Emergency neurosurgery · London
Craniotomy for extradural haematoma — time is brain.
A neurosurgical emergency where arterial blood collects between the skull and the dura, usually after a temporal-bone fracture. The window to a full recovery is measured in hours — this is a plain-English guide for patients and families.
Why families choose us
- 01
On-call consultant neurosurgeon
Not a registrar making the call at 3am. A consultant neurosurgeon in the building, decision to theatre in minutes, not hours.
- 02
Dedicated neuro-anaesthetic team
A neuro-anaesthetist for induction, ICP-aware ventilation and osmotherapy — the difference between a good and a poor early recovery.
- 03
Neuro-ICU on the same floor
Post-op ICP monitoring, sedation holds and imaging happen in one place — not moved between hospitals mid-recovery.
Indicative costs
What the emergency pathway costs.
In a genuine emergency, the surgery itself is not privately booked — it happens on the nearest available emergency route. These figures are for planned adjuncts and later reconstruction.
In short
Aim: knife to skin within 60 minutes of the decision to operate — then a stay on neuro-ICU.
| Item | Indicative range | Typical duration | Turnaround |
|---|---|---|---|
| Emergency craniotomy + evacuation | Emergency care — insurer/NHS route | 60–120 min | Immediate |
| Decompressive hemicraniectomy | Emergency care — insurer/NHS route | 90–150 min | Immediate |
| ICP monitor insertion | £2,500–£5,000 | 20–30 min | Same visit |
| Neuro-ICU per day | £3,000–£5,500 | 24 hr | Ongoing |
| Post-op CT head | £450–£800 | 10 min | Same day |
| Cranioplasty (later reconstruction) | £8,000–£18,000 | 90 min | Weeks later |
Costs vary by hospital, length of ICU stay, and whether cranioplasty is needed months later. In a live emergency, focus on the nearest neurosurgical unit — the finance conversation follows the surgery, not the other way round.
The problem
Speed to CT, speed to theatre, speed to ICU.
An extradural haematoma is one of the few neurosurgical emergencies where prompt operating turns a fatal situation into a full recovery. Every step from ED to theatre is measured in minutes.
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Recognise the lucid interval
Any head-injured patient who deteriorates after a period of being awake deserves a CT scan urgently — not later.
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Bridge before the theatre
Rapid sequence intubation, controlled ventilation and osmotherapy stabilise the brain while the theatre is prepared.
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Operate before the pupil goes
Once the pupil has been fixed and dilated for hours, outcomes drop sharply. The operation is easier and better done sooner.
The pathway
ED → CT → theatre in under 60 minutes → ICU.
One coordinated pathway from resuscitation to recovery — trauma team, radiology, neurosurgery, neuro-anaesthesia and ICU pulling in the same direction.
Phase 1 · Emergency department
Recognition, imaging, activation
Phase 2 · Theatre
Craniotomy and evacuation
Phase 3 · Neuro-ICU
Monitoring and rehab
- 01
ED
Head injury and ED assessment
Trauma call, primary survey, GCS scored, C-spine protected. Any deterioration triggers imaging immediately.
- 02
ED
Urgent CT head within minutes
Non-contrast CT confirms the diagnosis — a lentiform biconvex hyperdense collection between skull and dura, usually temporal.
- 03
ED
Neurosurgery activated
The on-call consultant neurosurgeon is called, blood cross-matched, anaesthetic room prepared, next of kin informed.
- 04
Theatre
Rapid sequence intubation
Airway secured, ventilation controlled to a target CO₂. Mannitol or hypertonic saline given if there are signs of raised ICP.
- 05
Theatre
Emergency craniotomy in theatre
Aim: knife to skin within 60 minutes of the decision. Bone flap raised over the clot, haematoma evacuated, middle meningeal artery secured.
- 06
Theatre
Haemostasis and dural tack-up
The bleeding vessel is coagulated or clipped. The dura is hitched to the skull edges to prevent re-accumulation. Bone flap replaced.
- 07
After
Neuro-ICU, ICP and rehab
Sedation, ICP monitoring, seizure prophylaxis, early imaging at 24 hours. Rehabilitation begins as soon as it is safe.
Target door-to-theatre: under 60 minutes. Neuro-ICU stay: 2–5 days for uncomplicated cases.
When it happens
The presentations that mean call 999.
The classic patterns — plus the red flag that means a fixed dilated pupil, and no time to think about it.
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Head injury with a lucid interval
A classic story — knocked out briefly, wakes up talking, then deteriorates over the next few hours.
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Temporal-bone fracture on CT
A fracture crossing the middle meningeal artery groove is the commonest cause in adults after trauma.
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Sudden severe headache after a bump
A worsening one-sided headache after a head injury — even a seemingly minor one — that keeps building.
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Vomiting, drowsiness or confusion
Any change in level of consciousness after a head injury is a red flag for an expanding intracranial bleed.
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One-sided weakness or slurred speech
A dilating pupil on one side, weakness on the opposite side — signs the clot is pushing on the brain.
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Sports and cycling injuries
Boxing, rugby, cycling without a helmet — high-impact temporal blows are a recognised mechanism.
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Children after a fall
Kids can look surprisingly well before deteriorating fast. Any concerning story after a fall deserves urgent assessment.
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Red flag: fixed dilated pupil
A blown pupil, deep coma or agonal breathing after head injury is time-critical — 999, not a clinic call.
Surgical options
Craniotomy is the standard — with variations.
The choice depends on how swollen the brain is at operation, how quickly the patient reached theatre, and what facilities are available on the night.
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Standard craniotomy + evacuation
The gold-standard operation. A bone flap is raised, the clot removed, the middle meningeal artery secured, and the dura tacked up.
