Operative Indications for Epidural Hematoma
Primary Surgical Indications
An epidural hematoma (EDH) greater than 30 cm³ should be surgically evacuated regardless of the patient's Glasgow Coma Scale (GCS) score. 1
Absolute Indications for Surgery
Volume >30 cm³: Immediate surgical evacuation is indicated regardless of neurological status 1
Comatose patients (GCS <9) with anisocoria: These patients require surgical evacuation as soon as possible, as this represents impending herniation 1
Thickness >15 mm: EDH exceeding this threshold warrants surgical intervention 1
Midline shift >5 mm: Significant mass effect requiring decompression 1
Neurological deterioration: Development of altered consciousness or new/worsening focal neurological deficits mandates immediate surgery 2, 3
Conservative Management Criteria
An EDH less than 30 cm³, with thickness <15 mm, and midline shift <5 mm in patients with GCS >8 without focal deficit can be managed nonoperatively with serial CT scanning and close neurological observation in a neurosurgical center. 1
High-Risk Features Requiring Close Monitoring
Even when initially managed conservatively, certain patients are at elevated risk for deterioration and may require delayed surgical intervention:
Skull fracture crossing a meningeal artery, vein, or major sinus: 55% of these patients subsequently required evacuation 4
CT diagnosis within 6 hours of trauma: 43% deteriorated and needed surgery 4
Combined risk factors (fracture over vessel + early CT): 71% required evacuation 4
Conversely, patients diagnosed more than 6 hours after trauma without fractures crossing major vessels have only a 13% risk of deterioration 4
Surgical Technique Considerations
Craniotomy provides more complete evacuation of the hematoma compared to other surgical methods, though insufficient data exist to definitively support one technique over another. 1
For midline EDH, separated craniotomies around the midline with preservation of the midline bone strip for dural tenting provides safer bleeding control 5
Critical Pitfalls to Avoid
Delaying surgery in comatose patients with anisocoria: This represents a neurosurgical emergency requiring immediate intervention 1, 3
Inadequate monitoring of "small" EDH: Serial CT scanning and continuous neurological observation in a neurosurgical center are mandatory, as 32% of initially asymptomatic patients required delayed evacuation 4
Missing high-risk features: Failure to identify fractures crossing major vessels or early presentation (<6 hours) leads to unexpected deterioration 4
Post-Operative Management
ICP monitoring is strongly indicated after hematoma evacuation if preoperative anisocoria was present, with target cerebral perfusion pressure maintained between 60-70 mmHg. 6, 3