03 / Neurosurgery · open
Craniotomy for extradural haematoma
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.
On the tray for this operation
Test yourself on the tray
Scalpel
Sharp division of tissue, most visibly the skin incision.
Electrosurgical pencil
Cutting and coagulating with high-frequency current.
Yankauer suction
Clearing blood and fluid from the field.
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Mosquito clamp
Clamping small bleeders and fine structures.
Needle driver
Holding the curved needle while suturing.
Stage
1 / 4
Positioning and the trauma flap
Head positioned and fixed, a question-mark incision turned over the clot's territory, usually temporo-parietal.
Watch for: Scalp flap ischaemia from a poorly based incision
Why are we operating?
Craniotomy for extradural haematoma removes a bone flap over the clot, delivers the arterial haematoma compressing the brain, and stops the middle meningeal bleeding at its source: done in time, it is one of the best operations in surgery, because the brain beneath is often uninjured, the lucid interval's promise kept. The whole operation is a race against the pressure-volume curve's cliff.
Pulls toward surgery
Gives the team pause
Shared foundations
What the surgeon is thinking
Positioning and the trauma flap
Why is the flap drawn where it is?
The classic EDH sits at the pterion, where the skull is thinnest and the middle meningeal artery is grooved into bone: the question-mark incision and flap are centred over the clot as the CT drew it, big enough to reach the bleeding source, not just the blood.
Raising the bone flap
What is the craniotome actually doing between the burr holes?
Its footplate rides the dura, lifting it off the inner table while the cutter joins the holes: the flap comes free as a lid. In the EDH the dura is already stripped by the clot beneath, which is what made the space, so the flap often lifts straight onto the haematoma.
Evacuation and the bleeding point
Evacuating the clot is easy. What is the real task?
The source: the middle meningeal artery or its branches, coagulated or ligated where they bleed, sometimes followed to the foramen spinosum and waxed there. A clot removed without its artery controlled is an operation that will be repeated tonight.
Hitching and closure
What are hitch stitches for?
They sew the dural edge up to the bone margins, closing the very space the haematoma inhabited: with the dura tacked to the skull, there is nowhere for a recurrent collection to form. It is prevention stitched directly into the anatomy, followed by the flap's return and a drain outside the dura.
Decision points
A deteriorating EDH patient in a hospital without neurosurgery, transfer time 90 minutes. What is defensible?
Rapid transfer with maximal medical bridging
Head-up, osmotherapy, controlled ventilation: buying minutes chemically while the ambulance spends them.
Local decompression by a non-neurosurgeon
The historical 'burr hole at the site of the fracture' exists for the dying-now patient with a blown pupil and an unreachable centre: doctrine, communication with the receiving surgeon, and honesty about its limits.
This is the classic system-design question wearing a clinical mask: the answer is decided by geography and network doctrine before the night it is needed. The medical bridge (osmotherapy, ventilation) is genuinely effective and often underdosed by hesitation.
The clot is out, the field is dry, but the brain looks tight and dusky. Return the bone flap?
Replace the flap
The default for the classic EDH with an uninjured brain: pressure was the clot's doing, and the clot is gone.
Leave the flap out (decompressive)
For the swollen, injured brain that will worsen overnight: the flap banked or stored, the skin closed over a brain given room.
The intraoperative brain is a prognosis being read in real time: a slack, pulsating brain closes normally; a tight one makes the team discuss tomorrow's pressure today. The decision is senior, shared and documented.
Leaving the OR
The handoff
- Procedure
- Right pterional craniotomy, extradural haematoma evacuated, MMA coagulated
- Pre-op course
- GCS 13 falling to 9 at induction; left pupil sluggish, recovered post-evacuation
- Closure
- Dural hitch stitches, flap replaced, extradural drain in
- Watch for
- Neuro obs and pupils hourly, drain output, sodium and seizure vigilance
A fictional educational patient, handed over the way real ones are.
The postoperative course
- POD 0The examination is the monitor: pupils and GCS charted against the pre-operative baseline, with any regression earning an immediate scan.
- POD 1-2Drain out, mobilisation, and often a rapid return toward baseline: the uninjured brain under an EDH recovers like the operation promised.
- POD 3-7The quieter agenda: seizure prophylaxis policy, sodium watching, wound care, and honest cognitive screening before discharge planning.
- WeeksHead-injury follow-up: fatigue, concentration and mood are the sequelae the scan cannot see, and the clinic should ask about them by name.
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