Hematoma extradural estudo radiológico comparativo entre pacientes em coma e não comatosos

Mello, Luis Renato; Ferraz, Fernando A. P.; Braga, Fernando M.

doi:10.1590/S0004-282X1992000300003

Resumos

Considerando o estado neurológico imediatamente antes da operação como a variável miais fidedigna para antecipação do prognóstico dos hematomas extradurais, os autores realizaram estudo radiológico comparativo de 129 pacientes operados por esta patologia. Desta amostra, 78 casos se encontravam em coma (Grupo I) e 51 eram não comatosos (Grupo II). No grupo I, os 30 casos investigados pré-operatoriamente com tomografia tiveram 23,3% de mortalidade e 50% de bons resultados; dos 31 casos submetidos a angiografia, 48,3% faleceram e 38,7% tiveram bons resultados; 17 casos foram operados pela radiografia simples de crânio e exame neurológico, com 47% de mortalidade e 35,2% de bons resultados. A presença de fratura de crânio e a densidade tomográfica do hematoma não interferiram nos resultados. A presença de lesão associada intracraniana aumentou a mortalidade e diminuiu a quantidade de bons resultados tanto no Grupo I quanto no Grupo II. A localização frontal do hematoma foi associada a elevada mortalidade (52,6%) no grupo comatoso, por estarem todos os pacientes entre 3 a 5 pontos na Escala de Glasgow e seis deles por apresentarem lesões associadas intracranianas únicas ou múltiplas.

hematoma extradural; coma; neuroimagem

A series of 129 patients harbouring extradural hematomas was analysed considering the neurological state immediately before operation as the most consistent variable. Seventy eight patients were considered to be comatous (Group I) and 51 were noncomatous. Among the comatous group, 30 were investigated with computerized tomography (23.3% mortality, 50% good results), 31 were submitted to angiography (48.3% mortality, 38.7% good results), and 17 were operated based on the neurological examination and skull radiography (47% mortality, 35.2% good results). The presence or absence of skull fracture and the density of hematoma did not change the final outcome. Associated intracranial lesions increased the mortality and lowered the good results in both groups. Frontal hematomas (10 cases) in the comatous group were associated with high mortality (52.6%) due to bad neurological state (Glasgow 3-5) and to isolated or multiple intracranial associated lesions (6 patients).

extradural hematoma; coma; neuroimage

Hematoma extradural estudo radiológico comparativo entre pacientes em coma e não comatosos

Extradural hematoma: comparative radiological study between, comatous and noncomatous patients

Luis Renato Mello^I; Fernando A. P. Ferraz^II; Fernando M. Braga^II

^IServiço de Neurocirurgia do Hospital Santa Isabel, Blumenau, SC

^IIDisciplina de Neurocirurgia, Escola Paulista de Medicina, São Paulo SP. Parte da Tese de Mestrado apresentada pelo primeiro Autor no Curso de Pos-Graduação em Neurocirurgia, Disciplina de Neurocirurgia, Escola Paulista de Medicina

RESUMO

Considerando o estado neurológico imediatamente antes da operação como a variável miais fidedigna para antecipação do prognóstico dos hematomas extradurais, os autores realizaram estudo radiológico comparativo de 129 pacientes operados por esta patologia. Desta amostra, 78 casos se encontravam em coma (Grupo I) e 51 eram não comatosos (Grupo II). No grupo I, os 30 casos investigados pré-operatoriamente com tomografia tiveram 23,3% de mortalidade e 50% de bons resultados; dos 31 casos submetidos a angiografia, 48,3% faleceram e 38,7% tiveram bons resultados; 17 casos foram operados pela radiografia simples de crânio e exame neurológico, com 47% de mortalidade e 35,2% de bons resultados. A presença de fratura de crânio e a densidade tomográfica do hematoma não interferiram nos resultados. A presença de lesão associada intracraniana aumentou a mortalidade e diminuiu a quantidade de bons resultados tanto no Grupo I quanto no Grupo II. A localização frontal do hematoma foi associada a elevada mortalidade (52,6%) no grupo comatoso, por estarem todos os pacientes entre 3 a 5 pontos na Escala de Glasgow e seis deles por apresentarem lesões associadas intracranianas únicas ou múltiplas.

