporal area, and tempor-
oparietal area. Head CT showed more cases in the frontotemporal
area than those in the temporal area. The MMA has generally been
considered the most common source of middle fossa EDHs.
Angiography in our study showed that MMA injury was the major
bleeding factor, and active extravasation from the MMA was the
common bleeding point. Bleeding ceased immediately after
embolization in all our cases.
www.WORLDNEUROSURGERY.org 207

YUHUI ZHANG ET AL.
Figure 1. A patient with acute traumatic epidural hematoma was treated
with endovascular embolization and microinvasive surgery. (A and B)
Preoperative cranial computed tomography scan shows a right epidural
hematoma. (C) Digital subtraction angiography reveals a bleeding lesion in
Gelfoam particles (diameter: 350e560 mm) were selected for
embolization in our study, knowing that Gelfoam can be absor-
bed. The affected artery was reanalyzed about a week later after
embolization, which should be long enough to prevent rebleeding.
As there were some dangerous extracranialeintracranial anasto-
moses with the external carotid artery (ECA) and the mean
diameter of these anastomoses was >100 mm, we chose Gelfoam
particles of 350e560 mm in diameter so that they would not be
irrigated into the intracranial system through anastomoses, thus
reducing possible complications of the brain or nerve infarction.
No cerebral infarction or dysfunction of cranial nerve was noticed
after embolization in our patient group.
Postembolization drainage operation was performed in cases
with mass effect of hematoma. It usually took 4e12 weeks before
the hematoma was fully reabsorbed after injury. The expansion of
the hematoma always appeared during the reabsorption phase due
to fibrinolytic activity. The expansion may be predominant in
some cases, and the volume of the hematoma increased from day
208 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2017.11.047
DOING MORE WITH LESS
TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA
the middle meningeal artery. (D) The middle meningeal artery stops
bleeding completely after embolization with polyvinyl alcohol particles.
(E and F) The hematoma disappeared 2 weeks after surgery.
5 and reached the peak on day 14.9 In our study, CT showed that
the volume of hematoma ranged from 22e46 mL (mean 32.5

15.1 mL). It took 4.5
2.5 days to drain the hematoma. After
drainage, the volume of hematoma was reduced to 5.5
4.2 mL
by about 83.1% as compared with the hematoma volume before
drainage, indicating that the new method can prevent expansion
of the hematoma effectively.
Narayan et al10 reported in 1985 that urokinase was safe and
effective for lysis of intracranial hematomas in their animal
model in that it could lyse and reabsorb clots effectively without
producing neurotoxicity or recurrent bleeding. Other studies
further reported good results concerning the clinical use of
urokinase for lysis of hematomas.11-15 However, early use of uro-
kinase may lead to a higher rate of rebleeding in 7%e15% of
intracerebral hematoma patients as reported by Montes et al.15 In
our study, the bleeding vessel was embolized before the use of
urokinase to prevent rebleeding, and no rebleeding case was
observed.
 DOING MORE WITH LESS
YUHUI ZHANG ET AL. TREATMENT STRATEGY FOR ACUTE TRAUMATIC EPIDURAL HEMATOMA

***
***
15

Glascow Outcoma Scale-Extended

8
13 7

Glascow Coma Scale 11 6

5
9
4
7
3
5 2

3 1
at admission at discharge at discharge at 6-month follow-up
A B
Figure 2. Plots show the improvement in the Glasgow GOSE score was also significantly improved on
Coma Scale (GCS) and Glasgow Outcome discharge compared with that at the 6-month follow-up
Scale-Extended (GOSE) of the patients. (A) The GCS (P < 0.001). ***P value < 0.001 considered very
score on admission was significantly improved significant.
compared with that on discharge (P < 0.001). (B) The

CONCLUSIONS The combination of the 2 treatments can be a viable minimally

Endovascular embolization of the MMA can prevent rebleeding invasive option for the treatment of EDHs, especially in
from the MMA. Further drainage surgery with the use of uro- elderly patients or those who are contraindicated for general
kinase can resolve and remove the mass effect of hematoma. anesthesia.

hole evacuation and drainage. A preliminary spontaneous intracerebral hematomas. Neurosurg

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Conflict of interest statement: This work was supported by a
grant from the National Natural Science Foundation of China
(81201988) and Shanghai Municipal Committee of Science
and Technology (12140901802, 14411967600).
Received 16 September 2017; accepted 7 November 2017
Citation: World Neurosurg. (2018) 110:206-209.
https://doi.org/10.1016/j.wneu.2017.11.047
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
1878-8750/$ - see front matter ª 2017 Elsevier Inc. All
rights reserved.

WORLD NEUROSURGERY 110: 206-209, FEBRUARY 2018 www.WORLDNEUROSURGERY.org 209