1988; 150:673. 26. Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical versus conservative management: two case reports and review of the literature. Neurosurgery 1999; 45:621. https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 13/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate 27. Hori E, Ogiichi T, Hayashi N, et al. Case report: acute subdural hematoma due to angiographically unvisualized ruptured aneurysm. Surg Neurol 2005; 64:144. 28. Nelson JA. Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma. Acad Emerg Med 2011; 18:78. 29. Peres CMA, Caldas JGMP, Puglia P, et al. Endovascular management of acute epidural hematomas: clinical experience with 80 cases. J Neurosurg 2018; 128:1044. 30. Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage. Acta Neurochir (Wien) 1988; 90:111. 31. Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma 1996; 41:120. 32. Sullivan TP, Jarvik JG, Cohen WA. Follow-up of conservatively managed epidural hematomas: implications for timing of repeat CT. AJNR Am J Neuroradiol 1999; 20:107. 33. Oertel M, Kelly DF, McArthur D, et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury. J Neurosurg 2002; 96:109. 34. Chang JH, Choi JY, Chang JW, et al. Chronic epidural hematoma with rapid ossification. Childs Nerv Syst 2002; 18:712. 35. Bullock R, Smith RM, van Dellen JR. Nonoperative management of extradural hematoma. Neurosurgery 1985; 16:602. 36. Cucciniello B, Martellotta N, Nigro D, Citro E. Conservative management of extradural haematomas. Acta Neurochir (Wien) 1993; 120:47. 37. Bezircio lu H, Er ahin Y, Demir ivi F, et al. Nonoperative treatment of acute extradural hematomas: analysis of 80 cases. J Trauma 1996; 41:696. 38. Chen TY, Wong CW, Chang CN, et al. The expectant treatment of "asymptomatic" supratentorial epidural hematomas. Neurosurgery 1993; 32:176. 39. Bricolo AP, Pasut LM. Extradural hematoma: toward zero mortality. A prospective study. Neurosurgery 1984; 14:8. 40. Heinzelmann M, Platz A, Imhof HG. Outcome after acute extradural haematoma, influence of additional injuries and neurological complications in the ICU. Injury 1996; 27:345. 41. Gennarelli TA, Spielman GM, Langfitt TW, et al. Influence of the type of intracranial lesion on outcome from severe head injury. J Neurosurg 1982; 56:26. 42. Lee EJ, Hung YC, Wang LC, et al. Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery. J Trauma 1998; 45:946. https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 14/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate 43. van den Brink WA, Zwienenberg M, Zandee SM, et al. The prognostic importance of the volume of traumatic epidural and subdural haematomas revisited. Acta Neurochir (Wien) 1999; 141:509. 44. Kim NY, Lim J, Lee S, et al. Hematological factors predicting mortality in patients with traumatic epidural or subdural hematoma undergoing emergency surgical evacuation: A retrospective cohort study. Medicine (Baltimore) 2020; 99:e22074. 45. Rivas JJ, Lobato RD, Sarabia R, et al. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery 1988; 23:44. 46. Lobato RD, Rivas JJ, Cordobes F, et al. Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma. J Neurosurg 1988; 68:48. Topic 1107 Version 23.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 15/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate GRAPHICS Epidural hematoma in adults: Rapid overview of emergency management Clinical manifestations When to suspect: Head trauma (eg, motor vehicle accident, fall, assault) Unexplained acute progressive neurologic symptoms (confusion, weakness, speech impairment) Transient loss of consciousness followed by lucid interval, then neurologic deterioration Neurologic signs and symptoms: Headache Nausea and/or vomiting Confusion or drowsiness Hemiparesis Signs of elevated intracranial pressure: Dilated pupil(s) with reduced/absent reactivity to light Progressive drowsiness Cushing triad (bradycardia, respiratory depression, hypertension) Evaluation Assess airway, breathing, circulation, and disability to initiate supportive care Determine GCS and neurologic deficits (eg, hemiparesis, speech impairment) Identify exposure to anticoagulant medications (eg, warfarin, DOACs, heparins) Obtain emergency imaging (eg, head CT or fast MRI) Laboratory evaluation: complete blood count, PT, PTT, INR; basic electrolytes; pregnancy test in female of childbearing age Serial monitoring for nonoperative patients: Neurologic examination (hourly) for