An epidural hematoma is a collection of blood between the skull and the periosteal layer of the dura mater, most commonly caused by traumatic laceration of the middle meningeal artery following a temporal bone fracture. EDH occurs in approximately 2% of all head injuries and carries mortality rates of 1.2–33% depending on presentation and timing of intervention. [1] Rapid recognition and neurosurgical intervention are critical, as this is one of the most treatable causes of death from traumatic brain injury.
1. History
- Mechanism of injury: Direct blow to the temporal region (assault, fall, MVC, sports); in children, falls from <1 meter are the most common mechanism [2]
- Classic "lucid interval": Initial LOC → period of apparent neurological normalcy → rapid deterioration; however, fewer than 20% of patients demonstrate this classic pattern [3-4]
- Headache (progressive, worsening), nausea/vomiting, confusion, seizures
- Timing: Symptom onset may be immediate or delayed hours to days; arterial EDH progresses rapidly, while venous EDH (more common in children) develops more slowly [5]
- Important negatives: No anticoagulant use, no prior neurosurgery, no coagulopathy
2. Alarm Features
- Rapidly declining GCS — the single most important clinical indicator
- Anisocoria (ipsilateral fixed, dilated pupil) — indicates uncal herniation; demands immediate surgical evacuation [6]
- Contralateral hemiparesis or posturing (decerebrate/decorticate)
- Cushing triad: hypertension, bradycardia, irregular respirations (late sign of brainstem herniation)
- Bilateral fixed dilated pupils
- New-onset seizures post-trauma
- In infants: bulging fontanelle, pallor, irritability, anisocoria [2]
3. Medications
- Contributors to risk: Warfarin (strongest signal, ROR 29.2), rivaroxaban, apixaban, dabigatran, LMWH, aspirin, clopidogrel, and other anticoagulants/antiplatelets [7-8]
- Reversal agents (if coagulopathy present):
- Warfarin → IV vitamin K + 4-factor PCC (preferred over FFP)
- DOACs → Idarucizumab (dabigatran); andexanet alfa or 4-factor PCC (factor Xa inhibitors)
- Heparin → Protamine sulfate
- Avoid: Anticoagulants and antiplatelets in the acute setting; NSAIDs (platelet dysfunction)
- Seizure prophylaxis: Levetiracetam or phenytoin may be considered per institutional TBI protocols
4. Diet
- NPO if surgical intervention anticipated
- No specific dietary triggers; standard TBI nutritional support (early enteral feeding) if admitted to ICU
- Adequate hydration to maintain cerebral perfusion
5. Review of Systems
- Neuro: Headache, LOC, confusion, visual changes, weakness, speech difficulty, seizures
- HEENT: Scalp swelling/hematoma, periorbital ecchymosis, otorrhea/rhinorrhea (skull base fracture), exophthalmia (rare, frontal EDH) [3]
- CV: Chest pain, palpitations (associated thoracic trauma)
- GI: Nausea, vomiting (raised ICP)
- MSK: Neck pain, extremity injuries (polytrauma)
6. Collateral History and Family History
- Witnesses to mechanism and timing of injury; any LOC at scene
- Pre-injury GCS and neurological baseline
- Medication list — especially anticoagulants, antiplatelets
- Alcohol/substance use at time of injury
- Family history: Bleeding disorders (hemophilia, von Willebrand disease)
- Social context: Non-accidental trauma (especially in pediatric patients — must be considered)
7. Risk Factors
- Temporal bone fracture crossing the middle meningeal artery — most important risk factor [9]
- Young adults and children (dura less adherent to skull)
- Male sex (~76% of cases) [10]
- Motor vehicle accidents, falls, assaults, contact sports
- Anticoagulant/antiplatelet use [7]
- Coagulopathy (congenital or acquired)
- Prior craniotomy or neurosurgical procedures
- In children: skull fracture absent in up to 23% of cases [11]
8. Differential Diagnosis
- Acute subdural hematoma (SDH): Crescent-shaped, crosses sutures; bridging vein injury; more common in elderly/anticoagulated patients
