Epidural Hematoma (EDH)

Our Specialists for Epidural Hematoma (EDH)

Epidural hematomas are managed around the clock at UChicago Medicine's Level 1 trauma center. The surgeons below lead the neurosurgical trauma service and are on call 24/7 for patients arriving through our emergency department or transferred from outside hospitals.

Paramita Das, M.D., M.S.

Director, Neurotrauma; Director, Neurosurgical Trauma Fellowship

Dr. Das is Director of Neurotrauma at UChicago's Level 1 Trauma Center and directs the Neurosurgical Trauma Fellowship, one of only a few dedicated neurosurgical trauma fellowships in the country. She manages both head trauma and acute spine pathology and has been named to the Bucksbaum-Siegler Institute for Clinical Excellence. She trained at the University of Minnesota for residency and completed a skull base fellowship at Cleveland Clinic. Dr. Das is the Director of Surgical Neurotrauma at UChicago Medicine, meaning she runs the service that takes in every traumatic epidural hematoma transferred to our Level 1 trauma center; her research focuses on how quickly neurosurgical intervention changes outcomes in severe traumatic brain injury (Neurosurgery, 2024). If you have an epidural hematoma and you arrive at UChicago, there is a strong chance she or one of her trauma fellows is in the operating room within minutes.

P. B. Raksin, M.D.

Associate Program Director, Neurological Surgery Residency

Dr. Raksin is an Associate Professor of Neurological Surgery and serves as Associate Program Director of the UChicago Neurological Surgery residency program. She is a senior clinician within the department and contributes broadly to resident education and general neurosurgical care. Dr. Raksin has spent her career at the intersection of neurotrauma and critical care, and is a co-author on the most recent review of neurocritical care in trauma published in Neurosurgical Clinics of North America. For epidural hematomas, her experience spans the full spectrum from immediate operative evacuation to the ICU management that determines whether a comatose patient walks out of the hospital.

What Is an Epidural Hematoma?

An epidural hematoma — sometimes called an extradural hematoma or EDH — is a pocket of blood that forms between the inside of your skull and the dura mater, the thick fibrous membrane that wraps around the brain. The dura is normally stuck tight to the inner surface of the skull. When an artery between the two tears, blood is pumped under pressure into that tight space, gradually peeling the dura off the bone and pushing on the brain underneath.

The bleeding vessel is almost always the middle meningeal artery, a thin artery that runs in a groove on the inside of the temporal bone (the bone above your ear). A blow to the side of the head — from a fall, a sports injury, an assault, or a motor vehicle crash — can fracture the temporal bone and lacerate the artery as it runs underneath. Less commonly, epidural bleeding comes from a torn dural vein or a fractured venous sinus.

Epidural hematomas account for roughly 1-4% of all head injuries and show up on the first CT scan in about 10% of patients hospitalized with traumatic brain injury. They are most common in adolescents and young adults, and about three out of four patients are male. Unlike acute subdural hematomas — which happen when the brain itself is badly bruised — an epidural hematoma is often a purely extra-axial problem. The brain underneath is frequently uninjured, which is a big part of why the outcomes with prompt surgery are so good.

What Does It Feel Like?

The classic presentation of an epidural hematoma is one of the most famous patterns in neurosurgery: a patient takes a blow to the head, briefly loses consciousness, wakes up and seems mostly normal for minutes to a few hours, and then rapidly deteriorates. That deceptively normal period in the middle is called the lucid interval, and it happens in an estimated 20-50% of patients with EDH. The lucid interval is dangerous precisely because the patient can look deceptively okay while the hematoma is silently expanding.

Early warning signs after a head injury

• A brief loss of consciousness at the time of impact, followed by recovery
• Severe and worsening headache — often focused on the side that was hit
• Nausea and vomiting
• Confusion, drowsiness, or difficulty staying awake
• Bruising or swelling over the temple or side of the head
• A scalp laceration over the temporal bone

Signs of rapid deterioration (call 911 immediately)

• A patient who was initially awake becomes very drowsy or unresponsive
• One pupil (usually on the same side as the bleed) becomes large and stops reacting to light
• Weakness or paralysis on the opposite side of the body
• Slurred speech or sudden difficulty speaking
• Seizures
• Slow heart rate, rising blood pressure, and irregular breathing — a late and ominous pattern called Cushing's triad

If you witness any of these signs after a head injury — even a seemingly minor one — treat it as a true emergency. An epidural hematoma can go from walking-and-talking to life-threatening in under an hour.

How Is It Diagnosed?

The diagnosis is made almost instantly by a non-contrast CT scan of the head, which is the first imaging test any patient with a significant head injury will get in the emergency room. On CT, an epidural hematoma has a very characteristic appearance.

The CT picture

An epidural hematoma looks like a bright white, biconvex (lens-shaped or football-shaped) collection hugging the inner surface of the skull. Because the dura is firmly attached to the skull at the cranial sutures, the blood usually does not cross those sutures — this is what gives the clot its distinctive rounded, lens-like shape. That shape is the single most important feature separating an epidural from a subdural hematoma, which is thinner, more crescent-shaped, and does cross sutures.

