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Epidural Hematoma

An epidural hematoma is a collection of blood between the inner surface of the skull and the dura mater (the brain’s outer protective covering), most often developing after head trauma. Its clinical significance lies in the fact that it can expand rapidly and compress the brain. In some patients, the classic lucid interval is observed: a brief period of apparent neurologic improvement after the injury, followed by abrupt deterioration.

At Neuroknife, management begins with a pragmatic clinical question: is careful observation safe, or is urgent surgical treatment required? Decision-making is guided by the neurologic examination (GCS, focal deficits) together with objective CT parameters, including hematoma volume, maximal thickness, and midline shift.

A condition that can deteriorate rapidly Primary test: Head CT Decision criteria: GCS / pupil findings / shift / hematoma size A skull fracture is commonly present Surgery when there is evidence of brain/brainstem compression Even “mild” head injury requires close clinical monitoring

What is an epidural hematoma?

This is bleeding “between the skull and the dura,” forming a collection that can place significant pressure on the brain.

An epidural hematoma (EDH) is a collection of blood in the epidural space. Simply put, it forms between the inner table of the skull and the dura mater, the brain’s outer protective covering. Because intracranial space is limited, expansion of an EDH can lead to elevated intracranial pressure, displacement of brain structures, and potentially dangerous compression of the brainstem.

Clinical significance: Epidural hematoma is one of the traumatic conditions in which neurologic status can change rapidly. Even when the initial neurologic examination is normal, close monitoring remains essential.

How does it happen? (cause and bleeding source)

Epidural bleeding most commonly follows head trauma and may be arterial or venous in origin.

The most common causes include motor vehicle collisions, falls, and blunt impact injuries. An EDH may result from injury to:

  • The middle meningeal artery (the classic arterial source),
  • Meningeal veins or diploic veins,
  • Dural venous sinuses in selected fracture patterns.

In children and in certain trauma patterns, the bleeding source may be venous. This can influence the rate of hematoma expansion—but never eliminates the need for strict clinical surveillance.

Symptoms and the “lucid interval”

A “lucid interval” is the classic teaching for epidural hematoma, but it is not always present. The most important factor is how the hematoma and neurologic status evolve over time.

An epidural hematoma may present with symptoms such as:

  • Headache (often progressive),
  • Nausea/vomiting, drowsiness, confusion,
  • Focal neurologic deficits (e.g., limb weakness),
  • Pupil asymmetry (anisocoria) — a red flag requiring urgent action,
  • Seizures in some cases.
Emergency: After head trauma, worsening level of consciousness, anisocoria, new weakness, or recurrent vomiting requires immediate evaluation at a specialized neurosurgical center, such as Neuroknife’s partner hospitals.

Diagnosis on CT — what do we assess?

Head CT is the cornerstone test. Hematoma size and objective imaging parameters (volume/thickness/shift) directly inform clinical decision-making.

Head CT is the study of choice. An epidural hematoma typically appears as a biconvex (lentiform), hyperdense collection that does not cross cranial sutures, because the dura is tightly adherent to the skull.

At Neuroknife, we pay particular attention to three imaging measurements that directly influence treatment decisions:

  • Hematoma volume (mL),
  • Maximal clot thickness (mm),
  • Midline shift (MLS) (mm), along with assessment of the basal cisterns.

We also systematically evaluate associated injuries (contusions, traumatic subarachnoid hemorrhage, subdural hematoma), and the presence/course of any skull fracture—especially when it traverses vascular structures.

When is surgery needed, and when is close observation appropriate?

Treatment decisions are made by integrating the patient’s neurologic status, objective CT criteria, and the trajectory of symptoms over time.

While every case is individualized, commonly used practical criteria include:

  • Hematoma volume > 30 mL: typically an indication for surgical evacuation, even if neurologic status appears stable.
  • Thickness > 15 mm and/or midline shift > 5 mm: generally favors surgical evacuation.
  • Neurologic deterioration, anisocoria, GCS < 9, or new focal deficits: managed on an emergent basis.
Important: Epidural hematomas in the temporal region often allow less “physiologic reserve” for observation. In this location, the threshold for surgery is lower, particularly if repeat CT demonstrates hematoma expansion.

How does Neuroknife approach head trauma?

Our goal is a clear, safest-possible pathway: structured observation with a defined protocol, or urgent surgical evacuation when indicated.

In day-to-day practice, our strategy follows clear clinical steps:

  • If there is decreased level of consciousness, anisocoria, or new weakness, then we prioritize immediate decompression (surgery) — the minutes to hours that follow are critical.
  • If the patient is clinically stable (e.g., GCS > 8), without focal neurologic deficit, and the hematoma is small on imaging (for example < 30 mL, < 15 mm, midline shift < 5 mm), then close observation may be appropriate—but only in a specialized neurosurgical center with immediate access to repeat CT and urgent surgery.
  • If the hematoma is temporal or there is an associated fracture involving major vascular structures, then we adopt a lower threshold for decisions that favor early surgical evacuation.

