title: Extradural haematoma--to evacuate or not? Revisiting treatment guidelines.
abstract: BACKGROUND
  We describe three cases of extradural haematomas (EDHs) and their management, focusing on operative and non-operative treatment. We also review the available literature from the past three decades as well as the guidelines for the management of EDH. An algorithm is formulated based on different factors, including the clinical course of the patients and their CT findings.
  
  
  METHODS
  The first patient presented to us after sustaining a fall with a GCS of 15/15 and a large parieto-occipital EDH with a volume of 90 cm3. He was treated non-operatively. Follow-up CT showed good resolution of the haematoma. The second patient presented with a GCS of 7/15, a posterior fossa EDH with a volume of 30 cm3, and obstructive hydrocephalus. Emergency ventriculostomy was performed, which was converted to a VP shunt. The third case was a patient presenting with a large hemispheric EDH, which was 130 cm3 in volume. The GCS at presentation was 14/15 but dropped to 6/15, following which he underwent craniotomy and evacuation of the EDH.
  
  
  RESULTS
  The Glasgow Outcome Scale (GOS) at three months was five for the first two cases and three for the third case with a dense right hemiplegia.
  
  
  CONCLUSIONS
  EDH, both supratentorial and in the posterior fossa, can be managed non-operatively. A large volume EDH (>30 cm3) can be managed non-operatively provided the GCS at presentation and follow up remains the same with symptomatic improvement. Prompt treatment of a large volume EDH may still result in a poor outcome.
authors.affiliation: Department of Neurosurgery, Cork University Hospital, Wilton, Cork, Ireland. zakariaz@tcd.ie
authors.forename: Zaitun
authors.initials: Z
authors.lastname: Zakaria
authors.forename: Chandrasekaran
authors.initials: C
authors.lastname: Kaliaperumal
authors.forename: George
authors.initials: G
authors.lastname: Kaar
authors.forename: Michael
authors.initials: M
authors.lastname: O'Sullivan
authors.forename: Charles
authors.initials: C
authors.lastname: Marks
mesh_terms: D000328:Adult; D000465:Algorithms; D005260:Female; D015600:Glasgow Coma Scale; D023261:Glasgow Outcome Scale; D017408:Guidelines as Topic; D006407:Hematoma, Epidural, Cranial / Q000601:surgery* / Q000628:therapy; D006429:Hemiplegia / Q000209:etiology; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D017287:Ventriculoperitoneal Shunt; D014696:Ventriculostomy
keywords: CT brain; Extradural haematoma; Glasgow Outcome Scale; Glasgow coma score; Head injury