Extradural hematoma management: A case-control study with historical controls reassessing the 'zero mortality' goal

Introduction: Extradural hematoma (EDH) remains a significant cause of mortality following traumatic brain injury (TBI), although fatality rates have declined. This study examines whether improvements in a regional trauma and neurosurgical care system over four decades have enabled the achievement of the long-standing goal of "zero mortality" in surgically treated EDH. Research question: Has the evolution of a regional trauma and neurosurgical care system over four decades reduced mortality and moved towards the 'zero mortality' goal in surgically treated extradural hematomas? Materials and methods: We retrospectively reviewed all patients who underwent surgery for EDH at our institution between 2011 and 2021. Demographic, clinical, and radiological data were collected and compared in a case-control design with a historical cohort treated at the same center in the early 1980s, when the "zero mortality" concept was first proposed. Results: Among 85 contemporary cases, most patients were aged 41-61 years (previously 11-20), and falls were the leading cause of injury (55% vs. 50% due to road traffic accidents; p = 0.007). Direct presentations increased (65% vs. 33%; p < 0.001), and 96% arrived within 6 h (vs. 65%; p < 0.001). Surgery within 6 h occurred in 68% of cases. Referred patients experienced significantly longer delays. Craniotomy was performed in 94% of cases. In-hospital mortality was 2.4% (vs. 4.7%). Discussion and conclusions: Although system-wide improvements have reduced mortality, the "zero mortality" target remains unmet. Delays in referral and triage continue to pose challenges, particularly in complex or rapidly evolving cases.