Traumatic brain injury (TBI) is a major global public health concern and remains one of the leading causes of death and long-term disability, particularly among young adults. It has a significant socioeconomic impact due to long hospital stays, rehab, and loss of productivity. Although the mortality and morbidity related to TBI have decreased over time due to progress in the treatment of trauma and neurosurgical management, TBI remains a significant cause of morbidity and mortality globally, particularly in low- and middle-income countries, where road traffic accidents are common [1]. Extradural hematoma (EDH) or epidural hematoma is a potentially life-threatening intracranial hemorrhage that results from the collection of blood between the inner table of the skull and the dura mater. Due to the possibility of rapid expansion of the hematoma, which increases intracranial pressure, causes cerebral herniation, and increases mortality if not treated promptly, EDH is a true neurosurgical emergency that constitutes about 3%–5% of the traumatic brain injuries (TBI) encountered in practice. Most EDHs are post-traumatic, and most frequently are associated with a fracture of the temporal or parietal bones [2,3]. Rupture of the middle meningeal artery is the most important cause of bleeding in EDH. However, bleeding from the dural venous sinuses or diploic veins may also play a role in individual cases. Posterior fossa EDH is relatively rare, and almost 90% of extradural hematomas occur in the supratentorial compartment. The cranial sutures usually confine the hematoma, and it appears biconvex on non-contrast computed tomography (CT) scan, the modality of choice for diagnosis [3,4]. The epidemiology of EDH shows that it is more common in males, especially young males, who have more exposure to high-energy trauma like road traffic accidents, falls from height, sports injuries, and interpersonal violence. Numerous studies have found that the 20-40 age group is the most affected population. EDH is more common in infants and older adults, but the firm adherence of the dura mater to the inner table of the skull in these age groups is a contributing factor [5]. Early recognition is vital because many patients have normal neurological function or may have a brief lucid interval before deteriorating rapidly clinically and radiologically. Prompt clinical and radiological evaluation is key [6]. Acute traumatic EDH requires treatment based on the hematoma size, neurological status, Glasgow Coma Scale (GCS) score, pupillary status, and radiological evidence of mass effect. The current guidelines for neurosurgery are that surgery is urgently required for hematoma volumes greater than 30 cm³, in cases where there is neurological deterioration, considerable midline shift, anisocoria, or deteriorating mental state. The early removal of a hematoma and craniotomy provides significantly better survival and functional outcome, while delayed intervention has been associated with poor neurological outcome and higher mortality [4,7]. The clinical features and prognosis of extradural hematoma have been reported in several studies. Still, there is a lack of detailed documentation of the patient population, anatomical distribution, and injury patterns across regions, especially in developing countries. Knowledge of such epidemiological features is essential for optimizing emergency management strategies, resource allocation, and preventive measures. Hence, the present study aimed to determine the age distribution and prevalence of common anatomical sites of acute traumatic extradural hematoma among patients who were treated surgically at a tertiary care neurosurgical center in Peshawar, Pakistan. The results may help expand the body of knowledge and help clinicians identify demographic and anatomical trends in this potentially lethal neurosurgical condition [8].

Study Design and Setting

This retrospective descriptive study was conducted in the Department of Neurosurgery, Lady Reading Hospital–Medical Teaching Institution (LRH-MTI), Peshawar, Pakistan, over six months from January 1, 2023, to June 30, 2023.

Sample Size and Sampling Technique

The sample size was calculated using the World Health Organization (WHO) sample size calculator, assuming an expected proportion of 45%, a 95% confidence level, and an 8% margin of error, yielding a required sample size of 43 patients. A non-probability purposive sampling technique was employed.

Study Population

A total of 43 consecutive patients with acute traumatic supratentorial extradural hematoma who underwent surgical evacuation were included. Patient information was retrieved from admission registers, operative records, medical records, and surgical reports.

