Epidural Hematoma

An epidural hematoma is blood collecting between the skull and the outermost layer of the brain's covering (the dura). It is almost always caused by a skull fracture that tears the middle meningeal artery — and it is one of the most time-critical neurosurgical emergencies, because the classic patient has a lucid interval before rapidly deteriorating.

What Is Epidural Hematoma?

An epidural hematoma (EDH) is an arterial bleed between the skull and dura, almost always from rupture of the middle meningeal artery following a temporal bone fracture. Unlike subdural hematomas, EDHs are not associated with underlying brain injury — the clot is outside the dura, and the underlying brain is often intact.

The classic presentation is the 'talk and die' patient: a brief period of unconsciousness at impact, a lucid interval of minutes to hours, then rapid deterioration as the hematoma expands. Immediate craniotomy for a large EDH is one of the most rewarding emergency operations in neurosurgery — properly managed, most patients recover completely.

At a Glance

Epidural hematoma is arterial bleeding between skull and dura — almost always from a middle meningeal artery tear after temporal bone fracture
Classic history: brief LOC → lucid interval → rapid deterioration (the 'talk and die' patient)
Diagnosed with CT scan; lens-shaped (biconvex) blood collection on the temporal side
Large EDHs (>30 mL, >15 mm thick, >5 mm shift) require emergency craniotomy
Prognosis is excellent when operated before pupil dilation — mortality <5% in good-grade patients

Symptoms

Brief loss of consciousness at the time of impact
Lucid interval (minutes to hours) during which the patient seems fine or complains only of headache
Rapid deterioration: increasing headache, agitation, drowsiness
One pupil becoming larger (blown pupil) on the side of the hematoma — a neurosurgical emergency
Contralateral hemiparesis
Without treatment: deterioration to coma and death

Diagnosis

Types

Emergency craniotomy: for large EDH with any neurologic deficit
A temporal craniotomy with opening of the dura is performed within minutes to 1-2 hours. The hematoma is evacuated and the bleeding artery is coagulated. Bone is replaced. The Seelig rule applies here too: every hour counts.

Surgical criteria (current guidelines)

EDH volume >30 mL — operative regardless of GCS
EDH >15 mm thick or >5 mm midline shift — operative in any patient
Acute EDH with GCS drop ≥2 points from presentation — operative

Observation with serial CT
For small (<30 mL), thin (<15 mm), no significant midline shift, and neurologically intact patient — careful neuro-ICU observation with repeat CT in 4-6 hours is safe. Risk of expansion in first 24 hours.

Treatment

Emergency craniotomy — for large EDH with any neurologic deficit
A temporal craniotomy with opening of the dura is performed within minutes to 1-2 hours. The hematoma is evacuated and the bleeding artery is coagulated. Bone is replaced. The Seelig rule applies here too: every hour counts.

Surgical criteria (current guidelines)

EDH volume >30 mL — operative regardless of GCS
EDH >15 mm thick or >5 mm midline shift — operative in any patient
Acute EDH with GCS drop ≥2 points from presentation — operative

Outcomes

Grade at surgery	Mortality	Good outcome (GOS 4-5)	Notes
Alert / GCS 13-15	<5%	>90%	Excellent; most return to normal
Obtunded / GCS 9-12	~5-10%	~75-85%	Good outcomes when operated early
Coma, no herniation / GCS 6-8	~15-25%	~60-70%	Outcome depends heavily on speed
Fixed dilated pupil(s) / GCS 3-5	~30-50%	~30-40%	Herniation already starting — every minute matters

Mortality after EDH in modern series is <10% overall when surgically treated — far lower than acute SDH, because underlying brain injury is usually absent.

References

Our Specialists

Paramita Das, MD, MS

Neurosurgery

P.B. Raksin, MD

Neurosurgery

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