Types of intracranial hematomas
Epidural hematoma (EDH): Blood accumulates between the skull and the outer covering of the brain (the dura), most commonly from a torn middle meningeal artery after temporal bone fracture. EDHs can expand rapidly and require urgent surgical evacuation. With timely surgery, outcomes are often very good even for patients who have deteriorated.
Acute subdural hematoma (ASDH): Blood accumulates between the dura and the brain surface. Often associated with significant underlying brain injury. Outcomes are more variable than for EDH and depend heavily on the degree of brain injury at the time of presentation.
Chronic subdural hematoma (CSDH): A slowly accumulating collection, often in older patients after minor or unrecognized trauma. Presents over weeks with headache, confusion, or focal weakness. Many are successfully drained through burr holes under local anesthesia — a less invasive approach than formal craniotomy.
Intracerebral hemorrhage (ICH): Bleeding within the brain parenchyma itself. Surgical evidence for ICH evacuation is more nuanced — most ICH is managed medically, and surgery is reserved for patients with large accessible hemorrhages causing progressive deterioration, or cerebellar hemorrhages compressing the brainstem.
The decision to operate
Timing is critical for acute hematomas. The interval between deterioration and decompression is one of the most important determinants of outcome. For chronic subdurals, the decision is based on symptom severity, hematoma size, and patient overall condition.
Not all hematomas require surgery. Smaller collections in neurologically intact patients may be safely observed with serial imaging. The decision to operate — and the approach chosen — is individualized to the clinical picture.