Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Epidural Hematoma (EDH) Evacuation

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with acute [left/right] [temporal/frontal/parietal/posterior fossa] epidural hematoma [__ mm max thickness, __ mm midline shift] following [trauma mechanism] presenting with [GCS ___ / lucid interval / pupil changes] planned for emergent craniotomy for evacuation.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

External sources — operative figures/atlases are copyrighted (linked, not copied). See media-sources.md for licensing.

Operative technique & approach

Imaging

Open-access figures

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Epidural Hematoma Evacuation — Figure 1 Figure 1. The plain CT brain showed acute left parietal epidural hematoma at the convexity of the left parietal bone (pointed in the image), measuring 9.7 x 5.2 x 8.4 cm in maximum AP, CC, and… Source: Epidural Abscess Following Epidural Evacuation in a Patient With Ventriculoperitoneal Shunt: A Case Report — Cureus 2021; CC BY.

Epidural Hematoma Evacuation — Figure 2 Figure 2. An MRI brain scan showed an enhancing epidural collection of 4 cm thickness (pointed in the image). Source: Epidural Abscess Following Epidural Evacuation in a Patient With Ventriculoperitoneal Shunt: A Case Report — Cureus 2021; CC BY.

Epidural Hematoma Evacuation — Figure 3 Figure 3. CT brain done three weeks postoperatively showed superficial collection beneath the surgical defect, extra-axial collection with an irregular enhancing rim measuring approximately 4.2 x… Source: Epidural Abscess Following Epidural Evacuation in a Patient With Ventriculoperitoneal Shunt: A Case Report — Cureus 2021; CC BY.

Epidural Hematoma Evacuation — Figure 4 Figure 4. CT brain done showed redemonstration of operative bed subgaleal and epidural heterogenous marginally enhancing collection measuring 7 x 4.5 x 4.5 cm (pointed in the image). Source: Epidural Abscess Following Epidural Evacuation in a Patient With Ventriculoperitoneal Shunt: A Case Report — Cureus 2021; CC BY.

Epidural Hematoma Evacuation — Figure 1: Figure 1:. Initial head CT after trauma 7 years before AV fistula development. (a) L temporal epidural hematoma with 0.5 cm midline shift. (b) Postoperative CT scan demonstrating evacuation of EDH… Source: Delayed presentation of a traumatic scalp arteriovenous fistula — Surgical Neurology International 2021; CC BY-NC-SA.

Epidural Hematoma Evacuation — Figure 2: Figure 2:. Engorged left temporal vessels 7 years following traumatic epidural hematoma evacuation. (a and b) Clinical presentation of the left anterolateral scalp swelling. (c and d) CTA head 7… Source: Delayed presentation of a traumatic scalp arteriovenous fistula — Surgical Neurology International 2021; CC BY-NC-SA.

Epidural Hematoma Evacuation — Figure 1 Figure 1. Case 2 from the re-operation group. The patient operated on for left frontal oligo-astrocytoma developed right frontal EDH. Re-operation of EDH evacuation through craniotomy were… Source: Vaccum drainage system application in the management of operation-related non-regional epidural hematoma — Annals of Surgical Innovation and Research 2013; CC BY.

Epidural Hematoma Evacuation — Figure 2 Figure 2. Case 7 from the re-operation group. The patient operated on for infratentorial Schwannoma developed supratentorial EDH. Re-operation of EDH evacuation through craniotomy were performed,… Source: Vaccum drainage system application in the management of operation-related non-regional epidural hematoma — Annals of Surgical Innovation and Research 2013; CC BY.

Epidural Hematoma Evacuation — Figure 3 Figure 3. Case 6 from the re-operation group. The patient operated on for infratentorial ependymoma developed infratentorial-supratentorial EDH. Re-operation of EDH evacuation through craniotomy… Source: Vaccum drainage system application in the management of operation-related non-regional epidural hematoma — Annals of Surgical Innovation and Research 2013; CC BY.

Epidural Hematoma Evacuation — Figure 4 Figure 4. Case 4 from the drainage group. The patient operated on for the IIIrd ventricle anaplastic haemangiopericytoma developed left temporal-occipital EDH. Epidural drainage with the vacuum… Source: Vaccum drainage system application in the management of operation-related non-regional epidural hematoma — Annals of Surgical Innovation and Research 2013; CC BY.

