What is the emergency management and surgical criteria for an extradural (epidural) hemorrhage?

Emergency Management and Surgical Criteria for Extradural (Epidural) Hemorrhage

All salvageable patients with life-threatening extradural hemorrhage require urgent neurosurgical consultation and emergency craniotomy after life-threatening systemic hemorrhage is controlled. 1

Immediate Stabilization and Assessment

Airway and hemodynamic management take absolute priority:

• Secure the airway with endotracheal intubation for patients with GCS ≤8, signs of herniation, or inability to protect the airway 2
• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg to ensure adequate cerebral perfusion during all interventions 1, 3
• Target PaCO₂ between 35-40 mmHg—avoid hypocapnia as it causes cerebral vasoconstriction and worsens ischemia 1, 3
• Maintain PaO₂ between 60-100 mmHg 1, 3

Perform rapid neurological examination:

• Document GCS score immediately, as 20% of patients deteriorate by ≥2 points between EMS assessment and ED arrival 2
• Examine pupils to identify herniation risk—abnormal pupils indicate impending herniation 2
• Assess for focal neurological deficits and signs of increased intracranial pressure 1

Diagnostic Imaging

Obtain non-contrast head CT immediately—this is the gold standard for identifying acute epidural hematoma. 2

• Measure maximal hematoma thickness and degree of midline shift 2
• Consider CT angiography to identify active contrast extravasation ("spot sign"), which predicts hematoma expansion 2

Surgical Indications (Absolute)

Emergency craniotomy is mandatory for:

• Any symptomatic patient with neurological deterioration, decreased consciousness, or signs of herniation 2
• Hematoma thickness >5 mm with midline shift >5 mm 2
• Any extradural hematoma in a comatose patient (GCS ≤8) regardless of size 2
• Hematoma volume >30 cm³ regardless of GCS 4

Contact neurosurgery immediately upon diagnosis—every ED must have a plan for rapid transfer to a tertiary center if neurosurgical capability is unavailable. 2 The commonly accepted target is surgery within 4 hours of injury, as earlier evacuation improves outcomes. 1

Conservative Management Criteria (Highly Selective)

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

• GCS 13-15 (non-comatose, neurologically intact) 5, 6
• Hematoma volume <30 cm³ 4
• Hematoma thickness <15 mm 4
• Midline shift <5 mm 4
• No other surgical lesions present 5
• Patient can be monitored in an intensive care unit with immediate neurosurgical availability 5

If conservative management is attempted, perform daily CT scans for the first 5 days and maintain continuous neurological monitoring. 5, 7 Resolution typically occurs by 21 days and is definitive by 3-6 months. 5

Medical Management of Increased Intracranial Pressure

For patients with signs of herniation awaiting or during emergency neurosurgery:

• Administer mannitol (0.25-0.5 g/kg IV every 6 hours, maximum 2 g/kg) for marked improvement in consciousness when signs of increased ICP develop 2, 3
• Consider hypertonic saline (23.4% sodium chloride 100 mL IV) for acute deterioration with posturing or pupillary changes 2
• Use osmotherapy and/or temporary hypocapnia in cases of cerebral herniation 1

Coagulation Management

Verify anticoagulant/antiplatelet use immediately, as these increase hematoma expansion risk:

• Maintain platelet count >50,000/mm³ for patients requiring intervention 1, 3
• Maintain PT/aPTT <1.5 times normal control during interventions 1, 3
• For warfarin-related hemorrhage, immediately discontinue warfarin, give IV vitamin K, and administer prothrombin complex concentrates (PCC) to rapidly normalize INR 8
• For dabigatran-related hemorrhage, give idarucizumab 5 g IV 8

Critical Pitfalls to Avoid

Never delay surgical intervention when neurological deterioration occurs—this directly worsens outcomes and increases mortality. 2, 3 The "lucid interval" followed by rapid deterioration is the classic presentation of expanding epidural hematoma requiring immediate craniotomy.

Do not rely solely on initial GCS—serial assessments are mandatory as early deterioration is common. 2 Patients may appear stable initially but deteriorate rapidly as the hematoma expands.

Avoid hypervolemia—it does not improve outcomes and causes complications. 2

In resource-limited settings where immediate craniotomy is not feasible, burr hole evacuation with continuous suction drainage under negative pressure can be life-saving, but requires daily CT monitoring and readiness to convert to formal craniotomy if consciousness does not improve within several hours. 7