Extradural hematoma management: A case-control study with historical controls reassessing the 'zero mortality' goal

Extradural hematoma (EDH) remains a significant cause of mortality following traumatic brain injury (TBI), although fatality rates have declined. This study examines whether improvements in a regional trauma and neurosurgical care system over four decades have enabled the achievement of the long-standing goal of "zero mortality" in surgically treated EDH.

Has the evolution of a regional trauma and neurosurgical care system over four decades reduced mortality and moved towards the 'zero mortality' goal in surgically treated extradural hematomas?

We retrospectively reviewed all patients who underwent surgery for EDH at our institution between 2011 and 2021. Demographic, clinical, and radiological data were collected and compared in a case-control design with a historical cohort treated at the same center in the early 1980s, when the "zero mortality" concept was first proposed.

Among 85 contemporary cases, most patients were aged 41-61 years (previously 11-20), and falls were the leading cause of injury (55% vs. 50% due to road traffic accidents; p = 0.007). Direct presentations increased (65% vs. 33%; p < 0.001), and 96% arrived within 6 h (vs. 65%; p < 0.001). Surgery within 6 h occurred in 68% of cases. Referred patients experienced significantly longer delays. Craniotomy was performed in 94% of cases. In-hospital mortality was 2.4% (vs. 4.7%).

Although system-wide improvements have reduced mortality, the "zero mortality" target remains unmet. Delays in referral and triage continue to pose challenges, particularly in complex or rapidly evolving cases.