What is the management and treatment for a patient diagnosed with an epidural hematoma?

Management of Epidural Hematoma

Immediate surgical evacuation is recommended for symptomatic epidural hematomas regardless of location to reduce mortality and improve neurological outcomes.

Initial Assessment and Management

• Immediate physiological stabilization, including airway management, ventilatory support, and circulatory support is essential for patients with epidural hematoma 1
• Rapid diagnosis through emergency medical services notification to receiving hospitals improves time to treatment 2
• Regional systems of stroke care should be utilized to ensure all potentially beneficial therapies are available as rapidly as possible 2

Surgical Management

• Wide craniotomy covering the hematoma is recommended for evacuation, control of bleeding, and prevention of blood reaccumulation 3
• For epidural hematomas with sinus injuries, combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures enables safe surgical intervention 3
• Timing of surgery is critical - patients taken to surgery within 12 hours have better neurological outcomes than those with identical preoperative conditions whose surgery is delayed beyond 12 hours 4

Indications for Immediate Surgical Intervention

• Symptomatic epidural hematoma regardless of location 2
• Epidural hematoma with thickness greater than 5 mm and displacement of the midline greater than 5 mm 2
• Patients with skull fractures traversing a meningeal artery, vein, or major sinus (55% of these patients will deteriorate) 5
• Epidural hematomas diagnosed within 6 hours of trauma (43% risk of deterioration) 5

Medical Management

Intracranial Pressure Control

• Mannitol is indicated for reduction of intracranial pressure and brain mass 6

  • Adult dosage: 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes 6
  • Pediatric dosage: 1 to 2 g/kg body weight or 30 to 60 g/m² body surface area over 30-60 minutes 6
  • Small or debilitated patients: 500 mg/kg 6

• External ventricular drainage should be considered to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults 2

Blood Pressure Management

• Blood pressure should be carefully controlled with a target systolic BP of 130-150 mmHg 7
• Avoid excessive acute drops in systolic BP (>70 mmHg) as they may cause acute renal injury and neurological deterioration 7
• Maintain adequate cerebral perfusion pressure (CPP) between 60-70 mmHg in patients with increased intracranial pressure 7

Conservative Management Considerations

• Conservative management may be considered only for small, asymptomatic epidural hematomas without risk factors for deterioration 5
• Risk factors requiring close monitoring or intervention include:
  • Skull fracture overlaying a major vessel or sinus 5
  • Diagnosis within 6 hours of trauma 5
  • Hematoma size progression on serial imaging 5

Monitoring and Follow-up

• Intracranial pressure monitoring is recommended after severe traumatic brain injury 2
• Regular neurological assessments and serial CT imaging are essential for patients managed conservatively 5
• Monitor for potential complications of mannitol therapy:
  • Renal complications including renal failure 6
  • Fluid and electrolyte imbalances (hypernatremia, hyponatremia) 6
  • Central nervous system toxicity 6

Prognosis Factors

• Better outcomes are associated with:
  • Incomplete neurological deficit prior to surgery 8
  • Lesions extending less than 4 vertebral segments (for spinal epidural hematomas) 8
  • Shorter interval between symptom onset and surgical intervention 4
  • Absence of spinal cord edema (for spinal epidural hematomas) 8

Complications to Monitor

• Remote epidural hematoma can occur as a postoperative complication after intracranial procedures, typically 0.5-5 hours after surgery 9
• Rebleeding may occur, particularly in patients with coagulopathies or on anticoagulant medications 4
• Mannitol administration may lead to renal failure, especially in patients with pre-existing renal disease or those receiving nephrotoxic drugs 6