A 25-year-old man involved in a motor vehicle accident presents with loss of consciousness, dilated pupils, Glasgow Coma Scale 8, and CT showing a convex temporal epidural hematoma—what is the appropriate management?

Emergency Craniotomy for Acute Epidural Hematoma

This patient requires emergency craniotomy immediately. 1, 2

Clinical Presentation Confirms Surgical Emergency

This 25-year-old man demonstrates the classic progression of acute epidural hematoma (EDH) with:

• Initial lucid interval followed by rapid deterioration - the hallmark presentation of expanding EDH 3
• GCS 8/15 - indicating severe traumatic brain injury requiring immediate airway protection and surgical intervention 4, 5
• Dilated pupils - signaling transtentorial herniation from mass effect 4, 3
• Convex (lentiform) temporal hematoma on CT - pathognomonic for epidural hematoma requiring evacuation 1, 6

Why Emergency Craniotomy is the Only Appropriate Answer

Neurosurgical guidelines explicitly state that removal of a symptomatic extradural hematoma is indicated regardless of location. 1 The evidence is unequivocal:

• Emergency surgical evacuation reduces mortality from 80% to 27% and improves independent outcome rates from 20% to 53% in patients with intracranial hematomas causing severely decreased consciousness 2
• Rapid intervention is critical - shorter time to treatment directly correlates with better outcomes 2
• Wide craniotomy covering the hematoma is recommended to evacuate the clot, control bleeding from the torn middle meningeal artery, and prevent reaccumulation 6

Why the Other Options Are Incorrect

High-Flow Oxygen (Option B)

• While maintaining PaO₂ ≥60-100 mmHg is part of supportive care 5, oxygen alone does nothing to address the expanding mass lesion causing herniation
• This is an adjunctive measure, not definitive treatment 4

High-Dose Steroids (Option C)

• Steroids have no role in traumatic brain injury management and are not mentioned in any current TBI guidelines 1
• They do not reduce intracranial pressure from mass lesions and may increase complications

Shunt (Option D)

• Shunts (external ventricular drains) are indicated for hydrocephalus or as adjunctive ICP management after hematoma evacuation 1
• Placing a shunt without removing the mass lesion would be futile and dangerous - the herniation would continue

Immediate Management Algorithm

Pre-operative stabilization (while preparing for craniotomy):

1. Secure airway via rapid sequence intubation - GCS ≤8 is absolute indication 4, 5
2. Maintain systolic BP >100 mmHg or MAP >80 mmHg to ensure cerebral perfusion 4, 5
3. Maintain PaCO₂ 35-40 mmHg to avoid cerebral vasoconstriction 5
4. Obtain urgent neurosurgical consultation - though in this case, the indication for surgery is already clear 5

Surgical technique:

• Large craniotomy (not burr holes) covering the entire hematoma extent 6
• Evacuate clot and control arterial bleeding (typically middle meningeal artery) 6, 3
• Consider leaving bone flap off if significant brain swelling present 6

Post-operative ICP monitoring is mandatory given this patient's preoperative GCS ≤8, dilated pupils (anisocoria), and severe CT findings 1, 2

Critical Timing Consideration

This is a neurosurgical emergency where minutes matter. 2, 3 Progressive transtentorial herniation with pupillary dilation indicates imminent brainstem compression and death if not immediately decompressed. The temporal location is particularly dangerous as it directly compresses the tentorial incisura. Any delay for "medical management" would be catastrophic. 3, 7