A 28-year-old patient sustains a severe head injury (GCS 7). CT shows a right-sided extradural hematoma (EDH) with a biconvex hyperdense collection and midline shift of 10 mm. Which arterial vessel is most commonly responsible, and what is the neurosurgical threshold for urgent evacuation?

• A Bridging cortical vein; any symptomatic EDH regardless of size
• B Anterior cerebral artery; GCS deterioration alone is the threshold
• C Middle meningeal artery; only if GCS falls below 8 regardless of CT findings
• D Middle meningeal artery; clot volume >30 mL or midline shift >5 mm or clot thickness >15 mm ✓

Explanation

The middle meningeal artery (running in a groove in the temporal bone) is torn in approximately 80% of EDHs, typically following temporal bone fractures. The hematoma accumulates between the skull and dura (extradurally), producing the classic biconvex/lenticular hyperdense appearance. Surgical evacuation criteria (NICE/BTF guidelines): hematoma volume >30 mL, clot thickness >15 mm, or midline shift >5 mm — regardless of GCS. This patient with 10 mm midline shift requires urgent craniotomy and hematoma evacuation.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.