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Textbook/Neurosurgery/Extradural haematoma
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Extradural haematoma

Recognise traumatic extradural haematoma, interpret the characteristic but non-universal clinical and CT patterns, and identify patients needing immediate evacuation or closely supervised non-operative care.

24 min full readUK scopeSources checked 13 Sept 2026Clinical review pending
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A rapidly expanding traumatic mass lesion

After head trauma, falling consciousness, a new unequal pupil, focal weakness, seizure without recovery or CT evidence of an extradural collection with mass effect can represent arterial or venous bleeding with impending herniation.

Action: Stabilise airway, breathing and circulation with cervical-spine protection, call neurosurgery immediately, obtain urgent non-contrast CT when safe, correct remediable coagulopathy through the applicable protocol, and do not let a reported lucid interval delay evacuation of a deteriorating patient.

Open the sections you need. The overview is shown first.
01Core principlesThe concepts and mechanisms needed to understand the subject.

The dura is firmly attached to the inner skull, so an extradural collection dissects it away from bone. Bleeding is commonly associated with a skull fracture crossing the middle meningeal artery in the temporal region, but the middle meningeal vein, diploic channels and dural venous sinuses can also be responsible. Because the dura is anchored at sutures, a supratentorial EDH is often lentiform or biconvex and usually does not cross a cranial suture. This appearance distinguishes its compartment but does not identify the bleeding vessel reliably.

Expansion compresses adjacent brain, effaces basal cisterns and can shift the medial temporal lobe across the tentorial edge. An initially conscious patient may deteriorate after a so-called lucid interval, yet many patients never follow this sequence because they remain unconscious, deteriorate continuously or have associated contusions and diffuse injury. Examination must be trended rather than fitted to a textbook story. Ipsilateral third-nerve compression can produce a dilated pupil while corticospinal compression often causes contralateral weakness, but false localising and bilateral signs occur.

Management integrates whole-trauma resuscitation, neurological trajectory and CT burden. An evacuable EDH is a time-critical mechanical problem. The BTF traumatic surgical guideline gives explicit supratentorial criteria, but these do not abolish judgement: haematoma location, other lesions, physiological instability, age, coagulopathy and transfer delay matter. Observation is an active neurosurgical strategy with serial examinations and imaging, not discharge based on a small first scan.

Key points

  • Extradural haematoma is usually a traumatic collection between skull and dura, often associated with a fracture and classically biconvex on CT; middle meningeal arterial injury is common, but venous sinus and other sources occur.
  • The lucid interval is memorable but neither sensitive nor required. Treat the trajectory: headache, vomiting, drowsiness, focal deficit, anisocoria or a falling GCS after trauma can mark rapid expansion.
  • Brain Trauma Foundation surgical guidance recommends evacuation when supratentorial EDH volume exceeds 30 cm³ regardless of GCS; smaller lesions are observed only when all specified size, shift, neurological and setting criteria are satisfied.
  • Non-contrast CT is the acute diagnostic test. Describe site, volume, maximal thickness, midline shift, cisterns, ventricles, skull fractures, other traumatic lesions and comparison with earlier imaging.
  • In coma with anisocoria, evacuation should occur as soon as possible. Temporising intracranial-pressure measures buy time and never replace removal of an operable clot.
  • The BTF surgical thresholds come from older traumatic literature and support specialist decisions; posterior-fossa lesions, children, coexisting injuries and deterioration require individual neurosurgical judgement.
02Mechanisms and patternsImportant relationships and how to distinguish them.
Reconstruct the injury

Establish time, mechanism, height or speed, direct temporal or occipital impact, loss of consciousness, amnesia, seizure, vomiting and subsequent change. Ask witnesses because a patient who is confused or initially unconscious cannot reliably report a lucid interval.

Trend consciousnessRed flag

Record eye, verbal and motor GCS components separately and repeat them. NICE requires neurosurgical discussion for persisting coma, GCS deterioration, progressive focal signs or seizure without full recovery, irrespective of whether imaging is already available.

Look for lateralising signsRed flag

Compare pupil size and reactivity, eye position, facial movement and limb power. New anisocoria, a poorly reactive pupil, unilateral weakness or posturing after head trauma indicates dangerous mass effect until shown otherwise.

Examine for fracture and associated trauma

Inspect and palpate without probing wounds. Haemotympanum, periorbital or mastoid bruising, CSF rhinorrhoea or otorrhoea and an open or depressed fracture affect imaging and referral. Maintain cervical-spine precautions and search for bleeding elsewhere.

