What is the appropriate management for a patient with an epidural brain bleed?

Management of Epidural Brain Bleed (Epidural Hematoma)

Patients with epidural hematoma >30 cm³ require immediate surgical evacuation via craniotomy regardless of Glasgow Coma Scale (GCS) score, while smaller hematomas (<30 cm³, <15mm thickness, <5mm midline shift) in patients with GCS >8 and no focal deficits can be managed conservatively with serial CT imaging and close neurological monitoring in a neurosurgical center. 1

Immediate Stabilization and Assessment

Airway and Hemodynamic Management

• Intubate immediately if GCS ≤8, signs of herniation, or inability to protect airway 2, 3
• Maintain systolic blood pressure >100-110 mmHg to ensure adequate cerebral perfusion 2, 3
• Maintain oxygen saturation >94% to prevent cerebral hypoxia 2
• Avoid hyperventilation during mechanical ventilation, as it increases mortality and decreases cardiac output 2
• Monitor end-tidal CO₂ and avoid hypocapnia, which causes cerebral vasoconstriction and ischemia 3

Neurological Examination

• Document GCS score immediately, as 20% of patients deteriorate by ≥2 points between initial assessment and ED arrival 3
• Perform pupillary examination—abnormal pupils indicate impending herniation 3
• Assess for focal neurological deficits and signs of increased intracranial pressure 3

Diagnostic Imaging

• Obtain non-contrast head CT immediately—this is the gold standard for identifying acute epidural hematoma 2, 3
• Measure maximal hematoma thickness and degree of midline shift 3
• Consider CT angiography to identify active contrast extravasation ("spot sign"), which predicts hematoma expansion 2, 3

Surgical Decision-Making Algorithm

Immediate Surgical Evacuation Required:

• Hematoma volume >30 cm³ 1
• GCS <9 with anisocoria—evacuate as soon as possible 1
• Neurological deterioration or decreased consciousness 2, 3
• Signs of cerebral herniation or brainstem compression 2
• Hematoma thickness >15mm with midline shift >5mm 3, 1

Conservative Management Acceptable:

• Hematoma <30 cm³ AND thickness <15mm AND midline shift <5mm 1
• GCS >8 without focal neurological deficits 1
• Must be managed in a neurosurgical center with serial CT scanning and close neurological observation 1

High-Risk Patients Requiring Close Monitoring:

Even with small hematomas, 32% may require delayed evacuation. Risk factors for deterioration include: 4

• Skull fracture transversing a meningeal artery, vein, or major sinus (55% deterioration rate) 4
• CT diagnosis within 6 hours of trauma (43% deterioration rate) 4
• Patients with both risk factors have 71% chance of requiring evacuation 4

Medical Management of Increased Intracranial Pressure

Osmotic Therapy

• Administer mannitol (0.5-1 g/kg IV bolus) for signs of increased ICP or acute deterioration 2
• May repeat once or twice provided serum osmolality has not exceeded 320 mosm/L 5
• Consider hypertonic saline (23.4% sodium chloride 100ml IV) for acute deterioration with posturing or pupillary changes 3

ICP Monitoring and Management

• Consider ICP monitoring in patients with GCS ≤8, hydrocephalus, or clinical evidence of herniation 2
• Maintain ICP <20-25 mm Hg 5
• Maintain cerebral perfusion pressure (CPP) 60-70 mmHg 2, 3

Supportive Measures

• Prevent hyperthermia, as it increases cerebral oxygen demand and worsens secondary brain injury 2
• Aggressively treat seizures, as they increase metabolic demand 2
• Avoid hypervolemia, which does not improve outcomes and causes complications 3

Reversal of Coagulopathy

• Reverse warfarin immediately with prothrombin complex concentrate (PCC) or fresh frozen plasma 2
• Use specific reversal agents for new oral anticoagulants (NOACs) when available 2
• Maintain platelet count >50×10⁹/L in patients with traumatic brain injury 5

Neurosurgical Consultation and Transfer

• Contact neurosurgery immediately upon diagnosis 2, 3
• The commonly accepted goal is surgery within 4 hours of injury 2
• Never delay transfer to a neurosurgical center—lack of critical care beds should never be a reason to reject admission of patients requiring emergency surgery 2
• For pediatric patients, this is a time-critical transfer requiring local team transport rather than waiting for specialized transport 3

Alternative Treatment Options

Middle Meningeal Artery Embolization

• Consider endovascular embolization in patients with progressive epidural hematoma who have significant medical comorbidities precluding surgery 6
• Can control contrast leakage and halt hematoma progression 6
• May serve as salvage therapy in complicated situations limiting surgical evacuation 6

Critical Pitfalls to Avoid

• Never delay surgical intervention when neurological deterioration occurs—this directly worsens outcomes 3
• Do not assume stability based on initial presentation—delayed epidural hematoma can develop hours after an initially negative CT 7
• Maintain high clinical suspicion with low threshold for repeat CT scanning 7
• Patients diagnosed >6 hours after trauma have only 13% deterioration rate, but early diagnosis (<6 hours) carries 43% risk 4
• Craniotomy provides more complete evacuation than other surgical methods 1