What is the treatment for an epidural hematoma (EDH) in the brain?

Treatment of Epidural Hematoma in the Brain

Immediate surgical evacuation via craniotomy is the standard treatment for symptomatic epidural hematomas (EDH) with thickness >5mm or midline shift >5mm, as delays in surgical intervention lead to neurological deterioration and worse outcomes. 1

Emergency Assessment and Stabilization

• Obtain non-contrast CT scan immediately to characterize hematoma size, location, and mass effect, as this is the gold standard for acute hemorrhage detection 2, 1
• Secure the airway via endotracheal intubation for patients with Glasgow Coma Scale (GCS) ≤8, maintaining PaO₂ between 60-100 mmHg and PaCO₂ between 35-40 mmHg to prevent cerebral vasoconstriction 2, 1
• Transfer immediately to a neuroscience intensive care unit or dedicated stroke unit with neurocritical care expertise, as early aggressive management in the first hours directly impacts mortality and morbidity 2
• Perform complete neurological assessment using GCS, pupillary examination, and evaluation of focal neurological deficits 1
• Verify anticoagulant or antiplatelet use, as these medications increase risk of hematoma expansion 1

Surgical Indications

Surgical evacuation is indicated for:

• Hematoma thickness >5mm with midline shift >5mm 1
• Any symptomatic EDH with clinical evidence of raised intracranial pressure or focal compression 3
• Life-threatening mass effect in all salvageable patients 2

Conservative Management Criteria

Conservative management may be considered only when ALL of the following are present:

• Small hematoma with minimal mass effect (<5mm thickness, <5mm midline shift) 1, 3
• No clinical signs of intracranial hypertension or neurological deterioration 1, 3
• Diagnosis made >6 hours after trauma (lower risk of delayed deterioration) 3
• No skull fracture overlying a major meningeal vessel or sinus 3

High-Risk Factors for Deterioration Requiring Surgery

Patients with the following factors have significantly higher rates of deterioration (55-71%) and should be monitored extremely closely or considered for early surgery 3:

• Skull fracture transversing a meningeal artery, vein, or major sinus (55% deterioration rate) 3
• CT diagnosis within 6 hours of trauma (43% deterioration rate) 3
• Both risk factors present (71% deterioration rate) 3

Medical Management During Conservative Observation

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during initial resuscitation 2
• Perform serial CT scans and careful neurological observation to detect hematoma expansion, which occurs in 28-38% of patients scanned within 3 hours 2, 3
• Monitor intracranial pressure for patients with GCS ≤8 or clinical evidence of transtentorial herniation 2
• Maintain cerebral perfusion pressure of 50-70 mmHg depending on autoregulation status 2

Reversal of Coagulopathy

• For patients on vitamin K antagonists, immediately withhold VKA and administer prothrombin complex concentrates (PCC) or fresh frozen plasma plus intravenous vitamin K to correct INR 2
• For severe thrombocytopenia or coagulation factor deficiency, administer appropriate factor replacement or platelets 2

Critical Pitfalls to Avoid

• Never delay surgical intervention in symptomatic patients, as this leads to neurological deterioration and poorer outcomes 1
• Avoid hypocapnia, as it induces cerebral vasoconstriction and increases risk of brain ischemia 1
• Avoid hypotension (SBP <100 mmHg or MAP <80 mmHg), which worsens secondary brain injury 2
• Do not assume small hematomas are safe in elderly patients or those on anticoagulants, as these can expand rapidly 1

Special Considerations for Chronic EDH

• If an EDH is observed during conservative management and fails to naturally absorb on serial follow-up, surgical removal must be considered even if the patient's condition is good, as there is risk of bone calcification and ossification 4
• Ossification can occur as early as 4 weeks after head injury and progress rapidly 4