Epidural Hematomas Treatment & Management

The treatment approach for patients with EDH depends on various factors. Adverse effects on brain tissue are mainly the result of mass effect causing structural distortion, life-threatening brain herniation, and increased intracranial pressure. Treatment options for these patients are (1) immediate surgical intervention and (2) initial, conservative, close clinical observation with possible delayed evacuation. Note that EDH tends to expand in volume rapidly, and patients require very close observation if the conservative route is taken.

A case report of a 31-year-old male patient who underwent a left craniotomy for acute EDH followed by successful postoperative embolization for an expanding right-sided EDH revealed that endovascular exploration and possible follow-up treatment can be justified in patients with EDH who do not have a clear surgical indication. ^[20]

Early follow-up scanning should be performed to assess a further increase in hematoma size prior to deterioration. Delayed epidural formation has been reported. If a rapid size increase is noted and/or if the patient develops anisocoria or a neurologic deficit, surgery is indicated. Middle meningeal artery embolization has been described in the early stages of EDH, especially when angiographic dye extravasation has been observed.

Not all cases of acute EDH require immediate surgical evacuation. ^{[21, 22]} If a lesion is small and the patient is in good neurologic condition, observing the patient with frequent neurologic examinations is reasonable. One subset of this entity, acute anterior temporal tip EDH, runs a benign course, which usually can be followed by imaging and observation. The likely venous origin of this condition contributes to slow expansion and eventual tamponade of the bleeding source. ^[8]

In a retrospective review over a 5-year period of patients with EDH who were initially triaged for conservative management, only 11.2% required surgery. Statistical comparison showed that younger age and coagulopathy were the only significant factors for conversion to surgery. ^[23]

Conservative management is often left to clinical judgment. The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Head Injury recommends that patients who exhibit an EDH that measures less than 30 mL, is less than 15 mm thick, and has less than 5-mm midline shift, with no focal neurologic deficit and with GCS greater than 8, can be treated nonoperatively. ^[24]  These traumatic brain injury (TBI) guidelines have been expanded, refined, and made increasingly more rigorous in conjunction with new clinical evidence and evolving methodologic standards. Perhaps the greatest limitation of TBI guidelines is the lack of high-quality clinical research, as well as of novel diagnostics and treatments, on which substantially new recommendations can be based. ^[25]

A population-based study examined effects on patient outcomes when clinicians adhered to BTF guidelines for intracranial pressure monitoring while treating patients with severe TBI. Study authors reported that greater adherence to these guidelines was associated with higher mortality rates (OR 2.01, 95% CI, 1.56-2.59; P< 0.001), greater morbidity, and increased intensive care unit and hospital lengths of stay (P< 0.001), leading them to conclude that current BTF criteria for insertion of ICP monitors may fail to identify patients likely to benefit. ^[26]

Temporal hematomas, if they are large or expanding, may lead to uncal herniation and rapid deterioration. Epidural hematoma in the posterior fossa, which is frequently related to interruption of the lateral venous sinus, often requires prompt evacuation because of the limited space available compared with the supratentorial compartment. ^[27]

When patients with spontaneous EDH are treated, the underlying primary disease process must be addressed in addition to the fundamental principles discussed above.

(See the images below.)

CT image of a pre-adolescent male with a left posterior fossa epidural hemorrhage (EDH). Such hemorrhages need to be watched carefully, and the surgical team should have a low threshold for surgical intervention because this region has less room to accommodate mass lesions.

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Bone window of the same patient as Media file 6 that reveals a diastasis (separation) of the left mastoid suture.

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Before the advent of CT scanning, drilling exploratory burr holes was commonplace, especially when the patient demonstrated lateralizing signs or rapid deterioration. Currently, with fast-scan techniques, this type of exploration is rarely required.

Drilling of exploratory burr holes is currently reserved for the following circumstances:

• Definitive localizing signs and clinical evidence of intracranial hypertension in patients who are unable to tolerate a CT scan because of severe hemodynamic instability

• Immediate surgical intervention for systemic injuries

Reports have described burr holes with negative pressure drainage as a primary mode of EDH treatment in select patients (ie, patients awaiting transfer to a higher-level trauma facility, or patients with hemorrhage of nonarterial origin). ^[28]  However, despite these reports, craniotomy remains the standard treatment.

