How should an epidural (extradural) hemorrhage be managed?

Management of Epidural (Extradural) Hemorrhage

Symptomatic epidural hematomas require immediate surgical evacuation via craniotomy, while carefully selected asymptomatic patients with small hematomas may be managed conservatively with intensive monitoring in a neurosurgical center. 1, 2, 3

Immediate Stabilization (Pre-Hospital and Emergency Department)

Airway and Hemodynamic Management:

• Perform endotracheal intubation and mechanical ventilation immediately for all patients with altered consciousness (GCS <9), beginning in the pre-hospital period 2, 3
• Confirm correct tube placement through continuous end-tidal CO2 monitoring to maintain normal PaCO2 and avoid hypocapnia-induced cerebral vasoconstriction 1, 2
• Maintain systolic blood pressure >110 mmHg from first contact using vasopressors (phenylephrine or norepinephrine) without delay, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcomes 1, 2, 3
• Never wait for fluid resuscitation or sedation adjustment before initiating vasopressors, as these have delayed hemodynamic effects 2, 3

Diagnostic Imaging

• Obtain non-contrast CT of the brain and cervical spine immediately without any delay 2, 3
• Use inframillimetric sections reconstructed with thickness >1mm, visualized with double fenestration (central nervous system and bone windows) 3, 4

Surgical Indications (Absolute)

The following epidural hematomas require immediate surgical evacuation via craniotomy: 1, 2, 5

• Any symptomatic extradural hematoma regardless of location or size 1, 2
• EDH volume >30 cm³ regardless of Glasgow Coma Scale score 5
• Comatose patients (GCS <9) with EDH and anisocoria—evacuate as soon as possible 5
• EDH with thickness >15mm 5
• EDH causing midline shift >5mm 5

Conservative Management Criteria (Highly Selective)

Conservative management may be considered ONLY when ALL of the following criteria are met: 5, 6

• EDH volume <30 cm³ 5
• Thickness <15mm 5
• Midline shift <5mm 5
• GCS score >8 5
• No focal neurological deficit 5
• Patient is neurologically stable or improving 6

Critical Risk Factors for Deterioration During Conservative Management:

• Skull fracture transversing a meningeal artery, vein, or major sinus (55% deterioration rate) 7
• CT diagnosis within 6 hours of trauma (43% deterioration rate) 7
• Presence of both risk factors (71% deterioration rate) 7

If conservative management is attempted, the following are mandatory: 7, 5, 6

• Serial CT scanning at regular intervals 7, 5, 6
• Continuous neurological observation in a neurosurgical center 5
• Immediate availability of neurosurgical intervention 5
• Repeat imaging if any change in neurological status occurs 7

Surgical Technique

• Craniotomy is strongly recommended over burr holes, as it provides more complete hematoma evacuation 5
• Evacuate the hematoma as soon as possible in comatose patients with anisocoria 5

Post-Operative Management

Intracranial Pressure Monitoring:

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension 2, 3
• Consider external ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary brain insults 1

Temperature Management:

• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death 2, 3, 4

Coagulation Management:

• Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes 3

Sedation:

• Use propofol by continuous infusion (never bolus) to avoid hemodynamic instability 3
• Avoid barbiturates, bolus midazolam, or bolus opioids due to risk of arterial hypotension 1

Critical Pitfalls to Avoid

• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 2, 3, 4
• Never use sedation in bolus form instead of continuous infusions 2, 3, 4
• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" 4
• Never attempt conservative management in patients with any of the absolute surgical indications listed above 5
• Never manage conservatively without immediate neurosurgical availability and serial CT capability 5

Prognosis

• Expeditious surgical evacuation of EDH is associated with excellent prognosis and is considered the most cost-effective neurosurgical operation 8
• Mortality rates range from 1.2% to 33% depending on timing of intervention 8
• Properly selected conservative management patients can achieve complete neurological recovery with hematoma resolution over 3-15 weeks 6