Acute Epidural Hematoma · Surgical Evacuation vs Observation

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Hematoma volume + thickness/midline + GCS/pupils
   Hematoma volume? Thickness and midline shift? GCS and pupils/focal signs?
   • >30 cm3 (any GCS) → >30 cm3 → emergency craniotomy evacuation
   • GCS <9 coma + anisocoria → Coma + anisocoria → immediate evacuation
   • <30 cm3 and <15 mm and midline <5 mm and GCS >8 and no focal deficit → Small and stable → close observation
   • Between thresholds / progressive worsening → Between thresholds/worsening → favor surgery
2. [End] >30 cm3 → emergency craniotomy evacuation
   >30 cm3 → emergency surgical evacuation regardless of GCS; craniotomy preferred (more complete than burr-hole evacuation), evacuate the clot + hemostasis (the source is often the middle meningeal artery, a venous sinus, or diploic bone).
3. [End] Coma + anisocoria → immediate evacuation
   Coma (GCS <9) + anisocoria → strongly recommend emergency evacuation as soon as possible. Time from neurological deterioration (coma/pupillary change/worsening) to surgery matters more than time from injury to surgery.
4. [End] Small and stable → close observation
   <30 cm3 and <15 mm and midline <5 mm and GCS >8 and no focal deficit → close observation at a neurosurgical center + serial CT + neuromonitoring; short-interval repeat after the first CT (mixed density suggests active bleeding, watch for expansion).
5. [End] Between thresholds/worsening → favor surgery
   Between thresholds or progressively worsening → favor surgery, individualized (age, location such as temporal/posterior fossa being higher risk, coagulation status, follow-up access); proceed to surgery once it deteriorates.

Source guidelines & references

• Surgical management of traumatic epidural hematoma (Brain Trauma Foundation surgical TBI guideline; Bullock 2006)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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