Palavras-chave: hematoma extradural, coma, neuroimagem.

SUMMARY

A series of 129 patients harbouring extradural hematomas was analysed considering the neurological state immediately before operation as the most consistent variable. Seventy eight patients were considered to be comatous (Group I) and 51 were noncomatous. Among the comatous group, 30 were investigated with computerized tomography (23.3% mortality, 50% good results), 31 were submitted to angiography (48.3% mortality, 38.7% good results), and 17 were operated based on the neurological examination and skull radiography (47% mortality, 35.2% good results). The presence or absence of skull fracture and the density of hematoma did not change the final outcome. Associated intracranial lesions increased the mortality and lowered the good results in both groups. Frontal hematomas (10 cases) in the comatous group were associated with high mortality (52.6%) due to bad neurological state (Glasgow 3-5) and to isolated or multiple intracranial associated lesions (6 patients).

Key words: extradural hematoma, coma, neuroimage.

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Dr. Luis Renato Mello Centro de Neurologia e Neurocirurgia, Hospital Santa Isabel -Rua Marechal Floriano Peixoto 300 - 89010 Blumenau SC - Brasil.

1. Ambrose J, Gooding MR, Uttleng D. EMI scan in the management of head injuries. Lancet 1976, 2:847-881.
2. Amirati M, Tomita T. Posterior fossa epidural hematoma during childhood. Neurosurgery 1984, 14:541-544.
3. Baykaner K, Alp H, Ceviker M, Keskil S, Seckin Z. Observation of 95 patients with extradural hematoma and review of the literature. Surg Neurol 1988, 30:339-341.
4. Becker D, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with earty diagnosis and intensive management. J Neurosurg 1977, 47:491-502.
5. Brambilla G, Raineldi F, Gipponi D, Paoletti P. Extradural haematoma of the posterior fossa: a report of eight cases and a review of the literature. Acta Neurochir (Wien), 1986, 80:24-29.
6. Bricolo AP, Pasut LM. Extradural hematoma: toward the mortality: a prospective study. Neurosurgery 1985, 16:602-606.
7. Chan KH, Mann KS, Yue CP, Fan YW, Cheng M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990, 72:189-194.
8. Choux M, Grisoli F, Peragut JC. Extradural hematomas in children: 104 cases. Childs Brain 1975, 1:337-347.
9. Coimbra CJP, Azevedo FHRC, Furtado CJ, Lima FT. Hematoma extradural: considerações sobre 66 casos. Arq Bras Neurocir 1983, 2:113-123.
10. Colohan ART, Alves WM, Gross CR, Torner JC, Menta V.S., Tandon P.N., Jane JA. Head injury mortality in two centers with different emergency medical services and intensive dare. J Neurosurg 1989, 71:202-207.
11. Cordobes F, Lobato R, Rivas JJ, Munõz MJ, Chillar D, Portillo JM, Lamas E. Observations on 82 patients with extradural hematoma: comparison of results before and after the advent of computerized tomography. J Neurosurg 1981, 54:179-186.
12. Dan MG, Berry G, Knok B, Mandryk JA, Ring JT, Seweel MF, Simpson DA. Experience with extradural haematomas in New South Wales. Aust NZ J Surg 1986, 56:535-541.
13. Devaux B, Roux FX, Chodkiewicz JP. L'hématome extra-dural à l'ère du S.A.M.U. et du scanner: comparation de deux séries du Centre Hospitalier Saint-Anne. Neurochirurgie 1986, 32:221-225.
14. Dhellemes P, Lejeune JP, Christiaens JL, Combeller G. Traumatic extradural hematoma in infancy and childhood. J Neurosurg 1985, 62:861-864.
15. Ericson K, Häkansson S. Computed tomography of epidural hematomas. Acta Radiol 1981, 22:513-519.
16. French BM, Dublin AB. The value of computerized tomography in the management of 1000 consecutive head injuries. Surg Neurol 1977, 7:171-183.
17. Gallagher JP, Browder EJ. Extradural hematoma: experience with 167 patients. J Neurosurg 1968, 29:1-12.
18. Gennarelli TA, Spielman GM, Langfitt TW, Gildenberg PL, Harrington T, Jane JA, Marshall LF, Miller D, Pitts L. Influence of the type of intracranial lesion on outcome from severe injury. J Neurosurg 1982, 56:26-32.
19. Gennarelli TA, Thibault LE, Adams JH, Graham DI, Thompson CJ, Mancini RP. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1983, 12:564-574.
20. Greenberg JD, Cohen WA, Cooper RP. The hyperacute extra axial intracranial hematoma: computed tomographic findings and clinical significance. Neurosurgery 1985, 17:48-56.
21. Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988, 90:111-116.
22. Heiskanen O. Epidural hematoma. Surg Neurol 1975, 4:23-26.
23. Hooper R. Observations on extradural haemorrhage. Br J Surg 1958, 47:71-87.
