Acute Epidural Hematoma - Surgical Decision (BTF Guidelines)

Algorithm Steps

1. ▶

   Start

   Acute Epidural Hematoma (EDH) Identified

   CT showing biconvex extra-axial collection, typically temporal/parietal location

   1. ◆

      Decision

      EDH Volume >30 cm³?

      Measure hematoma volume on CT (ABC/2 method)

      • Volume = (A × B × C) / 2
      • A = largest diameter on axial CT
      • B = perpendicular diameter
      • C = number of slices × slice thickness
      1. ●

         Action

         SURGICAL EVACUATION

         EDH >30cm³ requires surgery regardless of GCS (BTF Level II)

         • Craniotomy preferred over burr hole
         • Allows complete hematoma evacuation
         • Identify and control bleeding source
         • Consider middle meningeal artery ligation
         1. ◆

            Decision

            GCS <9 with Anisocoria?

            Comatose patient with pupillary asymmetry

            • Anisocoria suggests uncal herniation
            • Time-critical emergency
            • May have lucid interval history
            1. ⚠

               Warning

               ⚠️ EMERGENT SURGERY - AS SOON AS POSSIBLE

               Comatose + anisocoria = impending herniation (BTF Level III)

               • Do NOT delay for additional imaging
               • Operating room immediately
               • Consider mannitol/hypertonic saline en route
               • Alert anesthesia and OR staff
            2. ●

               Action

               SURGICAL EVACUATION

               Significant mass effect requires surgery

               • Thickness >15mm = significant compression
               • MLS >5mm = risk of herniation
               • Proceed to craniotomy
      2. ◆

         Decision

         Thickness >15mm OR Midline Shift >5mm?

         Measure maximum thickness and midline shift on CT

         1. ◆

            Decision

            GCS >8 AND No Focal Deficit?

            Assess neurological status

            • GCS must be >8 (not comatose)
            • No pupillary abnormalities
            • No motor deficits
            • Alert and oriented preferred
            1. ●

               Action

               NON-OPERATIVE MANAGEMENT

               Small EDH meeting all criteria (BTF Level III)

               • EDH <30cm³
               • Thickness <15mm
               • MLS <5mm
               • GCS >8
               • No focal neurological deficit
               1. ●

                  Action

                  Serial CT and Neuro Monitoring

                  Close observation in neurosurgical center

                  • Repeat CT at 6-8 hours
                  • Neurological checks q1h
                  • ICU admission preferred
                  • Low threshold for repeat imaging if change
                  1. ◆

                     Decision

                     Clinical Deterioration OR CT Progression?

                     GCS drop ≥2, new focal deficit, or hematoma expansion

                     1. ●

                        Action

                        PROCEED TO SURGERY

                        Failed non-operative management

                     2. ✓

                        Outcome

                        Continue Observation → Resolution

                        EDH resolves with conservative management

            2. ●

               Action

               SURGICAL EVACUATION

               Focal deficit or depressed consciousness requires surgery