Identify haemostatic risk

Record the exact anticoagulant or antiplatelet, last dose, indication, renal function and known bleeding disorder. Send appropriate tests, but recognise that routine coagulation tests may not quantify every direct oral anticoagulant effect.

Do not overvalue temporary improvementRed flag

Analgesia, oxygenation or a seizure ending may improve responsiveness without stopping the bleed. Continued observations and repeat imaging are required whenever the course or first scan warrants them.

Red flags requiring action

  • Any fall in GCS, especially a motor-score decline, new confusion, agitation or failure to recover after the injury requires urgent reassessment and neurosurgical discussion.
  • A new dilated or poorly reactive pupil, hemiparesis, posturing or abnormal breathing suggests transtentorial herniation and demands immediate resuscitation while surgery is mobilised.
  • A temporal or posterior-fossa extradural haematoma can deteriorate with little reserve; clinical progression outweighs an initially reassuring appearance.
  • Associated open, depressed or basal skull fracture, CSF leak, penetrating injury or major extracranial trauma changes infection, vascular, transfer and operative priorities.
  • Anticoagulant or antiplatelet exposure, a bleeding disorder or thrombocytopenia increases expansion risk and must be identified early without postponing imaging or transfer.
  • A normal examination soon after injury does not make an established extradural collection safe: selected observation requires a neurosurgical centre, serial CT and close neurological monitoring.
03Interpreting evidenceInformation, measurements and their limitations.
Reasoning sequence

Consider the information, its meaning and its limitations before deciding what follows.

  1. 01
    Urgent non-contrast CT head
    Why
    Confirm the extracerebral collection and identify mass effect, fracture and coexisting traumatic brain injury quickly.
    Interpretation and limitations
    A typical EDH is hyperdense and biconvex with suture-limited margins. Record estimated volume, maximal thickness, midline shift, basal cisterns and posterior-fossa involvement; mixed density can indicate active or unclotted bleeding. Imaging cannot override deterioration.
  2. 02
    Serial CT head
    Why
    Detect expansion when a selected EDH is managed without immediate surgery or when neurological status changes.
    Interpretation and limitations
    BTF describes early repeat CT with close neurological evaluation for non-operative care. Any enlargement, new shift, cisternal compression or clinical decline prompts renewed urgent operative assessment.
  3. 03
    Structured neurological observations
    Why
    Detect change between imaging studies and measure response to resuscitation or surgery.
    Interpretation and limitations
    Document GCS components, pupils, limb movements, respiratory rate, oxygen saturation, pulse, blood pressure and temperature. Confirm a deterioration promptly, then obtain immediate medical and neurosurgical reassessment rather than merely shortening the observation interval.
  4. 04
    Full blood count, coagulation screen, group and sample, renal function
    Why
    Identify anaemia, thrombocytopenia, conventional coagulopathy and factors that affect haemostatic or anaesthetic planning.
    Interpretation and limitations
    Abnormal results support targeted correction, but normal PT and APTT do not exclude clinically important direct oral anticoagulant activity. Treatment must be based on the named drug and timing as well as laboratory data.
  5. 05
    CT angiography or vascular imaging when selected
    Why
    Investigate an atypical spontaneous-appearing, vertex or recurrent extradural bleed, or suspected vascular injury, when directed by neuroradiology and neurosurgery.
    Interpretation and limitations
    A vascular lesion or venous-sinus injury changes operative planning. Routine angiography is unnecessary for the usual trauma-associated EDH already explained by fracture and anatomy.
04Applied reasoningWorked examples connecting principles to decisions.
01Worked case: deteriorating EDHHead trauma followed by anisocoriaA patient with a temporal impact becomes drowsier and develops a new unilateral dilated pupil or focal weakness.
  1. 1Call trauma, anaesthetic and neurosurgical teams immediately; stabilise airway, oxygenation and circulation with cervical-spine alignment, and document GCS components, pupils and motor responses without waiting for a complete herniation triad.
  2. 2Obtain immediate non-contrast CT if this can be done without interrupting resuscitation, transmit images during the referral, and prepare for urgent transfer or theatre while blood samples and drug history guide haemostatic support.
  3. 3If CT confirms an EDH with operative features, proceed to evacuation as soon as possible; use carefully monitored temporising pressure measures only while definitive source control is being arranged.
  4. 4After evacuation, continue neurocritical observations, repeat imaging when clinically indicated and manage associated fracture, contusion, diffuse injury, seizure and extracranial trauma.
02Selected observationSmall EDH without deficitEDH is under 30 cm³, under 15 mm thick, shifts the midline under 5 mm, and the patient has GCS above 8 with no focal deficit.
  1. 1Confirm with neurosurgery that every non-operative criterion and the anatomical context are acceptable, and admit to a neurosurgical centre for close observation.
  2. 2Perform frequent documented neurological examinations and serial CT; escalate immediately for any decline or expansion rather than relying on the first scan.
  3. 3Review haemostatic risk, associated injury and safe discharge criteria only after the observation period is complete and the trajectory is stable.
03Whole-trauma pathwayEDH with multisystem injuryThe intracranial lesion coexists with haemorrhagic shock, chest or abdominal injury, or an unstable cervical spine.
  1. 1Coordinate simultaneous haemorrhage control and neuroprotection, avoiding hypoxaemia and hypotension while preserving spinal alignment.
  2. 2Choose the receiving hospital and operative sequence through trauma and neurosurgical teams; isolated head-injury thresholds cannot determine priorities for a multiply injured patient.
  3. 3Reassess pupils, GCS, circulation and extracranial bleeding after every transfer or procedure because treating one compartment can destabilise another.
05Checking understandingVerify the reasoning, revisit uncertainties and apply feedback.
  • Trend GCS components, pupils and limb movement at the locally specified frequency and after every transfer, sedative dose or physiological change.
  • Maintain continuous oxygen saturation, ECG and blood-pressure monitoring in severe or deteriorating injury, with capnography after intubation.
  • Review CT volume, thickness, shift and cisterns alongside the examination; record comparison with the previous scan rather than writing only “stable”.
  • Track haemoglobin, platelets, conventional coagulation indices and renal function when haemostatic treatment or surgery is contemplated.
  • After surgery, monitor wound, drain if present, seizures, new focal signs, intracranial pressure when indicated and complications of associated injuries.
06Special situationsVariants, exceptions and circumstances that change the usual approach.