Most epidural hematomas sit in the temporoparietal region, right where the middle meningeal artery runs. A skull fracture — usually of the temporal bone — is present in about 75% of cases and is an important clue. Your neurosurgeon will also look at the volume of the clot in milliliters, the maximum thickness in millimeters, and how much the clot is pushing the normal midline of the brain to the other side (midline shift). These three numbers drive the decision about whether to operate.

What happens next

Once an EDH is identified, the emergency physician pages the neurosurgery team immediately. Depending on the size of the clot and how the patient looks, the next step is either a direct trip to the operating room, admission to the neuro ICU with a repeat CT in a few hours, or — for small, asymptomatic clots — close observation. There is no role for MRI in the acute setting; it takes too long and adds nothing to CT for this diagnosis.

How Is It Treated?

Surgery: emergency craniotomy

For any epidural hematoma that is large or causing symptoms, the treatment is a craniotomy for hematoma evacuation. The Brain Trauma Foundation and the Congress of Neurological Surgeons guidelines recommend surgery for any of the following:

• A clot volume greater than 30 mL, regardless of the patient's Glasgow Coma Scale (GCS) score
• A clot thickness greater than 15 mm
• A midline shift greater than 5 mm
• Any patient in a coma (GCS less than 9) with a blown pupil — these patients should go to the operating room as fast as humanly possible
• Any patient whose neurologic exam is worsening, regardless of clot size

During surgery, the neurosurgeon makes a curved incision over the clot, removes a window of bone (the craniotomy), scoops out the solid clot, finds the bleeding artery, and stops it with electrocautery or clips. The dura is then tacked back up to the inner surface of the skull so that blood cannot re-accumulate in the same space. The bone is replaced and the scalp closed. In experienced hands, this is a fast operation — often under two hours from skin incision to closure — and the relief of pressure on the brain is immediate.

When observation is reasonable

A small epidural hematoma in a patient who is awake, neurologically intact, and has a clot that is less than 30 mL, less than 15 mm thick, and causing less than 5 mm of midline shift can sometimes be managed without surgery. These patients are admitted to a neurosurgical ICU, watched closely, and rescanned with a repeat CT within a few hours and again the next day. If the clot is growing or the exam is changing, the plan switches to surgery. About 10-20% of patients initially observed ultimately need an operation.

Newer endovascular options

In select cases — particularly small, slowly expanding clots — middle meningeal artery embolization performed by a neurointerventionalist can stop the bleeding by plugging the artery from inside with tiny coils or glue. This is still an evolving technique for acute EDH and is not a substitute for open surgery in a deteriorating patient, but it is a useful tool in selected stable patients.

What to expect after surgery

Most patients go to the neuro ICU after the operation for 24-48 hours of close monitoring, then to a regular neurosurgery floor. A repeat CT within 24 hours confirms the clot is gone. Pain is typically much less than patients expect — the brain itself has no pain receptors, and the scalp incision is well-controlled with standard medications. Hospital stays are usually 3-7 days for an uncomplicated case, and most patients are cleared to resume normal activities within a few weeks.

What Are the Outcomes?

This is the part of the story that distinguishes epidural hematoma from almost every other traumatic brain injury: when it is recognized early and operated on before the patient deteriorates, the outcomes are excellent. That is because, most of the time, the brain underneath an epidural clot is not itself injured — the damage comes entirely from the mass effect of the blood pressing on otherwise healthy tissue. Take the pressure off in time, and the brain recovers.

Mortality is almost entirely a function of how the patient looks when they arrive

The single strongest predictor of survival after an epidural hematoma is the patient's Glasgow Coma Scale (GCS) score at presentation. In published trauma series:

In Lobato's classic series of patients already comatose at the time of surgery, overall mortality was about 28%, but roughly two-thirds of survivors made a functional recovery. More recent large series show the same pattern: patients who are awake and talking when they reach the hospital almost always go home to their previous lives, while patients who arrive in a deep coma have outcomes that hinge on how quickly the clot is removed.

Why EDH outcomes are so different from acute subdural hematoma

This is the key point that families often find reassuring. An acute subdural hematoma (acute SDH) happens when the brain itself is bruised and torn — the blood under the dura is usually just a marker of how severely the brain was injured. Even with a perfect operation, mortality for acute SDH is commonly 40-60%, because you are operating on an already-damaged brain. Epidural hematoma is fundamentally different: the brain is usually structurally intact, and surgery is essentially a mechanical problem of taking the pressure off. One older series of mixed head injuries found good recovery in roughly 58% of EDH patients versus 25% of acute SDH patients, and overall mortality about 25% for EDH versus 57% for SDH.

Functional recovery

For a patient with EDH who is awake on arrival and operated on promptly, the expected outcome is return to baseline — back to work, school, sports, and driving — within weeks to a few months. Post-concussive symptoms like headache, fatigue, and trouble concentrating are common in the first few weeks and almost always resolve. A small minority of patients develop post-traumatic epilepsy and may need anti-seizure medication for a period afterwards.

The takeaway is simple: the most important thing about an epidural hematoma is not letting it go unrecognized. Once the diagnosis is made and the patient is at a trauma center with a neurosurgeon immediately available, the odds are firmly on your side.

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