Patients are brought to the operating room as quickly as possible after CT scanning. The body is supine, and the head is placed on a donut or horseshoe head holder. Three-point head clamps, which are often used for intracranial surgery, are not routinely applied because they may propagate existing skull fractures.

Occipital or posterior fossa EDH requires positioning in the lateral, semi-prone, or prone position. Three-point head clamps are then applied with care to achieve stable head fixation.

If the cervical spine is not adequately cleared for fracture or instability in patients with trauma, a hard cervical collar is kept in place.

Surgical treatment of EDH involves opening the calvaria over the site of hemorrhage. The EDH, whcih is readily apparent after elevation of the bone flap, is removed. Coagulation of bleeding dural vessels is usually performed. Epidural tack-up sutures are placed from the dura to the craniotomy bone edge and to the center of the craniotomy flap to tamponade epidural bleeding from areas beyond the craniotomy edges and to prevent recurrence. Dural venous sinus bleeding is controlled with tamponade by gelatin sponges and cotton strips and by head-of-the-bed elevation, with care taken to avoid venous air embolism. The utmost care should be taken when depressed bone fragments on or near the dural venous sinuses are elevated. If present, the Cushing response remains untreated until it resolves spontaneously as the mass effect is relieved.

If the patient presents with a dilated pupil or with clinical signs of intracranial hypertension, a small incision is made in an area considered to be over the hematoma. A rapid burr hole is created, and the epidural is partially evacuated. This maneuver often provides some initial pressure relief until the entire epidural blood clot can be evacuated.

If other significant intracranial injuries (eg, subdural hematoma, intracerebral hematoma) are apparent after imaging or upon direct visualization, they are surgically evacuated as needed. Intraoperative ultrasonography is sometimes helpful in identifying such lesions. Occasionally, the bone flap (decompressive craniectomy) may not be reattached to the skull and instead is stored in a freezer, discarded, or preserved in the abdominal fat layer. This occurs when significant intracerebral swelling or injury is noted on initial CT scan or is encountered during the operation, or when intractable intracranial hypertension develops during the postoperative period. Such decompression can allow for further brain expansion.

Patients usually are treated in the intensive care unit or in a monitored setting until their condition improves. Associated intracranial or systemic injuries are managed as needed. Depending on their neurologic condition and on radiographic findings, some patients may require intracranial pressure monitoring.

Follow-up CT scans are performed to determine the extent of clot evacuation. These scans can also facilitate evaluation for delayed hematoma.

Many of the complications associated with EDH occur when pressure results in significant brain shifting. When the brain is subject to subfalcine herniation, the anterior and posterior cerebral arteries may occlude, resulting in cerebral infarction.

Downward herniation of the brain stem can result in Duret hemorrhages within the brainstem, most often in the pons.

Transtentorial herniation may result in an ipsilateral compressive third nerve palsy, which often takes many months to resolve once the pressure is relieved. Compressive third nerve palsy manifests as ptosis, pupillary dilation, and inability to move the eye in medial, upward, and downward directions.

Drifting of the extremity when the patient is asked to hold both arms outstretched with palms facing upward indicates subtle but significant mass effect.

Epidural hematoma is an emergent neurosurgical disease that can be managed with close clinical and radiographic observation or by surgical evacuation. Most cases involve skull fractures over the lateral convexities of the hemispheres, with rupture of middle meningeal artery branches. Prompt diagnosis and appropriate management have resulted in low mortality and excellent functional outcomes.

With growing interest and experience in minimally invasive techniques, the value of burr hole evacuation with negative pressure may need to be further investigated. ^[28] In addition, endovascular approaches may be a new avenue for investigation. 

A case report of a 31-year-old male patient who underwent a left craniotomy for acute EDH followed by successful postoperative embolization for an expanding right-sided EDH revealed that endovascular exploration and possible follow-up treatment can be justified in patients with EDH who do not have a clear surgical indication. ^[20]