- Subarachnoid hemorrhage (SAH): Blood in cisterns/sulci; thunderclap headache
- Intraparenchymal hemorrhage/contusion: Within brain parenchyma; coup-contrecoup pattern
- Tension pneumocephalus: Air under pressure intracranially post-trauma
- Cerebral venous sinus thrombosis: Can mimic with headache and focal deficits
- Meningitis/encephalitis: If fever and altered mental status present
- Post-concussion syndrome: Persistent headache after minor trauma without hematoma (subacute EDH can be misdiagnosed as this) [12]
9. Past Medical History
- Prior head trauma or neurosurgery
- Bleeding disorders or liver disease
- Current anticoagulation therapy
- History of seizures
- Chronic alcohol use (coagulopathy, falls)
- Previous episodes of intracranial hemorrhage
10. Physical Exam
- Vitals: Cushing response (hypertension + bradycardia + irregular respirations) = late, ominous sign
- Head: Scalp laceration, hematoma, palpable skull fracture (especially temporal), Battle sign, raccoon eyes
- Neuro:
- GCS assessment (serial)
- Pupil exam: Ipsilateral fixed dilated pupil (CN III compression from uncal herniation)
- Contralateral hemiparesis (or ipsilateral — Kernohan notch phenomenon)
- Plantar responses, deep tendon reflexes
- Fundoscopy: Papilledema (23% in one pediatric series) [11]
- C-spine: Assess for concomitant cervical spine injury
11. Lab Studies
- CBC: Baseline hemoglobin/hematocrit, platelet count
- Coagulation panel: PT/INR, aPTT, fibrinogen — critical if on anticoagulants
- Type and screen/crossmatch: Anticipate surgical need
- BMP: Electrolytes, glucose, renal function
- Blood alcohol level and urine toxicology: Altered mental status workup
- Troponin: If ECG abnormalities present (neurogenic cardiac injury) [13]
- TEG/ROTEM: If available, for rapid coagulopathy assessment in trauma
12. Imaging
- Non-contrast CT head — first-line, gold standard for acute diagnosis
- Classic finding: Biconvex (lenticular) hyperdense extra-axial collection that does not cross suture lines [5]
- Assess for midline shift, associated fractures, concomitant intracranial lesions
- "Swirl sign" or mixed attenuation within the hematoma suggests active bleeding [14-15]
- Lucent areas within the EDH are ominous, suggesting ongoing hemorrhage [14]
- Repeat CT: At 6–13 hours to detect enlargement (28% of EDHs enlarge on follow-up); EDH reaches ~98% of final size by 5–6 hours post-injury [15-16]
- CT angiography: If vascular injury suspected
- MRI: Not first-line acutely; useful for subacute/chronic EDH or to evaluate associated parenchymal injury
- Imaging is always indicated after significant head trauma with any neurological symptoms
13. Special Tests
- Glasgow Coma Scale (GCS): Serial assessments are essential for monitoring; decline triggers urgent re-imaging and surgical consultation [6]
- Marshall CT Classification: Grades severity of TBI based on CT findings
- Rotterdam CT Score: Predicts outcome in TBI
- Canadian CT Head Rule / New Orleans Criteria: Decision tools for when to obtain CT in minor head injury
- Point-of-care ultrasound: Optic nerve sheath diameter >5 mm suggests elevated ICP
14. ECG
- ECG abnormalities are common in severe TBI (incidence up to 88%) and include: [17-18]
- ST-segment depression (most clinically significant; independently associated with 48-hour mortality in TBI)
- QTc prolongation (independently associated with 48-hour mortality)
- T-wave inversions, "cerebral T waves"
- Sinus tachycardia or bradycardia
- Supraventricular arrhythmias
- These changes are typically neurogenic (sympathetic surge) and peak at ~24 hours [13]
- Obtain ECG in all severe TBI patients; continuous cardiac monitoring recommended
- Must exclude primary cardiac pathology, especially in older patients
15. Assessment
- EDH is a neurosurgical emergency when symptomatic or meeting surgical criteria
