[Two Cases of Difficult-to-Treat Acute Epidural Hematoma and a Review of Decompressive Craniectomy with Hematoma Evacuation].

Introduction: Decompressive craniectomy(DC)with craniotomy for acute epidural hematoma(AEDH)removal is controversial. Here, we summarized two difficult AEDH cases where DC was performed. CASE 1:A 26-year-old man sustained a head injury in a bicycle accident, with a Japan Coma Scale(JCS)score of 200, right pupil mydriasis, and a left decerebrate posture on admission. Computed tomography(CT)revealed right AEDH with a midline shift. Craniotomy was performed without DC. Postoperatively, his consciousness level and anisocoria improved(JCS score, 30). Furthermore, no cerebral infarction was observed on CT at 9 h after surgery;however, at 48 h after surgery, a cerebral infarction with a mild midline shift was evident in the right hemisphere. His consciousness level deteriorated(JCS score, 100), and we initiated glyceol infusion. Worsening of the midline shift was apparent on CT 100 h after surgery;thus, DC was immediately performed. CASE 2:A 15-year-old boy was injured in a fall. On admission, his JCS score was 10. Immediately afterward, he showed neurological deterioration(JCS score, 200), right pupil mydriasis, and a left decorticate posture. CT revealed right AEDH with a midline shift;thus, craniotomy was performed with DC. On hospitalization day 10, he had orthostatic headache and a JCS score of 1. CT revealed paradoxical midline shift to the opposite side of craniotomy, and syndrome of the trephined was considered. He was placed in the Trendelenburg position until cranioplasty was performed on hospitalization day 18.

Conclusion: Patients with AEDH presenting severe consciousness issues should undergo hematoma removal. Although DC is controversial, surgeons should administer intensive and prompt treatment according to the circumstance and should consider DC for appropriate AEDH cases.