History of Present Illness

Past Medical History

Imaging Review

CT Head

CT Angiography (if concern for vascular injury)

MRI (rarely obtained acutely — consider if subacute or diagnostic uncertainty)

Labs

Neurological Examination

Glasgow Coma Scale (GCS)

Pupillary Exam (CRITICAL for herniation assessment)

Motor Exam

Brainstem Reflexes (especially for posterior fossa EDH)

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Timing: EMERGENT — this is one of the most time-sensitive neurosurgical emergencies

Position

Incision

Equipment & Instrumentation

Monitoring

Anesthesia Considerations

Key Surgical Steps

  1. Rapid incision and craniotomy — speed is critical; Raney clips for scalp hemostasis
  2. Burr hole placement — initial burr hole over the thickest portion of the EDH; can partially decompress through burr hole if patient herniating while completing craniotomy
  3. Craniotomy centered over the EDH — must be large enough to evacuate all clot and visualize edges; typically 8-12 cm trauma flap
  4. Evacuate clot — suction and irrigation; clot is usually organized/solid; use cup forceps for large pieces, irrigation to flush residual
  5. Identify bleeding source:
    • Middle meningeal artery (most common for temporal EDH) — coagulate with bipolar; if artery retracts into foramen spinosum, drill out foramen spinosum with diamond burr, pack with bone wax, and apply Surgicel/Gelfoam
    • Dural venous sinus (for posterior fossa or vertex EDH) — Surgicel/Gelfoam packing; do NOT attempt to coagulate the sinus directly
    • Diploic veins — bone wax on exposed diploic edges
    • Dural surface bleeding — bipolar, Surgicel
  6. Tacking sutures — place circumferential 4-0 Nurolon dural tacking sutures to the inner table of the skull at the craniotomy edges and centrally through small drill holes; this eliminates the epidural dead space and prevents clot re-accumulation
  7. Inspect dura — if dura is blue/tense, may have underlying SDH or contusion; decision to open dura:
    • Open if dura remains tense after EDH evacuation
    • Open if preoperative imaging shows concurrent SDH or parenchymal hemorrhage
    • If brain is swollen and herniating through the craniotomy, consider converting to decompressive craniectomy
  8. Replace bone flap — EDH patients typically do NOT need craniectomy (brain is usually not swollen); secure with titanium plates and screws
  9. Place drain — subgaleal Jackson-Pratt drain; exit through a separate stab incision
  10. Closure — reapproximate galea with 3-0 Vicryl, skin with staples or running nylon

Posterior Fossa EDH — Approach Differences

Critical Anatomy

  1. Middle meningeal artery — in the temporal bone groove; most common EDH source
  2. Foramen spinosum — where MMA enters the middle cranial fossa; may need drilling for hemostasis
  3. Dural venous sinuses — sagittal sinus, transverse sinus (vertex or posterior fossa EDH)
  4. Temporal lobe — may be compressed but usually not contused
  5. Sigmoid sinus and transverse sinus — at risk in posterior fossa EDH

Potential Complications

  1. Rebleeding — from middle meningeal artery if not adequately controlled; dural tacking prevents re-accumulation
  2. Missed SDH — inspect dura after EDH evacuation; if dura is tense/blue, may need to open
  3. Seizure — cortical irritation from bone fracture and hematoma; prophylaxis
  4. Delayed contralateral EDH — rare but possible; post-op CT
  5. Brain swelling — if brain herniates through craniotomy, consider decompressive craniectomy
  6. Infection — compound skull fractures increase risk; ensure wound irrigation and antibiotics

Operative Note Template

Preoperative Diagnosis: Acute [left/right] [temporal/frontal/parietal/posterior fossa] epidural hematoma

Postoperative Diagnosis: Same

Procedure: Emergent [left/right] [temporal/frontotemporal/frontoparietal] craniotomy for evacuation of epidural hematoma

Surgeon: Assistant: Anesthesia: General endotracheal anesthesia

EBL: Fluids: Specimens: None Drains: [Subgaleal Jackson-Pratt drain / None] Complications: None Implants: [Titanium plates and screws for bone flap fixation]

Indications: The patient is a [age]yo [M/F] who presented following [mechanism of injury] with [headache and declining mental status / GCS _ / fixed dilated pupil]. CT head demonstrated an acute [left/right] [temporal] epidural hematoma measuring [_ mm] in maximum thickness with [__ mm] of midline shift [and an underlying temporal bone fracture crossing the middle meningeal artery groove]. Given the [clot thickness / midline shift / declining neurological status / pupillary changes], emergent surgical evacuation was indicated. The risks, benefits, and alternatives were discussed with [the patient / the patient’s family / medical decision-maker], and consent was obtained. [Anticoagulation was reversed with __ prior to surgery.]

