dr. Rachmat Andi H., Sp.BS(K).

 Incidence : 1% of head trauma admissions

 Male to female = 4 : 1 mostly young adults
 May be caused by:
 Temporoparietal skull fracture disrupts the middle
meningeal artery
 Dissection of the dura from the inner table occurs
first, then bleeding into the space
 Source of bleeding :
 85% arterial bleeding
 Middle meningeal vein and dural sinus
 Diploic vein

 70 % occurs laterally over the hemispheres

 “textbook” presentation
 Brief post-traumatic loss of conciousness (LOC)
 Followed by a “lucid interval” for several hours
 Contralateral hemiparesis (or ipsilateral 
‘Kernohan’s phenomenon’, ipsilateral pupilary
dilatation (85%)

 Deterioration usually occurs over few hours,

but may take days, rarely weeks
 Other signs
 Headache  Unilateral babinsky
 Vomitting sign
 Seizure  Bradycardia signs
 Hyperreflexia  In pediatric, 10% drop
in hematocrite
 Plain skull x-rays
 Fracture line
 No fracture (40%)
 Pineal shift

 Burr hole(s)  to be discussed later

 CT scan in EDH
 84 % with “classic” biconvex appearance
 Uniform density
 Sharply defined edges
 Mass effect is frequent
 Medical treatment for small EDH with no or
minimal neurological signs/symptoms (e.g.
slight lethargy, headache) and no evidence of
herniation
 Posterior fossa EDH is not recomended to be
treated conservatively
 Some patients required emergency
craniotomy when signs of herniation occur
 Indications for surgery (decompressive
craniectomy)
 Any symptomatic EDH
 An acute asymptomatic EDH > 1 cm in its thickest
measurement
 EDH in pediatric patients is riskier than adults
since there is less room for clot
 Surgical objectives
 Clot removal: lowers ICP and eliminates focal
mass effect
 Hemostasis: coagulate bleeding soft tissue (dural
veins & arteries). Apply bone wax.
 Prevent reaccumulation: Place dural tack-up
sutures
 Overall 20-55%
 Optimal diagnosis and treatment 5-10%
 Bilateral Babinski’s or decerebration pre-op
 worse prognosis
 Usually due to respiratory arrest from uncal
herniation
 EDH that is not present on the initial CT, but
found on subsequent CT
 Comprise 9-10% of all EDHs in several series
 Skull fracture is a common feature
 Theoritical risk factor:
 Lowering ICP
 Rapidly correcting shock
 Coagulopathies
 About 5% of EDH
 About 84% have occipital skull fracture
 The source of bleeding usually not found,
high incidence of tears of the dural sinuses
 Surgical evacuation is recomended for
symptomatic lesion
 Burr hole evacuation with negative pressure
may need to be further investigated

 Endovascular approach, in 2004 Suzuki et al

did embolization of the middle meningeal
artery during the early stages of epidural
hematoma.
 Burr holes are primarily a diagnostic tool
 Becoming infrequent because widespread
availability of CT
 In a trauma patient with
 Altered mental status
 Unilateral pupilary dilatation
 Contralateral hemiparesis
 Clinical criteria
 Indicators of transtentorial herniation/brainstem
compression
▪ Sudden drop in GCS
▪ One pupil fixes and dilates
▪ Paralysis or decerebration (usually contralateral to
blown pupil)

 Patients needing emergent surgery for

systemic injuries
 Guidelines

 If the O.R can be immediately available, burr

holes are preferably done in the O.R but if
delay in getting the O.R is foreseen,
emergency burr holes in the E/R should be
performed
 Position
 Shoulder roll
 Head turned with side to be explored up
 Three pin skull-fixation used or horse shoe head
holder
 Ipsilateral to the blown pupil.
 If both pupil are dilated, use the first one
 If the pupils are equal, place on side of
obvious external trauma
 If no localising clues, place on left side
 Placed along a path that can be connected to form
a trauma flap

 First outline the trauma flap with a skin marker

 Start at the zygomatic arch < 1cm anterior to the tragus
(spares the branch of the facial nerve to the frontalis
muscle and the anterior branch of the superficial
temporal artery
 Proceed superiorly and then curve posteriorly at the
level of top of the pinna
 4-6 cm behind the pinna it is taken superiorly
 1-2 cm ipsilateral to the midline curve anteriorly to end
behind the hairline
 First temporal burr hole
 If no epidural hematoma, open the dura if it
has bluish discoloration or strong suspicion
 If completely negative, perform temporal
contralateral side
 If negative and CT cannot be done, ipsilateral
frontal burr hole
 Ipsilateral parietal then posterior fossa
 Rapidly clotting blood collection below the inner
layer of the dura but external to the brain and
arachnoid membrane
 It conforms to the shape of the brain and the cranial
vault, exhibiting concave inner margins and convex
outer margins (crescent shape)
Typically, low-
pressure venous
bleeding of
bridging veins
(between the
cortex and venous
sinuses) dissects
the arachnoid
away from the
dura and layers
out along the
cerebral convexity
 Mortality
 Simple SDH (no parenchymal injury) is associated
with a mortality rate of about 20%

 Complicated SDH (parenchymal injury) is

associated with a mortality rate of about 50%
 Age
 It’s associated with age factors related to the risk
of blunt head trauma
 More common in people older than 60 years
(bridging veins are more easily damaged/falls are
more common)
 Bilateral SDHs are more common in infants since
adhesions existing in the subdural space are
absent at birth
 Interhemispheric SDHs are often associate with
child abuse
 It conforms to the shape of the brain and the cranial
vault, exhibiting concave inner margins and convex
outer margins (crescent shape)

 Non-contrast head CT scan (imaging study of choice

for acute SDH)
 The SDH appears as a hyperdense (white)
crescentic mass along the inner table of the skull,
most commonly over the cerebral convexity in the
parietal region. The second most common area is
above the tentorium cerebelli
 In the chronic phase, the lesion becomes hypodense
and is easy to appreciate on a noncontrast head CT
scan
ACUTE SDH CHRONIC SDH
 A thickness > 10 mm or a midline shift > 5 mm
on computed tomographic (CT) scan should
be surgically evacuated, regardless of the
patient’s Glasgow Coma Scale (GCS) score.
 A comatose patient (GCS score less than 9)
with an SDH < 10-mm thick and a midline
shift < 5mm should undergo surgical
evacuation of the lesion if the GCS score
decreased between the time of injury and
hospital admission by 2 or more points on the
GCS and/or the patient presents with
asymmetric or fixed and dilated pupils and/or
the ICP exceeds 20 mm Hg.
 Fitzgerald M.T., Folan-Curran J. Clinical
Neuroanatomy. 4th ed. Saunders. 2002
 Greenberg M.S. Handbook of Neurosurgery.
6th ed. Thieme: NewYork. 2006
 Lindsay K. W., Bone I. Neurology and
Neurosurgery Illustrated. Churchill
Livingstone. 2004.
 Winn. Youman’s Textbook of Neurosurgery.
6th ed. Elsevier. 2011.