24. Jacobson WHA. On middle meningeal haemorrhage. Guy's Hosp Rep London Series 3, 1886, 28:147-308.
25. Jamieson KG, Yelland JD. Extradural hematoma: report of 167 cases. J Neurosurg 1968, 29:13-23.
26. Jawahar G, Natarajan M. Mortality in extradural haematoma. J Indian MA 1987, 85:235-237.
27. Jennett B, Bond M. Assesment of outcome after severe brain damage: a practical scale. Lancet 1975, 1:480-484.
28. Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet 1977, 2:878-881.
29. Kvarnes TL, Trumpy JH. Extradural haematoma: report of 132 cases. Acta Neurochirur (Wien) 1978, 41:223-231.
30. Lake PA, Pitts FW. Recent experience with epidural hematoma. J Trauma 1971, 11:397-411.
31. LeCount ER, Apfelbach CW. Pathologic anatomy of traumatic fractures of cranial bones. JAMA 1920, 74:501-512.
32. Lobato R, Sarabia R, Cordobes F, Rivas JJ, Adrados A, Carrera A, Gomez P, Madera A, Lamas B. Posttraumatic cerebral hemispheric swelling: analysis of 55 cases with computerized tomography. J Neurosurg 1988, 68:417-423.
33. Lobato RD, Rivas JJ, Cordobes F, Alted E, Perez C, Sarabia R, Carrera A, Diez I, Gomez P, Lamas E. Acute epidural hematoma: an analysis of factors influencing the outcome of pacients undergoing surgery in coma. J Neurosurg 1988, 68:48-57.
34. Mazza C, Pascualin A, Feriotti G, Da Piab R. Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir (Wien) 1982, 65:67-80.
35. McKenzie K. Extradural haemorrhage. Br J Surg 1938, 26:346-365.
36. McKissock W, Taylor JC, Bloom WH, Till K. Extradural haematoma: observations on 123 cases. Lancet 1960, 2:167-172.
37. McLaurin RL, Ford LE. Extradural hematoma: statistical survey of forty-seven cases. J Neurosurg 1964, 21:364-371.
38. Mealey JJr. An extradural hematoma without demonstrable skull fractures. J Neurosurg 1960, 17:27-34.
39. Mendelow AD, Karni MZ, Paul KS, Fuller GA, Gillinghan FJ. Extradural haematoma effect of delayed treatment. Br Med J 1979, 1:1240-1242.
40. Mohsenipour I, Kostron H, Russeggu L. Das luzide Interval bein epiduralen Hamatom. Zbl Neurochir 1982, 43:121-125.
41. Munro D, Maltby GL. Extradural hemorrhage: a study of forty-four oases. Ann Surg 1941. 113:192-203.
42. Neubauer UJ. Extradural haematoma of the posterior fossa: twelve years experience with CT-scan. Acta Neurochir (Wien) 1987, 87:105-111.
43. Pasztor A. Characteristics of the treatment of the epidural hematomas in infancy and childhood. Zbl Neurochir 1985, 46:243-250.
44. Phonprasert C, Suwanela C, Hongsaprabhas C, Prichayduh P, Ocharoen S. Extradural hematoma: analysis of 138 cases. J Trauma 1982, 22:455-460.
45. Pringle JH. Traumatic meningeal haemorrhage with a review of seventy-one cases. Edinburgh Med J 1938, 45:741-760.
46. Reichert FL, Morissey EJ. Extradural venous hemorrhage. Ann Surg 1941, 113:204-208.
47. Rivas JJ, Lobato RD, Sarabia R, Cordobes F, Cabrera A, Gomez P. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988, 23:44-51.
48. Schulz W, Harns L, Geidatzis C. Das epiduralen Hämatom: diagnostische Besonderheiten, Klinischverlaufsformen und therapeutische Ergebnisse in einer 12-Jahre-Studie. Chirurgie 1988, 113:1280-1288.
49. Seelig J, Becker D, Miller O, Greenberg R, Ward J, Choi SC. Traumatic acute subdural hematoma. N Engl J Med 1981, 304:1511-1518.
50. Teasdale G, Galbraith S, Murray L, Ward P, Gentleman D, McKean M. Management of traumatic intracranial haematoma. Br Med J 1982, 285:1695-1697.
51. Van Donzen KJ, Braakman R, Gelpke GJ. The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 1983, 59:951-957.
52. Verbrugghen A. Extradural hemorrhage. Am J Surg 1937, 37:275-290.
53. Vilalta J, Sahuquillo J, Rial JP, Chica J, Lafuente J, Rubio B. Mortalidade evitable en el hematoma epidural: influencia del retraso en la operación. Analisis de 34 casos intervenidos en coma. Rev Clin Esp 1986, 179:352-354.
54. Weinman DF, Muttukumaru B. The mortality from extradural haematoma. Aust NZJ Surg 1968, 38:104-107.
55. Yodonawa M, Tamura M, Tsukahara Y, Ohe C. Skull fracture and intracranial complications in blunt head injury. Neurol Med Chir (Tokyo) 1984, 24:615-621.
56. Zander E, Campiche R. Extra-dural hematoma. In Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien: Springer, 1984, Vol. 1, p 121-139.
57. Zimmermann R.A., Bilaniuk LT. Computed tomography staging of traumatic epidural bleeding. Radiology 1982, 144:809-812.
58. Zuccarello M, Pardatscher K, Andriolo GC, Fiore DL, Iavicoli R, Cervellini P. Epidural hematomas of the posterior cranial fossa. Neurosurgery 1981, 8:434-437.