Inclusion Criteria

Patients of either sex aged 1–60 years with radiologically confirmed acute traumatic supratentorial extradural hematoma who required surgical evacuation were included.

Exclusion Criteria

Patients younger than 1 year or older than 60 years, those with hematoma volumes less than 30 cm³, those managed conservatively, those with recurrent extradural hematomas, and those with incomplete medical records were excluded.

Diagnostic and Surgical Management

The diagnosis of extradural hematoma was established using non-contrast computed tomography (CT) of the brain. Hematoma volume was estimated using the Petersen and Espersen (ABC/2) formula, where A represents the greatest hematoma length, B the maximum width perpendicular to A, and C the number of CT slices multiplied by the slice thickness demonstrating the hematoma. Following initial trauma resuscitation according to Advanced Trauma Life Support (ATLS) principles and stabilization of airway, breathing, and circulation, eligible patients underwent emergency craniotomy under general anesthesia. The extradural hematoma was evacuated, meticulous hemostasis was achieved, and the craniotomy wound was closed in layers according to standard neurosurgical practice. Patients were subsequently monitored in the neurosurgical unit for postoperative complications and clinical recovery.

Data Collection

Demographic characteristics, mechanism of injury, age, preoperative Glasgow Coma Scale (GCS) score, anatomical location of the hematoma, postoperative complications, and Glasgow Outcome Scale (GOS) score at discharge and at one-month follow-up were recorded using a standardized data collection proforma.

Statistical Analysis

Data were analyzed using IBM SPSS Statistics version 29.0 (IBM Corp., Armonk, NY, USA). Continuous variables, including age, were summarized as mean ± standard deviation (SD) using the formulas Continuous variables, including age, were summarized as mean ± standard deviation (SD). In contrast, categorical variables were expressed as frequencies and percentages.

Mean (x̄) = Σx / n

Standard Deviation (SD) = √[Σ(x − x̄)² / (n − 1)]

Categorical variables were presented as frequencies and percentages. Since this was primarily a descriptive study, the results were summarized using descriptive statistics and presented in tables.

Table 1. Anatomical location of extradural hematoma

Distribution of acute traumatic extradural hematomas by anatomical location.

Table 2. Severity of traumatic brain injury at presentation

Distribution of patients according to admission Glasgow Coma Scale (GCS).

Table 3. Postoperative complications

Percentages are calculated among the 9 patients who developed postoperative complications.Distribution of postoperative complications following surgical evacuation of extradural hematoma.

Table 4. Glasgow Outcome Scale at discharge

FunctiOutcomes of patients assessed using the Glasgow Outcome Scale (GOS) at discharge.

Traumatic brain injury (TBI) remains a major cause of morbidity and mortality worldwide, particularly among young adults involved in road traffic accidents and other high-energy traumatic events. is one of the few neurosurgical emergencies in which early diagnosis, followed by timely surgery, can result in a good neurological outcome and a low mortality rate. Because of the possible development of high ICP and cerebral herniation, the need for prompt surgical intervention is underscored, and delayed recognition or treatment could lead to rapid neurological deterioration [10].The present study revealed a significant male predominance, with 76.7% of the patients being males, and the male: female ratio was 3.3:1. This is in accordance with other studies that indicated that males were affected more often due to a higher level of exposure at work, road traffic accidents, and outdoor activities. The male-to-female ratio of 69.4% and 3.66:1 were reported by Aurangzeb et al. and Tataranu et al., respectively, in patients with extradural hematoma, which is similar to the result obtained in the present study [11,12]. These findings are consistent with the known epidemiological characteristic of EDH being primarily seen in young adult males. Most patients in our study were aged between 20 and 30, making this the age group most commonly affected by EDH, when individuals are most productive and active.

