Treatment

EDH is a neurosurgical emergency, as hematoma expansion can rapidly lead to brain herniation and death.

• Primary survey with simultaneous initiation of neuroprotective measures

• Empiric ICP management

• Urgent craniotomy and hematoma/clot evacuation

• Prevention of complications in brain injuries (e.g., anticoagulant reversal to prevent hematoma expansion)

• Conservative management with close observation and serial CT scans can be considered for a small, asymptomatic EDH.

• Consider skull trephination (burr hole surgery) as a temporizing procedure in patients with neurological deterioration if neurosurgical expertise is not immediately available.

• Minimize the duration of time between the onset of neurological decline and surgical clot evacuation.

• When to restart anticoagulation and antithrombotic therapy should be decided on an individual basis

Patients fulfilling any or all of these criteria should be operated on urgently.

• EDH volume > 30 mL (30 cm3) regardless of GCS

• EDH thickness > 15 mm

• Midline shift > 5 mm

• GCS ≤ 8

• Focal neurological deficit

• Evidence of neurological deterioration: pupillary abnormalities, signs of brain herniation

• Associated brain injuries (e.g. SDH, depressed skull fracture) that meet surgical criteria

as soon as possible (preferably within 2 hours of loss of consciousness in patients with neurological deterioration and/or GCS ≤ 8)

recommended in all patients to prevent meningitis (e.g., Cefazolin)

• First-line: urgent craniotomy, hematoma evacuation, and ligation of the ruptured blood vessel

• Emergency temporizing procedure: skull trephination

  • Indication: suspected or confirmed EDH with GCS ≤ 8 and/or signs of brain herniation or coma in a facility without an on-site neurosurgeon

  • Further management: urgent transfer to a neurocritical care unit for definitive management by a neurosurgeon

• Indications: Absence of all indications for surgery (see above)

• Procedure

  • Admission to neuro-ICU or ICU

  • Frequent GCS monitoring and neurological checks for at least 72 hours

  • Serial CT scans to monitor for early hematoma expansion

    • If clinically stable: Repeat within 4–6 hours.

    • Clinical deterioration or new neurologic deficits: Repeat immediately.

• Failure of conservative management (EDH progression during observation): Perform craniotomy and hematoma evacuation.

• In patients with no other associated brain injury, early decompression is associated with good neurological outcomes, including full recovery.

• Factors associated with a worse prognosis

  • GCS ≤ 8 at presentation

  • Pupillary abnormalities (especially fixed dilated pupil) at presentation

  • Prolonged period of time between onset of brain herniation and decompressive surgery

  • Age > 75 years

  • Large volume EDH causing significant midline shift

  • Associated brain injuries

• Every hour of delay from the onset of signs of brain herniation to decompressive surgery worsens the neurological outcome and increases the mortality rate.