Management of Extraaxial Hemorrhage
Immediate surgical evacuation is indicated for extraaxial hematomas causing mass effect with midline shift ≥5mm or clinical deterioration, while smaller hematomas with minimal mass effect can be managed conservatively with serial imaging and close neurological monitoring. 1, 2
Initial Assessment and Stabilization
Airway and Hemodynamic Management
- Secure the airway immediately in patients with decreased level of consciousness and provide high FiO2 to prevent secondary brain injury 1
- Establish large-bore IV access (preferably 8-Fr central access) for rapid fluid resuscitation and medication administration 1
- Control blood pressure targeting systolic BP of 80-100 mmHg until bleeding is controlled in patients without contraindications 1
Laboratory Evaluation
- Obtain baseline complete blood count, coagulation studies (PT, aPTT, fibrinogen), and cross-match blood products 1
- Activate major hemorrhage protocol immediately when massive hemorrhage is anticipated 3
Surgical Decision-Making
Indications for Emergency Surgery
- Hematoma volume ≥10 mL at the original impact location with progressive expansion 4
- Midline shift ≥5mm with clinical deterioration or brain herniation 4, 2
- Glasgow Coma Scale deterioration despite medical management 2
- Presence of brain herniation on imaging requires immediate decompressive surgery for any chance of favorable outcome 2
Conservative Management Criteria
- Clinically stable patients with midline shift <5mm can be managed conservatively with serial CT imaging 5
- Hematoma volume <10 mL without significant mass effect 4
- No evidence of brain herniation or progressive neurological deterioration 2
Critical caveat: Approximately 11% of conservatively managed extraaxial hematomas increase in volume on follow-up imaging, necessitating close observation even in stable patients 5. The absence of apparent midline shift is paradoxically a predictor of hematoma progression after contralateral decompressive surgery 4.
Management of Coagulopathy
Correction of Hemostatic Defects
- For fibrinogen <1 g/L or PT/aPTT >1.5 times normal, immediately administer fresh frozen plasma (15 ml/kg) to prevent established coagulopathy 3, 1
- Maintain platelet count above 75 × 10^9/L throughout the acute management phase 3, 1
- For established coagulopathy requiring >15 ml/kg FFP, the most effective rapid fibrinogen replacement is fibrinogen concentrate or cryoprecipitate 3
Blood Product Administration
- Use group-specific blood when possible; reserve O-negative blood only for immediate life-threatening situations 3
- In severely traumatized patients, implement 1:1:1 red cell:FFP:platelet transfusion regimens 3
- Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 3
Specific Considerations by Hematoma Type
Subdural Hematoma
- Subdural hematomas have the highest mortality rate (52.9%) when associated with brain herniation 2
- Most common type of extraaxial hematoma in road traffic accidents, particularly in patients aged ≥55 years 6
- Requires aggressive surgical intervention when symptomatic due to poor natural history 2, 6
Epidural Hematoma
- Epidural hematomas have the best prognosis with mortality of only 14.2% even when herniation is present 2
- Best survival probability at 6 and 12 months compared to other extraaxial hematoma types 6
- Adjacent skull fracture is frequently present and associated with decreased hematoma volume over time 5
Traumatic Subarachnoid Hemorrhage
- Associated with the poorest outcome and highest mortality among extraaxial hemorrhages 6
- MRI is significantly more sensitive than CT for detecting subarachnoid hemorrhagic localizations (P = 0.001) 7
Postoperative Management
Critical Care Monitoring
- Admit all patients to critical care unit for continued monitoring after hemorrhage control 1
- Monitor for postoperative intracranial pressure elevation, as high ICP values correlate strongly with mortality and unfavorable outcome 2
- Serial imaging to detect rebleeding or complications 3
Thromboprophylaxis
- Commence standard venous thromboprophylaxis as soon as hemostasis is secured, as patients rapidly develop a prothrombotic state following hemorrhage 3, 1
- Consider temporary inferior vena cava filtration in high-risk patients 3
Prognostic Factors
Predictors of Poor Outcome
- Low Glasgow Coma Scale scores at admission 2
- Longer interval from trauma to surgery (time is brain) 2
- Longer duration of brain herniation 2
- Presence of intraoperative brain swelling 2
- Larger and thicker hematomas with greater midline shift and basal cistern obliteration 2