In parallel, decisions incorporate additional factors: anticoagulant/antiplatelet therapy, associated injuries, age, and dynamic changes in neurologic status. In complex cases, planning is multidisciplinary (anesthesiology/ICU/neurosurgery) to ensure the patient is in the right environment at the right time.

Safe management of epidural hematoma requires a structured protocol that includes frequent neurologic reassessments, a clearly defined plan for repeat CT imaging, and a low threshold to escalate or revise the treatment strategy.

Surgery: goals, safety, and prevention of complications

Our objective is not only to remove the clot, but to control the bleeding source and reduce the risk of recurrence/re-accumulation.

When surgical evacuation is indicated, the operation is performed via an appropriately sized craniotomy, with the goals to:

  • evacuate the clot completely,
  • identify and control the bleeding source (arterial/venous, diploic),
  • reduce the risk of recurrent bleeding and re-accumulation (e.g., dural tack-up sutures when indicated).

At Neuroknife, we place particular emphasis on operative safety: an adequately sized craniotomy, meticulous hemostasis, and a clear postoperative monitoring plan. When performed in a timely fashion, evacuation most often leads to an excellent prognosis and rapid neurologic recovery.

Time-to-surgery is especially consequential in patients who are deteriorating: delayed evacuation after the onset of anisocoria, focal neurologic findings, or impaired consciousness is associated with worse outcomes. For this reason, traumatic brain injury care should occur in a specialized neurosurgical center, such as Neuroknife’s partner hospitals.

Non-operative management: what does it include?

Conservative treatment means strict surveillance with frequent neurologic reassessments in a specialized neurosurgical setting.

In carefully selected patients (e.g., fully awake, no focal deficit, small hematoma), conservative management can be safe only when the following are in place:

  • Continuous clinical monitoring (neurologic checks at intervals determined by the clinical team),
  • Ability to obtain immediate repeat head CT,
  • Ability to proceed with urgent surgery if the hematoma enlarges or neurologic status worsens.
When observation is no longer appropriate: if there is meaningful neurologic decline, new focal findings, hematoma enlargement, or increasing midline shift, the plan may need to change immediately.

Recovery, prognosis, and rehabilitation

In general, with timely diagnosis and appropriate management, outcomes after epidural hematoma are excellent.

Prognosis depends primarily on neurologic status at presentation (GCS), the presence of focal deficits, associated injuries, and the time to decompression—especially when rapid clinical deterioration occurs.

After surgery or conservative treatment, recovery is individualized and typically includes symptom control, gradual mobilization, guidance to prevent repeat injury, and a follow-up plan. Return to normal activities depends on the overall severity of the injury and the clinical presentation.

Frequently asked questions (FAQ)

Is surgery always required for an epidural hematoma?

No. In selected patients with a small hematoma, stable neurologic examination, and favorable CT criteria, close observation in a specialized neurosurgical center may be appropriate. The decision must be strictly individualized, because deterioration in epidural hematoma can be rapid.

Which CT findings increase the likelihood of surgery?

Examples include hematoma volume > 30 mL, thickness > 15 mm, midline shift (MLS) > 5 mm, compression of the basal cisterns, and associated injuries. Imaging findings are always interpreted in the context of the clinical examination.

What does a “lucid interval” mean?

This is the classic pattern in which a patient may improve briefly after the injury and then deteriorate rapidly. It does not occur in every case. Monitoring should be based on neurologic evolution and changes in hematoma size on head CT.

When should I go to the hospital immediately after a head injury?

Urgent evaluation is necessary if there is worsening level of consciousness, drowsiness/confusion, persistent vomiting, new weakness, speech difficulty, seizures, or changes in pupil size or reactivity (anisocoria).

How often is repeat head CT needed if surgery is not performed?

The exact timing is individualized. Often, the first repeat scan is obtained within 6 to 8 hours after injury, or sooner if new symptoms develop. Observation should occur in an organized neurosurgical center with immediate surgical capability.

When do you need a specialist neurosurgical evaluation?

If an epidural hematoma has been identified on CT—or if, after a head injury, symptoms evolve (worsening headache, drowsiness, confusion, vomiting, or focal neurologic signs)—timely neurosurgical assessment is crucial. At Neuroknife, we promptly integrate the clinical examination with objective CT criteria (hematoma size and midline shift) and determine whether urgent surgical evacuation is required or whether structured observation can be performed safely under a defined protocol.

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