What is the treatment for an epidural hematoma?

Treatment of Epidural Hematoma

Surgical evacuation via craniotomy remains the definitive treatment for acute epidural hematoma (AEDH) requiring intervention, with the primary goal of preventing mortality from mass effect and herniation. 1, 2

Initial Assessment and Medical Stabilization

Immediate reversal of coagulopathy is critical before any intervention, with target platelet count ideally above 100 × 10⁹/L to minimize bleeding risk during surgical procedures. 3 Discontinue anticoagulation immediately if present. 1

For patients with signs of elevated intracranial pressure or neurological deterioration:

• Administer mannitol 0.25 to 2 g/kg IV as a 15-25% solution over 30-60 minutes for reduction of intracranial pressure and brain mass. 4 Evidence of reduced cerebral spinal fluid pressure should be observed within 15 minutes of starting infusion. 4
• Hypertonic saline (10% or 23.4% sodium chloride) can be used as an alternative or adjunct osmotic agent, particularly for acute deterioration with signs of herniation. 1
• Emergency intubation is indicated for patients with acute somnolence, extensor posturing, or pupillary abnormalities. 1

Surgical Indications and Techniques

Wide craniotomy covering the entire hematoma is the recommended surgical approach for AEDH evacuation, as it allows complete hematoma removal, control of bleeding sources, and prevention of reaccumulation. 2 This approach can easily be converted to decompressive craniectomy if brain swelling develops. 2

Key technical considerations:

• Expose the floor of the middle cranial fossa and carefully identify injuries to dural sinuses and bridging veins during evacuation. 2
• For AEDH with sinus injuries, combined multiple craniotomies leaving a bone bridge over the sinus for dural tenting sutures enables safe surgical intervention. 2
• Maintain cerebral perfusion pressure between 60-70 mmHg postoperatively in the absence of multimodal monitoring. 1

Alternative Treatment Approaches

Burr-hole drainage can be considered as a less invasive alternative in select patients with coagulopathy and liquefied (isodense) hematoma on CT. 5 This approach involves placement of a closed drainage system in the epidural space for 3 days, with successful evacuation reported in coagulopathic patients where craniotomy carries higher risk. 5

Middle meningeal artery (MMA) embolization is emerging as a primary treatment option for AEDH with active bleeding, particularly when:

• CT angiography demonstrates a "leakage sign" or "spot sign" indicating active hemorrhage. 1, 6, 7
• The patient is a poor surgical candidate or has contraindications to craniotomy. 6
• There is expanding hematoma without immediate surgical indication. 7

MMA embolization using coils can achieve complete hemostasis and prevent hematoma expansion without craniotomy, with favorable outcomes including complete hematoma regression at 1 month. 6, 7

Postoperative Management

ICP monitoring is strongly recommended after AEDH evacuation if any of the following criteria are present: 1

• Preoperative Glasgow Coma Scale motor response ≤5
• Preoperative anisocoria or bilateral mydriasis
• Preoperative hemodynamic instability
• Severity signs on cerebral imaging (compressed basal cisterns, midline shift >5 mm, other intracranial lesions)
• Intraoperative cerebral edema
• Postoperative appearance of new intracranial lesions

The incidence of postoperative intracranial hypertension ranges between 50-70% after hematoma evacuation, with more than 40% developing uncontrollable intracranial hypertension. 1

Thromboprophylaxis should be initiated once hemostasis is secured to prevent thromboembolic complications, following American College of Chest Physicians guidelines. 3

Conservative Management

Close clinical observation with serial imaging can be considered for asymptomatic patients with small AEDH without mass effect or neurological deficits. 8 Spontaneous resolution has been documented in rare cases, particularly in the pediatric population, though this remains exceptional. 8

Critical Pitfalls to Avoid

• Never delay surgical intervention in patients with neurological deterioration or signs of herniation while attempting medical management alone. 1
• Do not perform craniotomy in coagulopathic patients without first correcting coagulation parameters, as this significantly increases surgical morbidity. 3, 5
• Avoid inadequate craniotomy size, as small openings may prevent adequate visualization of bleeding sources and complete hematoma evacuation. 2
• Do not overlook active bleeding on angiography (spot sign), as this predicts hematoma expansion and may warrant endovascular intervention even without clear surgical indication. 1, 7