Small extradural hematoma- what to do?

Background: Standard neurosurgical management are likely to mandate prompt evacuation of extradural hematomas to obtain a good outcome. A number of authors have suggested that small epidural hematomas may be managed conservatively with normal outcome and without risk to the patient in selected cases. The goal of this study was to define the clinical parameters that may help in the management of the patient with small epidural hematoma where the hematoma was asymptomatic.
Objective: This study was conducted to find out the factors influencing the decision making of asymptomatic extradural hematoma (No clinical evidence of raised intracranial pressure or focal compression) either surgical or conservative.
Methods: Two hundred patients got admitted with head injury with CT scan findings of small extradural hematoma in the department of Neurosurgery, Dhaka Medical College and Hospital from January, 2015 to December, 2018. All these patients were evaluated on the basis of clinical findings, radiological parameters like size of hematoma, location of hematoma, midline shift and overlying skull fractures etc. The choice of management will be either conservative or surgical intervention.
Results: All 200 patients were diagnosed within 72 hours of trauma and were managed expectantly. Analysis of the patients revealed that age, sex, GCS score and initial size of hematoma are not the risk factors for deterioration. However, skull fracture traversing meningeal artery, vein or major sinuses were seen in 136(68%) patients. One hundred and fifty (75%) patients underwent CT scan of head within 24 hours of trauma. 34(17%) deteriorated and 21(10.5%) patients required surgical evacuation of hematoma.
Conclusion: It may be concluded that patients with small epidural hematoma with a fracture overlying major vessels or major sinuses, diagnosed within 24 hours of trauma are at risk of subsequent deterioration and may require surgical evacuation.