Nontraumatic epidural haemorrhage
ICD-10 I62.1 · ICD-11 8B03

When Conservative Management Fails to Control Hematoma Expansion in Nontraumatic Epidural Haemorrhage

Patients with nontraumatic epidural haemorrhage who initially present with preserved consciousness and favourable CT parameters may be managed conservatively — but when hematoma expansion is not halted, a structured surgical escalation protocol becomes necessary.

Initial clinical scenario
Conservative management applies when the patient has a preserved level of consciousness, no focal neurological deficit, no associated intracranial lesion, and CT findings showing hematoma volume below 30 ml, thickness below 15 mm, and midline shift below 5 mm — under continuous clinical observation with serial CT monitoring.
When first-line treatment is insufficient
If conservative treatment — continuous clinical observation with CT monitoring together with tranexamic acid for bleeding control — does not achieve the goal of halting hematoma volume expansion on CT, escalation is indicated. Volume increase, when it occurs, can evolve over a defined window; failure to reverse it, or any neurological decompensation, triggers the move to the next protocol step.
Next-step approach (partial overview)
The escalation protocol involves an immediate surgical intervention — beginning with a targeted approach above the hematoma for rapid decompression — followed by definitive drainage and vessel control. The complete decision criteria, procedural sequence, and thresholds are in the full structured protocol.
Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1055/s-0044-1796652

Conservative treatment is indicated in patients with a preserved level of consciousness, without focal neurological deficit, absence of associated intracranial lesion, and CT showing IEH volume below <30 ml, thickness below 15 mm, and midline shift below 5 mm six hours or more after trauma, but with constant clinical observation and CT monitoring; in case of neurological decompensation, immediate surgery is indicated.

In cases where a patient presents in the emergency room with unilateral pupillary dilation, decerebrate posture, and signs of elevated intracranial pressure, emergency action may involve making a small incision in the suspected area above the hematoma.

A quick trephine hole is made, allowing for partial drainage of the hematoma to relieve intracranial hypertension, followed by craniotomy, definitive hematoma drainage, and coagulation of the injured vessel.

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