Acute traumatic epidural haematoma (EDH) on CT: adult
Biconvex extra-axial clot on CT, often temporal or parietal. For supratentorial EDH in adults.
All Pathways
NeurosurgeryManagement
Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines)
Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines): Acute traumatic epidural haematoma (EDH) on CT: adult → Children or posteri...
Pathway Overview
19 steps
Algorithm Steps
19 total
01Start 02Warning Children or posterior fossa EDH: this pathway does not apply
Get urgent specialist neurosurgical advice (paediatric neurosurgery for children).
- The size thresholds below come from adult supratentorial EDH series
- Posterior fossa EDH can deteriorate fast: discuss with neurosurgery at once
03Warning Resuscitate and call neurosurgery now
No on-site neurosurgery: call the neurosurgical centre and retrieval service at once for urgent transfer. Adult within 3 h of injury: tranexamic acid 1 g IV over 10 min, then 1 g IV over 8 h (not after 3 h).
- Primary survey; prevent hypoxia and hypotension
- Do not delay transfer for more imaging
- Transfer too slow and signs of herniation: emergency decompression by a local surgeon only on direct neurosurgical advice
04Warning On an anticoagulant or antiplatelet, or coagulopathic? Reverse now
For every EDH, before observation or surgery. Check INR, APTT, platelets, fibrinogen. Do not delay emergency surgery for results. Antiplatelets: no routine platelet transfusion; discuss platelets with neurosurgery and haematology before surgery. Heparin, LMWH or other agents: get haematology advice.
- Warfarin, INR 1.5 or more (adult): vitamin K 5-10 mg IV + 4-factor PCC (Beriplex) 50 IU/kg (weight up to 100 kg; max 5000 IU); consider a lower PCC dose if INR 1.5-1.9
- Dabigatran (adult): idarucizumab 5 g IV (2 x 2.5 g/50 mL vials)
- Apixaban, rivaroxaban or edoxaban: 4-factor PCC (off-label); dose per local haematology protocol (andexanet alfa is not on the ARTG)
05Decision GCS <9 with anisocoria?
Coma with unequal pupils means brain herniation. Check this first, whatever the EDH size.
- If Yes
06Warning Coma + anisocoria: evacuate the EDH as soon as possible
Every hour of delay worsens outcome. Craniotomy is preferred.
- Go straight to theatre; do not delay for more imaging
- While theatre is prepared: osmotherapy (mannitol or hypertonic saline) on neurosurgical or ICU advice; avoid hypotension
- No on-site neurosurgery: see transfer step above
07Action After evacuation: neurosurgical or ICU care
Postoperative care per neurosurgeon.
- Neuro observations; urgent CT for any deterioration
- Restart of anticoagulants or antiplatelets: neurosurgery and haematology decide timing
08Outcome Post-evacuation: recovery and follow-up per neurosurgery
Plan rehabilitation needs and follow-up.
If No09Decision EDH volume 30 cm³ or more?
No coma with anisocoria. Estimate volume on CT with ABC/2: A = largest diameter, B = diameter at 90 degrees to A, C = number of slices with clot x slice thickness (all in cm).
- If Yes
- Yes (30 cm³ or more)
10Action EDH 30 cm³ or more: surgical evacuation, regardless of GCS
Urgent neurosurgery.
- Craniotomy gives more complete evacuation than burr holes
- Find and control the bleeding source (often the middle meningeal artery)
- Path rejoins step 07Shared downstream outcome
If No- No (under 30 cm³)
11Decision EDH under 30 cm³: thickness ≥15 mm or midline shift ≥5 mm?
Measure maximum clot thickness and midline shift on CT.
- If Yes
12Action Thickness ≥15 mm or shift ≥5 mm: consider surgery
Surgery should be considered; the neurosurgeon decides. Non-operative care only in selected cases, in a neurosurgical centre, with the serial CT and neuro observations below.
- Temporal EDH: lower threshold for surgery (higher failure of non-operative care)
- Path rejoins step 07Shared downstream outcome
If No13Decision Small EDH: GCS >8 and no focal deficit?
Focal deficit includes a pupil abnormality or limb weakness.