Description of Procedure: After informed consent was verified and the surgical site was confirmed, the patient was brought to the operating room and placed supine on the operating table. General endotracheal anesthesia was induced via rapid sequence induction. [C-spine precautions were maintained with in-line stabilization during intubation.] An arterial line, Foley catheter, and two large-bore peripheral IVs were placed. [Mannitol ___ g IV was administered.] Preoperative cefazolin [2g] and levetiracetam [1000 mg] were administered.

The patient was positioned supine with the head rotated [___] degrees to the [contralateral] side. The head was secured in a [Mayfield skull clamp / horseshoe headrest]. All pressure points were padded. A time-out was performed.

The [left/right] [temporal/frontotemporal] region was prepped and draped in the standard sterile fashion.

Incision: A curvilinear (question-mark) skin incision was made beginning at the zygomatic root, curving posterosuperiorly above the pinna, and extending superiorly to above the parietal eminence. Raney clips were applied for scalp hemostasis. The scalp and temporalis muscle were reflected as a myocutaneous flap, exposing the [temporal/frontotemporal] calvarium. [A linear temporal bone fracture was noted.]

Craniotomy: A burr hole was made over the [thickest portion of the hematoma], and epidural clot was immediately encountered, providing partial decompression. [Additional burr holes were placed at ___.] A craniotomy was performed with the craniotome, and the bone flap was elevated, exposing a large [organized/acute] epidural hematoma.

Evacuation: The epidural clot was systematically evacuated using suction, irrigation, and cup forceps. The clot was [dark, organized / mixed acute and subacute] and estimated at approximately [___ mL] in volume. The clot was evacuated circumferentially until all edges of the hematoma were visualized against normal dura.

Hemostasis: The bleeding source was identified as [the middle meningeal artery, which was coagulated with bipolar cautery / the middle meningeal artery, which had retracted into the foramen spinosum — the foramen was drilled out with a diamond burr and packed with bone wax and Surgicel / diploic bleeding from the fracture site, which was controlled with bone wax / dural surface bleeding, which was controlled with bipolar cautery and Surgicel]. Meticulous hemostasis was achieved throughout the epidural space.

Tacking sutures: Multiple 4-0 Nurolon dural tacking sutures were placed circumferentially at the craniotomy edges and centrally through small drill holes in the bone flap to eliminate the epidural dead space and prevent hematoma re-accumulation.

Dural inspection: The dura was inspected and found to be [slack and pulsatile, with normal-appearing underlying brain / tense and blue, suggestive of underlying subdural hematoma — the dura was opened and ___].

Closure: The bone flap was replaced and secured with [titanium plates and screws]. [A subgaleal Jackson-Pratt drain was placed and brought out through a separate stab incision.] The temporalis muscle and galea were reapproximated with 3-0 Vicryl interrupted sutures. The skin was closed with staples. A sterile head dressing was applied.

Postoperative: The patient was awakened from anesthesia, extubated [/ remained intubated due to __], and found to be [following commands with improved neurological exam / GCS __]. The patient was transferred to the neurosurgical ICU in stable condition.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Epidural Hematoma (EDH) Evacuation:

Common Pimp Questions

Use these to pressure-test preparation for Epidural Hematoma (EDH) Evacuation:

  1. What is the life-threatening mass-effect problem and what is the operative endpoint?
  2. What anticoagulant/antiplatelet reversal and blood-product plan is required before incision?
  3. What exposure gives rapid control while preserving options for expansion?
  4. What ICP, seizure, sodium, ventilation, and blood-pressure targets matter immediately postop?
  5. What injury pattern or associated lesion would change the incision, bone flap, or disposition?

Attending Preference Variables

Items that commonly vary by surgeon or institution: