Worldwide, trauma is a leading cause of death and major disabilities and various

disfigurements. Every individual in the world is at risk for traumatic injury and the

etiologies of injury are as diverse as the lifestyles and socioeconomic backgrounds of its

victims, ranging from interpersonal violence to motor vehicle crashes and occupational

accidents.(D1,D2)

Traumatic brain injury is a very important issue in the field of trauma, as it does not

only hamper the function but also causes serious psychological and cosmetic deficiencies.

The study of traumatic brain injuries entails many important aspects. There are many

studies in the literature that have analyzed the demographic factors associated with

traumatic brain injuries according to various criteria. An understanding of the incidence,

epidemiology, cause, type and associated injuries in traumatic brain injury can aid in

establishing clinical and research priorities for effective treatment of these injuries.
(D3,D4,D5,D6)

The present study is a prospective, hospital- based study, for 70 patients with acute

traumatic epidural hematoma. It was found to be more among young patients, in the third

and second decades of life. This is in agreement with the results of Bricolo and Paust

study,(D7) which discussed extradural hematoma toward zero mortality showed higher

percentage for younger age group in the second and third decodes of life.

In the current study, we did not report any patients in first 2 years, one patient with

60 years and only 2 patients over 60 years. This is may be attributed to the increased

adherence of the dural to the inner table of the skull in older ages, while in children is

attributed to the fact that the skull is still elastic. This is the same results that reported by

Wilkins and Rengachary.(D8)

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 The possible explanation for the higher frequency of traumatic brain injuries in

youths is that the second and third decades of human life are the most active decades in life

and thus people in these decades are more vulnerable to trauma.

These age groups also show more activity in sports, fights, violent activities, industry

and high speed transportation. In developing countries the old aged people are

economically dependent on the young for their livelihood. The low frequencies of very

young and old age groups are due to the low activities of these age groups.

Regarding sex; 59 patients were males (83.3%) and 11 patients were females

(15.7%) with male: female ratio of 5.3:1. This is close to the results of Malik et al, (D9)

where the male: female ratio was 4:1. While in Duthie et al, (D10) reported that 70% of their

patients, were male and 30% were females and the ratio was 2.3: 1.

This male predominance is probably due to higher physical activity by men and also

because men are more involved in outdoor activities and traffic accidents and also they are

more prone to violence and assault.

The classic clinical presentation of an extradural hematoma follows a relatively

minor head injury, particularly to temporal region in a young patient, with or without brief

loss of consciousness, followed by a lucid interval of duration, rapidly followed by

headache, depressed conscious state, and contra lateral hemiparesis, ipsilateral dilated

pupil. Lucid interval being seen in one-third of patients with extradural hematoma. (D11) We

observed a variable spectrum of clinical presentation, but the common were vomiting,

fractured skull, otorrhea and seizures.

In the current study, we observed fractured skull among 81.4% of the studied

patients. Extradural hemorrhage is most often due to a fractured temporal or parietal bone

damaging the middle meningeal artery or vein with blood collecting between the dura and

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the skull. It occurs in about 2% of all cases of head injury but 5 to 15% of cases of fatal

head injury.(D9)

In our study regarding mode of trauma, the road traffic accidents (RTA) took the

largest share among the other modes of trauma causing acute traumatic epidural hematoma

with 47 patients (67.14%) followed by falling from height with 23 patients (32.86%).

There is agreement with Dubey et al,(D12) who reported that RTA are the most

common cause of epidural hematoma in the literature followed by fall from height and also

in agreement with Roka et al, (D13) who reported that the most common cause of injury was

RTA.

Increased incidence of road traffic accidents is mostly due to many factors: the rapid

increase in the number of vehicles, in addition to over population and the lack of proper

strategy for prevention of RTA. Pedestrians are the most affected group due to bad design of

many roads with lack of safety measures where drivers and many pedestrians do not adhere to

traffic rules. An increasing incidence of sensory deficit, muscle weakness, gait unsteadiness

and arrhythmia contribute to the higher risk of falls in older patients.

In our study regarding Glasgow coma score (GCS), the initial GCS on presentation

of 44 patients (62.86%) was ≥ 13 denoting mild traumatic brain injuries, while 16 patients

(22.86%) presented with GCS from 9-12 denoting moderate traumatic brain injuries. This

is in agreement with Pang et al,(D14) who reported higher percentage of GCS of > 13.

The primary diagnostic investigation for extradural hematoma is a CT without

contrast in the majority of cases this will show a hyper dense leniform (biconvex) extra-

axial collection adjacent to calvarium.(D15) In our study, all patients performed the CT scan

examination after the acute brain trauma. It revealed hyperdense collection in the majority

of them (92.9%).

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 We found that regarding the time between trauma and management; there are several

hours elapsed till surgery. This latency may be due to timing of transfer of these patients

from the site of initial trauma till reaching care facilities where there are sufficient

equipment's and expert neurosurgical team for managing patients with acute traumatic

epidural hematomas.

It is very important to know the time between the injury and the arrival to the

hospital as it is crucial in management of primary lesion and control of secondary brain

insults due to hypoxia and hypotension, early management arrival provides better survival

rates through early operative intervention and early stabilization of general condition. The

delay in transporting the patient to the hospital affects greatly the management and

neurological outcome. The delay will affect the clinical condition as it worsens the

hemodynamic stability. These secondary insults are usually preventable if managed early.

Regarding the volume of hematoma in the studied patients, we found 30(42.9%) of

patients with hematoma volume of <30 ml and 40(57.1%) of patients with hematoma

volume of 30 ml or more. Most of those with an estimated hematoma volume of <30 ml by

CT scan were kept for conservative management and follow-up. Only 2 patients during

follow-up developed clinical deterioration that necessitate surgical intervention.

This is in agreement with the findings of Marshall et al, (D16) and bullock and

Teasdale,(D17) who discussed the volume of surgical intervention of epidural hematoma.

Regarding the correlation between Glasgow outcome score and other factors in the

studied patients with acute traumatic epidural hematoma. It was found that significant

statistical associations were related to age group of 20-40 years, accidents injury (mainly

car accidents), GCS of < 8, late surgical intervention (after 6 hours), and hematoma

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volume of 30ml or more. Similar to our finding, Kuday et al, (D18) reported that lower GCS

correlated with a more unfavorable outcome.

It was previously believed that tissue damage occurs immediately and irreversibly at

the time of brain trauma. Today, we have a better understanding of the mechanisms of both

primary damage caused by the initial insult and the destructive processes which are

triggered by it. The monitoring technology required to detect adverse secondary events has

evolved considerably in the past few years.(D19)

Significant reduction in mortality and morbidity associated with severe head injury

has been achieved with aggressive management protocols that emphasize maintenance of

blood pressure, prompt evacuation of mass lesions; and control of intracranial pressure.(D20)

It was found that early surgery was associated with better prognosis, while delay in

surgery more than 6 hours had the worst prognosis. Our study reported that preoperative

GCS and epidural hematoma volume mainly influence the outcome after surgery that was

the same reported by Lobato et al(D21) and Lee et al(D22) studies.

Finally, it should be mentioned that the knowledge of factors that correlate to the

outcome of acute traumatic epidural hematoma will help in reaching better prognosis and

lower morbidity and mortality rates.