The interval is not a rule

A lucid interval is a possible pattern, not a diagnostic requirement. A persistently reduced GCS or continuous decline can still be EDH.

Compartment shapes CT

Dural attachment at sutures produces the classic lens shape. Subdural blood usually spreads more widely along the convexity.

Size criteria work together

Only a patient meeting all small-volume, thickness, shift, GCS and no-deficit criteria is described as suitable for non-operative BTF management.

Location changes reserve

Temporal EDH threatens uncal herniation; posterior-fossa EDH can compress the fourth ventricle and brainstem without the same supratentorial geometry.

Definitive treatment is mechanical

Osmotherapy and ventilation can reduce pressure briefly but cannot stop the bleeding vessel or remove the clot.

07Common pitfallsFrequent interpretation and management errors.
  1. 01

    Waiting for a lucid interval or bradycardia before considering EDH in a deteriorating trauma patient.

  2. 02

    Describing a biconvex collection without recording thickness, volume, shift, cisterns, location and associated lesions.

  3. 03

    Applying the observation criteria when one component is missing, or observing outside a neurosurgical centre without serial CT.

  4. 04

    Delaying resuscitation or evacuation to obtain non-essential tests or to normalise every laboratory value.

  5. 05

    Assuming a normal conventional coagulation screen excludes direct oral anticoagulant effect.

  6. 06

    Using supratentorial adult thresholds as an automatic rule for posterior-fossa lesions or children.

Practice

Two practice questions

Question 1 of 20 correct
NeurosurgeryOriginal SBA

Selected non-operative management

A neurologically stable adult has a traumatic supratentorial extradural haematoma. Which complete set of findings matches the Brain Trauma Foundation description for non-operative management in a neurosurgical centre?

Sources and review status3 sources · checked 13 Sept 2026 · clinical review pending
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.

  • NICE NG232 Head injury recommendationsPublished May 2023; assessment, CT, neurosurgical discussion and observation recommendations read 13 September 2026. UK national guidance for traumatic head injury across ages; it does not provide EDH operative-size thresholds.
  • Brain Trauma Foundation Surgical Management of TBICurrent BTF index checked and EDH recommendation body read 13 September 2026; source guideline published 2006. Used only for traumatic EDH operative and selected-observation criteria; age, posterior-fossa and multi-injury decisions remain specialist.
  • Brain Trauma Foundation severe TBI guidelineFourth edition published 2016; monitoring, blood-pressure, ICP, CPP and ventilation recommendation body read 13 September 2026. Used only to frame severe adult traumatic physiology while evacuation remains lesion-specific.
Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom