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Craniotomy for extradural haematoma
Why are we operating?
The lucid-interval emergency: a window of bone over the clot, the middle meningeal bleeding point chased and killed, the dura hitched so it cannot happen again.
Indication: Extradural haematoma with mass effect or deterioration; the operation is measured from decision, not admission.
Read the imaging first
Practice before you scrub
Name the compartment
Knocked out briefly at football, talking normally in the ED, now drowsy two hours later. CT head. (Fictional educational case.)
- Lens means extradural, and extradural means arterial: a middle meningeal bleed under a pterional impact, on a clock measured in hours.
- Shift and effacement grade the urgency better than the collection's size alone: mass effect is the pressure story made visible.
The operation in 4 steps
01Positioning and the trauma flap
Head positioned and fixed, a question-mark incision turned over the clot's territory, usually temporo-parietal.
Why: The extradural's home ground is the temporal region, where the middle meningeal artery lies in its bony groove; the flap is planned from the scan to put the whole clot inside the window.
02Raising the bone flap
Burr holes are connected with the craniotome and the bone flap lifted; dark clot is immediately on show, on top of the dura.
Why: Extradural blood sits between skull and dura, which is exactly why bone must come off to reach it, and why the clot stops at suture lines where the dura is welded down.
03Evacuation and the bleeding point
Clot is delivered by suction and irrigation; the middle meningeal artery or its branches are coagulated or ligated, and bone-edge bleeding waxed.
Why: The operation is not finished when the clot is out; it is finished when the vessel that made the clot cannot make another. The artery is chased to its foramen when it must be.
04Hitching and closure
The dura is tacked to the bone edges and flap centre, the bone flap replated, and scalp closed over a drain.
Why: Hitching sutures press the dura against the skull, closing the plane where the haematoma lived; done properly, the space this emergency needed no longer exists.
Anatomy you need
The skull at the pterion, where the bone is thinnest and the middle meningeal groove runs beneath.
What can go wrong
Watch it done
CNS Neurosurgery 100: epidural hematoma
The society's core teaching on the lentiform bleed and the craniotomy that treats it.
Source: Congress of Neurological Surgeons · Watch on YouTube
Conceptual teaching for learners preparing to observe and assist under supervision, not operative instructions. Five minutes from now you should know why this operation exists, what its shape is, and which structures it is designed not to injure.