Datas de Publicação

Publicação nesta coleção
22 Fev 2011
Data do Fascículo
Set 1992

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Ambrose J, Gooding MR, Uttleng D. EMI scan in the management of head injuries. Lancet 1976, 2:847-881.

[2] 2. Amirati M, Tomita T. Posterior fossa epidural hematoma during childhood. Neurosurgery 1984, 14:541-544.

[3] 3. Baykaner K, Alp H, Ceviker M, Keskil S, Seckin Z. Observation of 95 patients with extradural hematoma and review of the literature. Surg Neurol 1988, 30:339-341.

[4] 4. Becker D, Miller JD, Ward JD, Greenberg RP, Young HF, Sakalas R. The outcome from severe head injury with earty diagnosis and intensive management. J Neurosurg 1977, 47:491-502.

[5] 5. Brambilla G, Raineldi F, Gipponi D, Paoletti P. Extradural haematoma of the posterior fossa: a report of eight cases and a review of the literature. Acta Neurochir (Wien), 1986, 80:24-29.

[6] 6. Bricolo AP, Pasut LM. Extradural hematoma: toward the mortality: a prospective study. Neurosurgery 1985, 16:602-606.

[7] 7. Chan KH, Mann KS, Yue CP, Fan YW, Cheng M. The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study. J Neurosurg 1990, 72:189-194.

[8] 8. Choux M, Grisoli F, Peragut JC. Extradural hematomas in children: 104 cases. Childs Brain 1975, 1:337-347.

[9] 9. Coimbra CJP, Azevedo FHRC, Furtado CJ, Lima FT. Hematoma extradural: considerações sobre 66 casos. Arq Bras Neurocir 1983, 2:113-123.

[10] 10. Colohan ART, Alves WM, Gross CR, Torner JC, Menta V.S., Tandon P.N., Jane JA. Head injury mortality in two centers with different emergency medical services and intensive dare. J Neurosurg 1989, 71:202-207.

[11] 11. Cordobes F, Lobato R, Rivas JJ, Munõz MJ, Chillar D, Portillo JM, Lamas E. Observations on 82 patients with extradural hematoma: comparison of results before and after the advent of computerized tomography. J Neurosurg 1981, 54:179-186.