Tariq et al. and Reaz et al. reported similar age distribution, with the second and third decades of life representing the largest proportions of surgically treated cases of EDH [13,14]. The higher incidence observed in this age group may be due to increased motor vehicle use, workplace injuries, and sports injuries. Assessment of neurological status at presentation revealed that most patients (83.7%) had moderate traumatic brain injury (Glasgow Coma Scale score 9–13). A similar study by Soon et al. showed that moderate neurological status was most commonly found in those who needed surgical evacuation. Similarly, Patel et al. found that most patients with EDH undergoing surgical decompression had admission GCS scores in the middle range of injuries, highlighting the need for prompt diagnosis and treatment to prevent neurological damage [15,16]. As far as anatomical distribution, in the present study the most common location was the parietotemporal region (37.2%).

This finding is similar to that reported by Kapoor et al. and Rosyidi et al., who also identified the parietotemporal region as the most common site of extradural hematoma. This distribution is due to the close association of the middle meningeal artery to the temporal-parietal aspect of the skull, which is a common site of traumatic vascular injury after skull fracture [16,17]. Our results also showed that the ratio of right- to left-sided extradural hematomas was approximately 2:1. While Ndoumbe et al. found the left side of the body to be more prone to hematomas, variations in injury mechanisms, regional trauma patterns, and patient characteristics could explain these differences [18]. However, the anatomical location of the hematoma seems to play a lesser role than other prognostic factors, including hematoma size, pre-hematoma neurological status, and hematoma evacuation timing. About 1/5 of patients developed some postoperative complications; recurrent extradural hematoma was the most common complication.

The overall morbidity in our study was similar to that of Bullock et al., who reported a postoperative morbidity rate of around 18% after surgical evacuation of EDH [19 These findings emphasize the importance of meticulous intraoperative hemostasis and careful postoperative neurological monitoring. The mortality rate observed in the present study was similar to that reported by Bayleyegn et al., who found similar results among patients treated in a resource-limited neurosurgical environment [20,21]. Advances in emergency transport, prompt neuroimaging, uniform trauma management, and timely neurosurgical treatment have significantly improved functional outcomes in the management of acute extradural hematoma [22]. This emphasizes the excellent prognosis of early diagnosis and timely surgical treatment, with a positive Glasgow Outcome Scale score (GOS 4–5) in more than 4/5 of patients in our cohort[23]. Overall, the findings of the present study are consistent with previously published literature and further support that young adult males constitute the highest-risk population for acute traumatic extradural hematoma. The predominance of parietotemporal lesions and the favorable postoperative outcomes observed in this study emphasize the importance of rapid diagnosis, early referral to specialized neurosurgical centers, and prompt surgical evacuation to minimize disability and mortality.

Limitations

This study has several limitations. It was conducted at a single tertiary care center with a relatively small sample size, limiting the generalizability of the findings. The retrospective design may also have introduced selection and information bias. Furthermore, long-term neurological outcomes beyond one month were not evaluated.

Acute traumatic extradural hematoma predominantly affected young adult males, with the 20–30-year age group being the most commonly involved. The parietotemporal region was the most frequent anatomical location. Most patients presented with moderate traumatic brain injury and achieved favorable neurological outcomes following timely surgical evacuation. Early diagnosis, prompt referral, and immediate neurosurgical intervention remain the key determinants of successful management and improved survival.

Recommendation

Large-scale, prospective, multicenter studies are recommended to characterize better the epidemiology, clinical presentation, and long-term outcomes of acute traumatic extradural hematoma. Strengthening trauma referral systems, ensuring rapid neuroimaging, and minimizing delays in surgical intervention may further improve patient outcomes.

Ethical Approval

This study was approved by the Institutional Review Board (IRB)/Ethical Review Committee of Lady Reading Hospital–Medical Teaching Institution (LRH-MTI), Peshawar, Pakistan. The study was conducted in accordance with the principles of the Declaration of Helsinki.

Consent to Participate

As this was a retrospective review of hospital records, the requirement for written informed consent for participation was waived by the Institutional Review Board. Patient confidentiality and anonymity were strictly maintained throughout the study.

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