What is the management of extra dural (epidural) hemorrhage?

Management of Extradural (Epidural) Hemorrhage

Extradural hemorrhage requires immediate neurosurgical intervention for patients with significant mass effect, neurological deterioration, or large hematoma volume (>30 cm³) to prevent potentially fatal outcomes. 1

Initial Assessment and Management

• Control obvious bleeding points using pressure, tourniquets, or hemostatic dressings 1
• Secure airway with tracheal intubation and mechanical ventilation with end-tidal CO₂ monitoring to maintain appropriate PaCO₂ levels 1
• Establish large-bore IV access (including central access if needed) for fluid resuscitation 1
• Obtain baseline blood tests including full blood count, prothrombin time, activated partial thromboplastin time, and fibrinogen 1
• Perform urgent neuroimaging (CT scan) to confirm diagnosis and assess hematoma size, location, and mass effect 1

Neurosurgical Indications

Immediate surgical evacuation is indicated for:

• Symptomatic extradural hematoma regardless of location 1
• Extradural hematoma with thickness >5 mm and midline shift >5 mm 1
• Patients with GCS <15 and large volume hematoma (>30 cm³) 1, 2
• Patients with neurological deterioration regardless of initial GCS 2

Surgical Management Options

1. Traditional craniotomy:

   • Gold standard approach for evacuation of extradural hematoma 3
   • Involves osteoplastic craniotomy with complete evacuation of blood clot 4

2. Burr hole evacuation:

   • Alternative emergency approach in resource-limited settings 4
   • Can be performed under local anesthesia with intravenous sedation 4
   • Involves placement of flexible tubes through burr holes with continuous negative pressure suction 4
   • Requires close monitoring with daily CT scans to ensure adequate evacuation 4

3. Endovascular treatment:

   • Emerging alternative in select cases where immediate surgery is not required 3
   • Involves angiography and embolization of the middle meningeal artery 3
   • May be considered for small, non-expanding hematomas in neurologically stable patients 3

Non-operative Management

Non-operative management may be considered in select cases:

• Patients with GCS 15/15 (fully alert) 2
• No neurological deficits 2
• Small hematoma or even large volume hematoma (>30 cm³) if patient remains neurologically stable 2
• Close neurological monitoring and serial CT scans are mandatory 2

Transfer Considerations

For patients requiring transfer to neurosurgical centers:

• Extradural hematoma is considered a time-critical condition requiring urgent transfer 1
• Maintain systolic blood pressure <160 mmHg but avoid hypotension (systolic <110 mmHg) 1
• Ensure adequate sedation and ventilation during transfer 1
• Transfer team should include personnel experienced in managing brain-injured patients 1

Special Considerations in Pediatric Patients

• Extradural hematoma in children requires the same urgent approach as in adults 1
• Time-critical transfer from referring hospital by local team is appropriate for pediatric extradural hematoma 1
• Team transferring children should ideally include an anesthetist with pediatric experience 1
• Age-appropriate equipment should be available for transfer 1

Post-operative Management

• Admit to critical care for monitoring and observation 1
• Monitor coagulation, hemoglobin, and blood gases 1
• Assess wound drains to identify overt or covert bleeding 1
• Commence venous thromboprophylaxis as soon as bleeding is controlled 1
• Normalize blood pressure, acid-base status, and temperature 1
• Avoid vasopressors if possible 1

Pitfalls and Caveats

• Patients may compensate well despite significant blood loss; rapid clinical assessment is crucial 1
• Dilutional coagulopathy can develop with massive fluid resuscitation; early infusion of FFP is recommended 1
• Consumptive coagulopathy is common following massive trauma, especially with head injury 1
• Non-operative management requires vigilant monitoring; any neurological deterioration mandates immediate surgical intervention 2
• Even with prompt treatment of large volume extradural hematoma, outcomes may still be poor 2