- If Yes
14Action All criteria met: non-operative care in a neurosurgical centre
Only if all apply: isolated EDH (no other lesion that needs surgery), volume under 30 cm³, thickness <15 mm, midline shift <5 mm, GCS >8, no focal deficit, and antithrombotic effect reversed.
- Temporal EDH fails non-operative care more often: lower threshold for surgery
15Action Non-operative: serial CT and close neuro observation
In a neurosurgical centre.
- First repeat CT within 6-8 hours of injury
- Higher risk of growth: first CT within 6 h of injury, or fracture across a major vessel: closer watch
- Frequent neuro observations: GCS, pupils, limb power
- Urgent repeat CT for any deterioration
16Decision Neuro deterioration or larger EDH on CT?
Any fall in GCS, new pupil change, new focal deficit, or clot growth.
- If Yes
17Action Deteriorated or EDH larger: urgent surgical evacuation
Failed non-operative care.
- Path rejoins step 07Shared downstream outcome
If No18Outcome Stable neuro exam and stable EDH: continue observation
Neurosurgeon plans further imaging and follow-up.
If No19Action GCS ≤8 or focal deficit: consider surgery
Surgery should be considered; the neurosurgeon decides. Non-operative care only in selected cases, in a neurosurgical centre, with close observation. If a small EDH does not explain the coma or deficit, look for other lesions.
- Temporal EDH: lower threshold for surgery
- GCS ≤8: severe TBI care in ICU per neurosurgery
- Path rejoins step 07Shared downstream outcome
Guideline Source
Bullock MR et al. Surgical Management of Acute Epidural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S2-7-S2-15
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- All recommendations are option level (Class III evidence only); surgery for EDH that does not meet non-operative criteria is a neurosurgical judgement
- Adults with supratentorial EDH only; not for children or posterior fossa EDH
- Antithrombotic reversal doses are adult doses; follow local haematology protocol for factor Xa inhibitors
- ABC/2 volume estimate is approximate and depends on slice thickness
- Does not replace neurosurgical consultation
Contraindicated Populations
children (paediatric EDH)posterior fossa EDH
Applicable Regions
AUUSEUGlobal
AU: Hospitals without neurosurgery: call the regional neurosurgical centre and the state retrieval service early. 4-factor PCC (Beriplex AU) is on the ARTG; andexanet alfa is not.
EU: Reversal steps follow the European trauma bleeding guideline (6th edition, 2023).
US: Based on BTF 2006 surgical guidelines (current BTF surgical recommendations).
Version 2Next review: 2027-09-30
Next steps
Finish the workflow by opening the most relevant calculator, then convert the session into a live account when you are ready.
Related Resources
Frequently Asked Questions
What is the Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines)?
The Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines) is a management clinical algorithm for Neurosurgery. It provides a structured decision tree to guide clinical decision-making, based on Bullock MR et al. Surgical Management of Acute Epidural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S2-7-S2-15.
What guideline is the Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines) based on?
This algorithm is based on Bullock MR et al. Surgical Management of Acute Epidural Hematomas. Guidelines for the Surgical Management of Traumatic Brain Injury (Brain Trauma Foundation). Neurosurgery 2006;58(3 Suppl):S2-7-S2-15 (DOI: 10.1227/01.NEU.0000210363.91172.A8).
What are the limitations of the Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines)?
Known limitations include: All recommendations are option level (Class III evidence only); surgery for EDH that does not meet non-operative criteria is a neurosurgical judgement; Adults with supratentorial EDH only; not for children or posterior fossa EDH; Antithrombotic reversal doses are adult doses; follow local haematology protocol for factor Xa inhibitors; ABC/2 volume estimate is approximate and depends on slice thickness; Does not replace neurosurgical consultation. Individual patient factors may require deviation from these recommendations.
Get AI-Powered Analysis Alongside This Algorithm
In AttendMe.ai, the Acute Epidural Haematoma - Surgical Decision (BTF 2006 Surgical Guidelines) appears automatically when your clinical question matches — alongside evidence from 3M+ peer-reviewed articles.
Try AttendMe Free