[12] 12. Dan MG, Berry G, Knok B, Mandryk JA, Ring JT, Seweel MF, Simpson DA. Experience with extradural haematomas in New South Wales. Aust NZ J Surg 1986, 56:535-541.

[13] 13. Devaux B, Roux FX, Chodkiewicz JP. L'hématome extra-dural à l'ère du S.A.M.U. et du scanner: comparation de deux séries du Centre Hospitalier Saint-Anne. Neurochirurgie 1986, 32:221-225.

[14] 14. Dhellemes P, Lejeune JP, Christiaens JL, Combeller G. Traumatic extradural hematoma in infancy and childhood. J Neurosurg 1985, 62:861-864.

[15] 15. Ericson K, Häkansson S. Computed tomography of epidural hematomas. Acta Radiol 1981, 22:513-519.

[16] 16. French BM, Dublin AB. The value of computerized tomography in the management of 1000 consecutive head injuries. Surg Neurol 1977, 7:171-183.

[17] 17. Gallagher JP, Browder EJ. Extradural hematoma: experience with 167 patients. J Neurosurg 1968, 29:1-12.

[18] 18. Gennarelli TA, Spielman GM, Langfitt TW, Gildenberg PL, Harrington T, Jane JA, Marshall LF, Miller D, Pitts L. Influence of the type of intracranial lesion on outcome from severe injury. J Neurosurg 1982, 56:26-32.

[19] 19. Gennarelli TA, Thibault LE, Adams JH, Graham DI, Thompson CJ, Mancini RP. Diffuse axonal injury and traumatic coma in the primate. Ann Neurol 1983, 12:564-574.

[20] 20. Greenberg JD, Cohen WA, Cooper RP. The hyperacute extra axial intracranial hematoma: computed tomographic findings and clinical significance. Neurosurgery 1985, 17:48-56.

[21] 21. Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988, 90:111-116.

[22] 22. Heiskanen O. Epidural hematoma. Surg Neurol 1975, 4:23-26.

[23] 23. Hooper R. Observations on extradural haemorrhage. Br J Surg 1958, 47:71-87.

[24] 24. Jacobson WHA. On middle meningeal haemorrhage. Guy's Hosp Rep London Series 3, 1886, 28:147-308.

[25] 25. Jamieson KG, Yelland JD. Extradural hematoma: report of 167 cases. J Neurosurg 1968, 29:13-23.

[26] 26. Jawahar G, Natarajan M. Mortality in extradural haematoma. J Indian MA 1987, 85:235-237.

[27] 27. Jennett B, Bond M. Assesment of outcome after severe brain damage: a practical scale. Lancet 1975, 1:480-484.

[28] 28. Jennett B, Teasdale G. Aspects of coma after severe head injury. Lancet 1977, 2:878-881.

[29] 29. Kvarnes TL, Trumpy JH. Extradural haematoma: report of 132 cases. Acta Neurochirur (Wien) 1978, 41:223-231.

[30] 30. Lake PA, Pitts FW. Recent experience with epidural hematoma. J Trauma 1971, 11:397-411.

[31] 31. LeCount ER, Apfelbach CW. Pathologic anatomy of traumatic fractures of cranial bones. JAMA 1920, 74:501-512.

[32] 32. Lobato R, Sarabia R, Cordobes F, Rivas JJ, Adrados A, Carrera A, Gomez P, Madera A, Lamas B. Posttraumatic cerebral hemispheric swelling: analysis of 55 cases with computerized tomography. J Neurosurg 1988, 68:417-423.

[33] 33. Lobato RD, Rivas JJ, Cordobes F, Alted E, Perez C, Sarabia R, Carrera A, Diez I, Gomez P, Lamas E. Acute epidural hematoma: an analysis of factors influencing the outcome of pacients undergoing surgery in coma. J Neurosurg 1988, 68:48-57.

[34] 34. Mazza C, Pascualin A, Feriotti G, Da Piab R. Traumatic extradural haematomas in children: experience with 62 cases. Acta Neurochir (Wien) 1982, 65:67-80.

[35] 35. McKenzie K. Extradural haemorrhage. Br J Surg 1938, 26:346-365.