- Severity stratification based on:
- GCS score (comatose <9 vs. non-comatose)
- Hematoma volume (<30 cm³ vs. ≥30 cm³)
- Thickness (<15 mm vs. ≥15 mm)
- Midline shift (<5 mm vs. ≥5 mm)
- Presence of anisocoria [6]
- 71% of EDH patients have concomitant subdural hematomas and/or intraparenchymal hemorrhages — isolated EDH is relatively infrequent [10]
- Typical presentation: Young male after temporal trauma with skull fracture
- Atypical: Posterior fossa EDH (lower threshold for surgery), vertex EDH (high rate of delayed deterioration — 57% eventually require surgery), pediatric EDH without fracture [19]
16. Treatment Plan
Initial stabilization
- ABCs, cervical spine immobilization
- Intubation if GCS ≤8
- Maintain SBP >100 mmHg; avoid hypotension (associated with increased mortality)
- Reverse coagulopathy immediately if present
- Elevate head of bed 30°; avoid jugular venous compression
- Hyperosmolar therapy (mannitol 1 g/kg or hypertonic saline 3%) for signs of herniation as a temporizing bridge to OR
Surgical indications (Brain Trauma Foundation guidelines): [6][20]
- EDH >30 cm³ → surgical evacuation regardless of GCS
- Comatose patient (GCS <9) with anisocoria → emergent craniotomy as soon as possible
- Even with high GCS, evacuate large (>25 mL) hematomas before neurological deterioration [20]
- Craniotomy is preferred over burr holes for more complete evacuation [6]
Conservative management criteria: [6]
- EDH <30 cm³, thickness <15 mm, midline shift <5 mm
- GCS >8 with no focal neurological deficit
- Requires serial CT scanning and close neurological observation in a neurosurgical center
- ~11% of conservatively managed patients require delayed surgery [21]
17. Disposition
- Admission to neurosurgical ICU: All patients with EDH requiring surgery, GCS ≤8, or neurological deficits
- Admission with neuro-checks and serial CT: All conservatively managed EDH patients — must be at a facility with neurosurgical capability [6]
- Transfer: If presenting to a facility without neurosurgery, arrange emergent transfer; do not delay for repeat imaging if initial CT is diagnostic
- Observation: Minimum 24–48 hours for small EDH meeting conservative criteria; repeat CT at 6–8 hours and again at 24 hours [15-16]
- Neurosurgery consultation: All EDH patients, regardless of size
- Posterior fossa EDH: Lower threshold for surgical intervention due to risk of rapid brainstem compression [20]
18. Follow Up / Return Precautions
- Discharged patients (rare — only after prolonged observation of very small, stable EDH):
- Return immediately for worsening headache, vomiting, confusion, weakness, vision changes, seizures, or any decline in alertness
- Follow-up CT in 1–2 weeks
- Neurosurgery follow-up within 1–2 weeks
- No driving, contact sports, or alcohol until cleared
- Expected recovery: With timely surgery, 74% achieve favorable outcomes (GOS-E ≥5 at 6 months); mortality ~11% overall. Mortality is virtually restricted to patients who undergo surgery while comatose [10][22]
- Counsel on post-concussive symptoms (headache, cognitive difficulties, fatigue) which may persist weeks to months
- Pediatric patients generally have better outcomes — lower rebleeding and mortality rates than adults [21]
References
1. Traumatic Acute Extradural Haematoma - Indications for Surgery Revisited. — Soon WC, Marcus H, Wilson M. British Journal of Neurosurgery. 2016.
2. Management of Traumatic Epidural Hematoma in Infants Younger Than One Year: 50 Cases - Single Center Experience. — Baş NS, Karacan M, Doruk E, Karagoz Guzey F. Pediatric Neurosurgery. 2021.
3. Epidural Hematoma Revealed by Exophthalmia, Two Cases Reports. — Bahloul K, Xhumari A. Clinical Neurology and Neurosurgery. 2009.
4. The Lucid Interval Associated With Epidural Bleeding: Evolving Understanding. — Ganz JC. Journal of Neurosurgery. 2013.
