Epidural Hematoma Management

Glen Sandi Saapang

SUB DEPARTEMENT BEDAH SARAF FK UNUD/RSUP
SANGLAH
 Introduction

• Acute epidural hematoma (EDH) common secondary insult

requiring neurosurgical intervention following traumatic
brain injury (TBI).

• Incidence of around 8% and an overall mortality of 10%

• The rapid hematoma expansion and significantly increased

intracranial pressure may lead to brain herniation and
midbrain damage, or even death due to respiratory arrest.
The middle meningeal artery (MMA) is the most common
• Early diagnosis and timely neurosurgical intervention may source of bleeding in patients with EDH.

effectively reduce EDH-related disability and mortality

 Definition
• Epidural hematoma (EDH) is
an extra-axial collection of
blood within the potential
space between the outer
layer of the dura mater and
the internal tabula of the
skull.

This bleeding is limited by the lateral sutures

(especially the coronary sutures) through which the
dura enters.
Anatomy
 Epidemiology
• Incidence of epidural hematoma (EDH): 1% of head trauma admissions (which is ≈
50% the incidence of acute subdurals)

• Ratio of male:female = 4:1

• Usually occurs in young adults, and is rare age < 2 yrs or > 60 yrs (perhaps because
the dura is more adherent to the inner table in these groups).

• EDHs with a clear prevalence of motor vehicle accidents (MVA), showed

overlapping percentages of falls and MVAs
Presentation
• Classic presentation:
• Brief posttraumatic LOC : from initial impact
• Followed by lucid interval for several hours
• Contralateral hemipharesis, ipsilateral pupillary dilatation as result of mass effect from hematoma

• Deterioration occurs over few hours, days and rarely, weeks (associated with the venous bleeding)
• Other presenting:
• Hedache
• Vomiting
• Seizure
• Hemi-hyperreflexia + unilateral babinski sign.
• Bradycardia is usually late finding
• In ped; 10% drop in hematocrit after admission = susp EDH
Surgical Indication
• EDH Surgical Indications :

 GCS score ≤ 8 and anisocoria → operating room as soon as

possible
 Hematoma volume ≥ 30 cm
 Hematoma volume ≤ 30 cm3 but accompanied by :
• - Thickness ≥ 15 mm
• - Midline shift ≥ 5 mm
• - GCS ≤ 8
• - Focal motor deficit
 Effaced cisterns
 Deteriorating neurologic status
 PRE – PROCEDURE CONSIDERATION

 Radiographic Imaging
Preoperative imaging; CT is essential to evaluate :
- The presence and size the extra-axial hematomas
- Degree of midline shift
- Appearance of perimesencephalic cisterns
- Presence of other space – occupying lesion
 Medication  preoperative antibiotic, seizure prophylaxis, FFP/blood products
 Operative Field Preparation
- Positioning
- Washing  savlon (desinfectan)
- Markering  hairline, sinus, suture, zygoma
- Desinfective  betadine, adrenalin 1 : 200.000 with lidocaine 0.5%, doek sterile
 SURGICAL PROCEDURES
The head is turned so as
to expose the operative
hemicranium
SURGICAL PROCEDURES
Bur Holes
 SURGICAL PROCEDURES
Skin incision Subcutaneous dissection
 SURGICAL PROCEDURES
Craniotomy

Evacuation of EPIDURAL HEMATOM

 SURGICAL PROCEDURES
EPIDURAL HEMATOM
A large frontotemporoparietal craniotomy provides the best access for surgical management
 improved preoperative localization by CT and earlier detection of smaller EDHs  more
targeted craniotomy through a limited “slash” incision for evacuation of EDHs

After skin incision and muscle-splitting exposure, the periosteum is stripped to expose the
cranium fully in the region of the hematoma 

Correct placement of the craniotomy is crucial to occlude the epidural space optimally and
to visualize the bleeding points on the dura, usually the middle meningeal artery  be
controlled with bipolar cautery 
SURGICAL PROCEDURES
Dural tenting
 SURGICAL PROCEDURES
BONE FLAP
• A large 12 × 15-cm FTP bone flap is planned to achieve wide exposure and adequate
decompression
• Bur holes are placed at the keyhole in the frontal bone behind the zygomatic arch,
adjacent to the root of the zygoma and over the parietal bone at the most posterior extent
of the planned bone flap 
• The keyhole approximates the floor of the anterior fossa, and the root of the zygoma
approximates the floor of the middle fossa.
• The bur holes are connected epidurally and the bone flap is elevated.
 SURGICAL PROCEDURES
Bone Flap Replacement Drain Placement
 POST OPERATIVE MANAGEMENT

 Monitoring
- Recovery room, progressive care unit, ICU
- Drains output ever 4 hours for the first 8hours  8 hours shift
- The incision / dressing : bleeding, erythema, exudate, edema post operative
 Medication
 Radiologic Imaging (post operative imaging)
 Further Management
- Drains are removed on the first postoperative day, provided input has slowed suciently. If there is
significant output, removal maybe delayed another 1 to 2 days.
- The dressing is removed and the wound is cleansed with warm water and mild soap or shampoo
after 24 hours.
- Skin sutures or staples are removed on or about post operative day 10 to 14.
Complications

INTRAOPERATIVE : POSTOPERATIVE :
1. Cerebral swelling 1. New hemorrhage
2. Herniation of the brain tissue 2. New or expanded hemorrhagic
above craniotomy opening contusions
3. Hemorrhage 3. Wound infection
4. Coagulopathy 4. Subgaleal hygromas  CSF leaks
5. Hemodilution from resuscitation & 5. Wound dehiscence
transfusion 6. Posttraumatic hydrocephalus
7. Ventriculomegaly
 CONCLUSION

Traumatic brain injury is a heterogeneous disease that requires

multidisciplinary approach for optimal management. Multimodality physiologic
monitoring and neuromonitoring are used to guide protocol-driven therapies to
optimize cerebral perfusion and oxygenation in order to prevent secondary
injuries. Surgical decompression and evacuation of traumatic mass lesions can
alleviate mechanical compression of brain tissue, decrease the neurotoxic effect
of extravasated blood, and reduce ICP.
THANK YOU