signs of deterioration Repeat head CT 6 to 8 hours after initial study and for any clinical signs of deterioration https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 16/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Treatment Manage trauma patients according to principles of advanced trauma life support* Perform tracheal intubation for any patient unable to protect their airway, with rapidly deteriorating mental status, or with GCS 8 Obtain immediate neurosurgical consultation Reverse anticoagulation (agent specific): Warfarin reverse with 4-factor PCC and IV vitamin K Dabigatran reverse with idarucizumab Factor Xa inhibitors (apixaban, edoxaban, rivaroxaban) reverse with 4-factor PCC or andexanet alfa Heparin (unfractionated) reverse with protamine sulfate Low molecular weight heparin reverse with andexanet alfa; protamine sulfate is an alternative Medical management of intracranial pressure: Prevent HYPOtension to maintain SBP >100 mmHg: fluid resuscitation with isotonic IV fluids; phenylephrine for refractory symptoms initial dose 0.5 to 2 mcg/kg per minute IV; maintenance dose 0.25 to 5 mcg/kg per minute Treat HYPERtension: Initial treatment to rapidly reduce SBP to <220 mmHg: nicardipine 5 mg/hour IV, titrate by 2.5 mg/hour every 5 to 15 minutes (maximum dose 15 mg/hour); alternate: labetalol 20 mg IV bolus, may repeat every 10 minutes Subsequent treatment to reduce SBP to <160 mmHg while monitoring for stability of neurologic status Elevate head of bed >30 degrees Give antipyretics for temperature >38 degrees Celsius (eg, acetaminophen [paracetamol] 325 to 650 mg orally or PR every 4 to 6 hours or 650 mg IV every 4 hours) Osmotic therapy (mannitol or hypertonic saline) or hyperventilation is temporary treatment for patients with signs of elevated intracranial pressure GCS: Glasgow Coma Scale; DOAC: direct oral anticoagulant; CT: computed tomography; MRI: magnetic resonance imaging; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; PCC: prothrombin complex concentrate; IV: intravenous; SBP: systolic blood pressure; PR: per rectum. Refer to the UpToDate topics on trauma management in adults. https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 17/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Refer to the UpToDate topics on management of elevated intracranial pressure in adults. Graphic 138469 Version 2.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 18/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Non contrast head CT demonstrates an acute traumatic epidural hematoma over the left parietal region Courtesy of Neuroradiology Department, Thomas Je erson University, Philadelphia, PA. Graphic 60726 Version 4.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 19/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate MRI of the brain demonstrates a traumatic epidural hematoma in the left parieto-occipital region MRI: magnetic resonance imaging. Courtesy of Neuroradiology Department, Thomas Je erson University, Philadelphia, PA. Graphic 77358 Version 3.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 20/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Emergency reversal of anticoagulation from warfarin for life-threatening hemorrhage in adults: Suggested approaches based upon available resources A. If 4-factor prothrombin complex concentrate (4F PCC) is available (preferred approach): 1. Give 4F PCC* 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion of the infusion. If INR is not 1.5, give additional 4F PCC (refer to topic or drug reference for details). 2. Give vitamin K 10 mg IV over 10 to 20 minutes. B. If 3-factor prothrombin complex concentrate (3F PCC) is available but 4F PCC is not available: 1. Give 3F PCC* 1500 to 2000 units IV over 10 minutes. Check INR 15 minutes after completion of the infusion. If INR is not 1.5, give additional 3F PCC (refer to topic or drug reference for details). 2. Give Factor VIIa 20 mcg/kg IV OR give FFP 2 units IV by rapid infusion. Factor VIIa may be preferred if volume overload is a concern. 3. Give vitamin K 10 mg IV over 10 to 20 minutes. C. If neither 3F PCC nor 4F PCC is available: 1. Give FFP 2 units IV by rapid infusion. Check INR 15 minutes after completion of infusion. If INR 1.5, administer 2 additional units of FFP IV rapid infusion. Repeat process until INR 1.5. May wish to administer loop diuretic between FFP infusions if volume overload is a concern. 