Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma

OBJECTIVES: The patient with epidural hematoma and cerebral herniation has a good prognosis with immediate drainage, but a poor prognosis with delay to decompression. Such patients who present to nonneurosurgical hospitals are commonly transferred without drainage to the nearest neurosurgical center. This practice has never been demonstrated to be the safest approach to treating these patients. A significant minority of emergency physicians (EPs) have advised and taught bedside burr hole drainage or skull trephination before transfer for herniating patients. The objective of this study was to assess the effect of nonneurosurgeon drainage on neurologic outcome in patients with cerebral herniation from epidural hematoma.

METHODS: A structured literature review was performed using EMBASE, the Cochrane Library, and the Emergency Medicine Abstracts database.

RESULTS: No evidence meeting methodologic criteria was found describing outcomes in patients transferred without decompressive procedures. For patients receiving local drainage before transfer, 100% had favorable outcomes.

CONCLUSIONS: Although the total number of patients is small and the population highly selected, the natural history of cerebral herniation from epidural hematoma and the best available evidence suggests that herniating patients have improved outcomes with drainage procedures before transport.