Nonoperative management of acute epidural hematomas: a "no-brainer"

Acute epidural hematomas are generally considered to require urgent operation for clot evacuation and bleeding control. It has become increasingly apparent, however, that many epidural hematomas will resolve with nonoperative management. The purpose of the current study was to review our experience with nonoperative management of acute epidural hematomas.

Patients admitted to our busy urban level I trauma center with an epidural hematoma were identified using our trauma registry. Patients were excluded if they suffered other significant intracranial injury mandating operative intervention. Patient records were reviewed and relevant data collected. Patients who required subsequent craniotomy were compared to those who did not in order to identify risk factors for failure of nonoperative treatment.

Between January 1995 and June 2004, 84 patients were identified. The mean age was 27 +/- 1.6 years and 68 (81%) were male. Mean Glasgow Coma Scale in the emergency department was 13.7 +/- 0.3. The most common mechanism of injury was a fall. Fifty-four (64%) patients were initially managed nonoperatively and 30 (36%) were taken directly to the operating room for craniotomy. Nonoperative management was successful in 47/54 (87%) patients. Failure of initial nonoperative management was not associated with adverse outcome. There were no deaths in patients managed operatively or nonoperatively. Seventy-two (86%) patients were discharged to home with excellent neurologic outcome.

Epidural hematomas can be successfully managed nonoperatively in an appropriately selected group of patients. Moreover, failure of initial nonoperative management has no adverse effect on outcome.