[36] 36. McKissock W, Taylor JC, Bloom WH, Till K. Extradural haematoma: observations on 123 cases. Lancet 1960, 2:167-172.

[37] 37. McLaurin RL, Ford LE. Extradural hematoma: statistical survey of forty-seven cases. J Neurosurg 1964, 21:364-371.

[38] 38. Mealey JJr. An extradural hematoma without demonstrable skull fractures. J Neurosurg 1960, 17:27-34.

[39] 39. Mendelow AD, Karni MZ, Paul KS, Fuller GA, Gillinghan FJ. Extradural haematoma effect of delayed treatment. Br Med J 1979, 1:1240-1242.

[40] 40. Mohsenipour I, Kostron H, Russeggu L. Das luzide Interval bein epiduralen Hamatom. Zbl Neurochir 1982, 43:121-125.

[41] 41. Munro D, Maltby GL. Extradural hemorrhage: a study of forty-four oases. Ann Surg 1941. 113:192-203.

[42] 42. Neubauer UJ. Extradural haematoma of the posterior fossa: twelve years experience with CT-scan. Acta Neurochir (Wien) 1987, 87:105-111.

[43] 43. Pasztor A. Characteristics of the treatment of the epidural hematomas in infancy and childhood. Zbl Neurochir 1985, 46:243-250.

[44] 44. Phonprasert C, Suwanela C, Hongsaprabhas C, Prichayduh P, Ocharoen S. Extradural hematoma: analysis of 138 cases. J Trauma 1982, 22:455-460.

[45] 45. Pringle JH. Traumatic meningeal haemorrhage with a review of seventy-one cases. Edinburgh Med J 1938, 45:741-760.

[46] 46. Reichert FL, Morissey EJ. Extradural venous hemorrhage. Ann Surg 1941, 113:204-208.

[47] 47. Rivas JJ, Lobato RD, Sarabia R, Cordobes F, Cabrera A, Gomez P. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988, 23:44-51.

[48] 48. Schulz W, Harns L, Geidatzis C. Das epiduralen Hämatom: diagnostische Besonderheiten, Klinischverlaufsformen und therapeutische Ergebnisse in einer 12-Jahre-Studie. Chirurgie 1988, 113:1280-1288.

[49] 49. Seelig J, Becker D, Miller O, Greenberg R, Ward J, Choi SC. Traumatic acute subdural hematoma. N Engl J Med 1981, 304:1511-1518.

[50] 50. Teasdale G, Galbraith S, Murray L, Ward P, Gentleman D, McKean M. Management of traumatic intracranial haematoma. Br Med J 1982, 285:1695-1697.

[51] 51. Van Donzen KJ, Braakman R, Gelpke GJ. The prognostic value of computerized tomography in comatose head-injured patients. J Neurosurg 1983, 59:951-957.

[52] 52. Verbrugghen A. Extradural hemorrhage. Am J Surg 1937, 37:275-290.

[53] 53. Vilalta J, Sahuquillo J, Rial JP, Chica J, Lafuente J, Rubio B. Mortalidade evitable en el hematoma epidural: influencia del retraso en la operación. Analisis de 34 casos intervenidos en coma. Rev Clin Esp 1986, 179:352-354.

[54] 54. Weinman DF, Muttukumaru B. The mortality from extradural haematoma. Aust NZJ Surg 1968, 38:104-107.

[55] 55. Yodonawa M, Tamura M, Tsukahara Y, Ohe C. Skull fracture and intracranial complications in blunt head injury. Neurol Med Chir (Tokyo) 1984, 24:615-621.

[56] 56. Zander E, Campiche R. Extra-dural hematoma. In Krayenbühl H (ed): Advances and Technical Standards in Neurosurgery. Wien: Springer, 1984, Vol. 1, p 121-139.

[57] 57. Zimmermann R.A., Bilaniuk LT. Computed tomography staging of traumatic epidural bleeding. Radiology 1982, 144:809-812.

[58] 58. Zuccarello M, Pardatscher K, Andriolo GC, Fiore DL, Iavicoli R, Cervellini P. Epidural hematomas of the posterior cranial fossa. Neurosurgery 1981, 8:434-437.