2. Give vitamin K 10 mg IV over 10 to 20 minutes. These products and doses are for use in life-threatening bleeding only. Evidence of life-threatening bleeding and over-anticoagulation with a vitamin K antagonist (eg, warfarin) are required. Anaphylaxis and transfusion reactions can occur. It may be reasonable to thaw 4 units of FFP while awaiting the PT/INR. The transfusion service may substitute other plasma products for FFP (eg, Plasma Frozen Within 24 Hours After Phlebotomy [PF24]); these products are considered clinically interchangeable. PCC will reverse anticoagulation within minutes of administration; FFP administration can take hours due to the volume required; vitamin K effect takes 12 to 24 hours, but administration of vitamin K is needed to counteract the long half-life of warfarin. Subsequent monitoring of the PT/INR is needed to guide further therapy. Refer to topics on warfarin reversal in individual situations for further management. PCC: unactivated prothrombin complex concentrate; 4F PCC: PCC containing coagulation factors II, VII, IX, X, protein S and protein C; 3F PCC: PCC containing factors II, IX, and X and only trace factor VII; FFP: fresh frozen plasma; PT: prothrombin time; INR: international normalized ratio; FEIBA: factor eight inhibitor bypassing agent. Before use, check product label to confirm factor types (3 versus 4 factor) and concentration. Activated complexes and single-factor IX products (ie, FEIBA, AlphaNine, Mononine, Immunine, BeneFix) are NOT used for warfarin reversal. https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 21/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate PCC doses shown are those suggested for initial treatment of emergency conditions. Subsequent treatment is based on INR and patient weight if available. Refer to topic and Lexicomp drug reference included with UpToDate for INR-based dosing. Graphic 89478 Version 10.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 22/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Direct oral anticoagulant reversal agents for life-threatening bleeding (imminent risk of death from bleeding) Reversal agent (all are given Anticoagulant intravenously) Dabigatran (Pradaxa; oral thrombin inhibitor) Idarucizumab (Praxbind). Dose: 5 grams* Oral factor Xa inhibitors: Andexanet alfa (AndexXa). Dosing for the initial bolus and subsequent infusion depend on the dose level of the factor Xa inhibitor and the interval since it was last taken. Apixaban (Eliquis) Edoxaban (Lixiana, Savaysa) Rivaroxaban (Xarelto) OR- 4-factor PCC (Kcentra, Beriplex P/N, Octaplex). Dosing can be done with a fixed dose of 2000 units OR a weight-based dose of 25 to 50 units per kg. Reversal agents carry a risk of life-threatening thrombosis and should only be used under the direction of a specialist with expertise in their use and/or in a patient at imminent risk of death from bleeding. In general, a single dose is given; dosing may be repeated in rare situations in which the oral anticoagulant persists for longer in the circulation, such as severe kidney dysfunction. Andexanet dosing is as follows: If the patient took rivaroxaban >10 mg, apixaban >5 mg, or dose unknown within the previous 8 hours: Andexanet 800 mg bolus at 30 mg/minute followed by 960 mg infusion at 8 mg/minute for up to 120 minutes. OR- If the patient took rivaroxaban 10 mg or apixaban 5 mg, or if 8 hours have elapsed since the last dose of a factor Xa inhibitor: Andexanet 400 mg bolus at 30 mg/minute followed by 480 mg infusion at 4 mg/minute for up to 120 minutes. Refer to UpToDate topics on treatment of bleeding in patients receiving a DOAC or perioperative management of patients receiving a DOAC for additional information on administration, risks, and alternative therapies. DOAC: direct oral anticoagulant; PCC: prothrombin complex concentrate; FEIBA: factor eight inhibitor bypassing activity. If idarucizumab is unavailable, an activated PCC (FEIBA, 50 to 80 units per kg intravenously) may be a reasonable alternative. Graphic 112299 Version 9.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 23/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 24/25 7/5/23, 11:53 AM Intracranial epidural hematoma in adults - UpToDate Contributor Disclosures William McBride, MD No relevant financial relationship(s) with ineligible companies to disclose. Jos Biller, MD, FACP, FAAN, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator- initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults/print 25/25