What is the management of Epidural Hematoma (EDH)?

Management of Epidural Hematoma (EDH)

Prompt surgical evacuation is the standard treatment for symptomatic epidural hematomas, while small, asymptomatic EDH in neurologically intact patients may be managed conservatively with close monitoring and serial imaging. 1

Initial Assessment and Stabilization

Airway and Ventilation Management

• Control ventilation immediately through tracheal intubation with mechanical ventilation and end-tidal CO2 monitoring, even during pre-hospital transport. 2
• Maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and increases risk of brain ischemia. 2
• Monitor end-tidal CO2 continuously to verify correct tube placement and maintain appropriate ventilation. 2

Coagulation Correction

• Reverse anticoagulation immediately if present, targeting a platelet count above 100 × 10⁹/L before surgical intervention to minimize bleeding risk. 3, 1
• For elevated INR, use prothrombin complex concentrate (PCC), fresh frozen plasma (FFP), or vitamin K for rapid normalization. 1
• Rapid normalization of coagulation status is mandatory to prevent hematoma expansion. 1

Surgical Indications

Absolute Indications for Emergency Craniotomy

• Any symptomatic EDH regardless of location requires immediate surgical evacuation. 1
• EDH with thickness >5mm and midline shift >5mm. 2
• Progressive neurological deterioration with signs of transtentorial herniation (loss of consciousness, pupillary dilation, focal deficits). 4
• Patients with cerebellar EDH who are deteriorating neurologically or have brainstem compression and/or hydrocephalus from ventricular obstruction. 1

High-Risk Features Requiring Surgery

• Skull fracture transversing a meningeal artery, vein, or major sinus (55% deterioration rate). 5
• EDH diagnosed within 6 hours of trauma (43% deterioration rate). 5
• Patients with both risk factors have 71% chance of requiring evacuation. 5

Conservative Management Criteria

Patient Selection for Non-Operative Management

Conservative management may be considered only in highly selected cases meeting ALL of the following criteria:

• Glasgow Coma Scale score of 14-15 with no clinical evidence of raised intracranial pressure or focal compression. 5, 6
• Small EDH volume without significant mass effect. 5, 6
• No skull fracture overlying major vessels or sinuses. 5
• EDH diagnosed >6 hours after trauma (only 13% deterioration rate). 5
• Must be performed in specialized neurosurgical centers with capability for immediate surgical intervention. 6

Monitoring Protocol for Conservative Management

• Serial neurological examinations with continuous observation. 5, 6
• Repeat CT scanning to monitor for hematoma expansion. 5, 6
• Immediate surgical intervention if any neurological deterioration occurs. 5, 6
• Follow-up imaging demonstrates complete resolution typically within 2-3 months. 6

Refractory Intracranial Hypertension Management

First-Line Interventions

• Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults. 2
• Drainage of small CSF volumes can markedly reduce intracranial pressure. 2

Rescue Therapy

• Consider decompressive craniectomy for refractory intracranial hypertension after multidisciplinary discussion. 2
• Large temporal craniectomy (>100 cm²) with enlarged dura mater plasty is the most commonly used technique. 2
• Bifrontal craniectomy indicated for patients with diffuse lesions. 2

Post-Treatment Management

Thromboprophylaxis

• Consider thromboprophylaxis once hemostasis is secured to prevent thromboembolic complications. 3, 1

Ongoing Care

• Close neurological monitoring during recovery period. 1
• Rehabilitation to optimize functional recovery. 1
• Coordination between neurosurgery, critical care, and rehabilitation specialists. 1

Critical Pitfalls to Avoid

• Do not delay surgery in symptomatic patients—clinical outcome depends on time to treatment. 4
• Age, sex, and initial hematoma size are NOT reliable predictors of deterioration; focus on fracture location and timing of diagnosis. 5
• Conservative management should never be attempted outside specialized neurosurgical centers with immediate surgical capability. 6
• Insufficient sedation or failure to correct secondary brain insults before considering advanced interventions. 2