5. Imaging of Intracranial Haemorrhage. — Kidwell CS, Wintermark M. The Lancet. Neurology. 2008.
6. Surgical Management of Acute Epidural Hematomas. — Bullock MR, Chesnut R, Ghajar J, et al. Neurosurgery. 2006.
7. Pharmacovigilance Study of Spinal Epidural Hematoma Reports Associated With Direct Oral Anticoagulants and Warfarin. — Porwal M, Stegamat N, Reddy V, et al. Acta Neurochirurgica. 2026.
8. Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy: American Society of Regional Anesthesia and Pain Medicine Evidence-Based Guidelines (Fifth Edition). — Kopp SL, Vandermeulen E, McBane RD, et al. Regional Anesthesia and Pain Medicine. 2025.
9. The Management of "Asymptomatic" Epidural Hematomas. A Prospective Study. — Knuckey NW, Gelbard S, Epstein MH. Journal of Neurosurgery. 1989.
10. Clinical and Imaging Characteristics, Care Pathways, and Outcomes of Traumatic Epidural Hematomas: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Study. — Pisică D, Volovici V, Yue JK, et al. Neurosurgery. 2024.
11. Extradural Haematoma in Children. Primary and Secondary Lucid Intervals. — Oatey PE, Dinning TA, Simpson DA. The Medical Journal of Australia. 1983.
12. Epidural Hematoma: Report of Seven Cases With Delayed Evolution of Symptoms. — Benoit BG, Russell NA, Richard MT, et al. The Canadian Journal of Neurological Sciences. Le Journal Canadien Des Sciences Neurologiques. 1982.
13. The Heart-Brain-Metabolism Axis in Cardiovascular and Neurologic Disease. — Tardo DT, Cortes-Canteli M, Fuster V, Sachdev PS, Kovacic JC. Journal of the American College of Cardiology. 2025.
14. Nonoperative Management of Acute Epidural Hematoma Diagnosed by CT: The Neuroradiologist's Role. — Hamilton M, Wallace C. AJNR. American Journal of Neuroradiology. 1992.
15. Risk Factors for Epidural Hematoma Expansion and the Need for Surgery. — Radmard M, Miller L, Tafazolimoghadam A, et al. AJNR. American Journal of Neuroradiology. 2025.
16. Could a Traumatic Epidural Hematoma on Early Computed Tomography Tell Us About Its Future Development? A Multi-Center Retrospective Study in China. — Xiao B, Ma MY, Duan ZX, et al. Journal of Neurotrauma. 2015.
17. The Association of Early Electrocardiographic Abnormalities With Brain Injury Severity and Outcome in Severe Traumatic Brain Injury. — Lenstra JJ, Kuznecova-Keppel Hesselink L, la Bastide-van Gemert S, et al. Frontiers in Neurology. 2021.
18. Role of Electrocardiogram Findings in Predicting 48-H Mortality in Patients With Traumatic Brain Injury. — Lee JH, Lee DH, Lee BK, et al. BMC Neurology. 2022.
19. Clinical Features and Treatment Strategies for Vertex Epidural Hematoma: A Systematic Review and Meta-Analysis From Individual Participant Data. — Kim JH, Yoon WK, Kwon TH, Kim JH. Neurosurgical Review. 2022.
20. Best Practices In The Management Of Traumatic Brain Injury. — Geoffrey T. Manley MD PhD, Gregory W. Albert MD MPH FAANS FACS FAAP, Gretchen M. Brophy PharmD BCPS FCCP FCCM FNCS MCCM, et al American College of Surgeons (2024). 2024.
21. Management of Epidural Hematomas in Pediatric and Adult Population: A Hospital-Based Retrospective Study. — Gok H, Celik SE, Yangi K, et al. World Neurosurgery. 2023.
22. Acute Epidural Hematoma: An Analysis of Factors Influencing the Outcome of Patients Undergoing Surgery in Coma. — Lobato RD, Rivas JJ, Cordobes F, et al. Journal of Neurosurgery. 1988.