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Decompressive hemicraniectomy
For severe brain swelling: a larger bone flap is removed and left out, giving the brain room to swell without coning.
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Burr-hole evacuation
A resource-limited or damage-control option — a hole is drilled to release the clot when a full craniotomy is not immediately available.
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Intraoperative ICP monitor
A pressure bolt or ventricular drain placed at the time of surgery to guide the first 24–72 hours of neuro-ICU care.
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Cranioplasty (later)
Months later, if the bone flap was left out, a titanium or custom implant is used to restore the skull vault.
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Neuro-anaesthesia and osmotherapy
Mannitol, hypertonic saline and controlled ventilation as a bridge to theatre — not a substitute for surgery.
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Seizure prophylaxis
Levetiracetam or phenytoin is usually given for the first week to reduce the risk of early post-traumatic seizures.
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Rehabilitation pathway
Physio, occupational therapy and neuropsychology — planned from the ICU stay, not left until discharge.
Our vetted network
Neurosurgical units, we picked them.
Consultant neurosurgeons, neuro-anaesthetic teams and neuro-ICUs across London. In a live emergency the nearest unit is always the right one — we help with second opinions, transfers and rehabilitation.
Selection criteria
How we choose every neurosurgical unit in our network.
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Consultant neurosurgeons on call 24/7, not registrars unsupervised
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Dedicated neuro-anaesthetic and neuro-ICU teams on site
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CT and MRI available within minutes, seven days a week
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Rehabilitation pathway planned from the ICU stay, not the discharge letter
Risks and red flags
The complications worth knowing about — honestly.
Prognosis is genuinely excellent when operated promptly. It falls quickly with delay, coning, coagulopathy or associated brain injury — worth understanding before consent.
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Time is brain
Prognosis is excellent if operated within two hours of deterioration, and grim once the pupil has been fixed and dilated for more than six.
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Rapid deterioration and coning
An untreated extradural haematoma can go from talking to unresponsive in under an hour — the reason no head injury with a lucid interval is ignored.
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Pupil signs guide the surgery
A unilateral dilated pupil is a late sign of brain-stem compression. It is the trigger to move straight to theatre if imaging is not immediately available.
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Associated diffuse axonal injury
A big impact often causes shear injury as well as the clot. The craniotomy fixes the clot; the underlying brain injury declares itself over days.
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Coagulopathy and anticoagulants
Warfarin, DOACs and antiplatelets are reversed urgently. A known bleeding disorder changes the surgical and anaesthetic plan.
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Skull-base fracture with CSF leak
Clear fluid from the nose or ear after head injury suggests a base-of-skull fracture — antibiotics, watchful waiting, sometimes repair.
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Contralateral haematoma post-op
Occasionally, decompressing one side unmasks a bleed on the other. Post-op imaging at 24 hours is routine for this reason.
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DVT, PE and post-traumatic seizures
Immobility, brain injury and surgery all raise the risk. Prophylactic anticoagulation is timed carefully; anticonvulsants are used for the first week.
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Red flags after discharge
Worsening headache, new weakness, vomiting, seizures or fever after going home — 999, then the neurosurgical team.
Reading the operation note
The op note in four parts. Read the last one first.
The neurosurgeon’s note follows the same shape whether it was a straightforward evacuation or a decompressive hemicraniectomy.
A quiet reminder
Neurosurgical language is precise and can read coldly — we translate it for you.
If you would like us to talk you and the family through the note before the review, just ask.
- 01 Header
Mechanism, timing and admission GCS
How the injury happened, how long between injury and theatre, and the Glasgow Coma Score on arrival and just before intubation.
- 02 Technique
Craniotomy site and evacuation
The side and size of the bone flap, the volume of clot removed, and how the middle meningeal artery was secured.
- 03 Findings
Brain appearance and associated injury
Whether the brain was slack, tight or bulging, and any dural tears, contusions or shear injury noted at the time.
- 04 Impression
Prognosis and rehabilitation plan
Read this first: expected recovery, ICU length of stay, seizure-prophylaxis plan and the rehabilitation pathway from day one.
Recognised by major UK insurers
Emergency neurosurgery is generally covered under UK insurance and NHS emergency care. Later reconstruction (cranioplasty) and rehabilitation are usually covered — we confirm the route before booking.
Frequently asked
Everything patients and families ask about extradural haematoma.
Quick, plain-English answers on diagnosis, timing, surgery, ICU and prognosis.
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What is an extradural (epidural) haematoma?
A collection of blood between the inner surface of the skull and the dura mater — the tough outer covering of the brain. It is usually caused by a tear of the middle meningeal artery after a temporal-bone fracture, and it expands quickly because the bleeding is arterial.
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What is the "lucid interval" and why does it matter?
Classically the patient is knocked out briefly, wakes up talking, and then deteriorates over minutes to hours as the clot expands and compresses the brain. It is the reason no head injury with a period of unconsciousness is ever dismissed lightly.
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How is it diagnosed?
A non-contrast CT of the head. An extradural haematoma looks like a lens-shaped (lentiform, biconvex) bright collection that does not cross skull suture lines, most often over the temporal region, often with an overlying skull fracture.
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What is the treatment?
Urgent craniotomy — a bone flap is raised over the clot, the haematoma is evacuated, and the bleeding artery is secured. In severe swelling the bone flap may be left out (decompressive hemicraniectomy) and replaced later.
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How quickly does it need to be operated on?
As soon as possible after deterioration — ideally within one to two hours. Outcomes are excellent if surgery happens before the pupil dilates and consciousness is deeply lost, and poor once those signs have been present for more than six hours.
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What are the medical measures before surgery?
Rapid sequence intubation to protect the airway and control CO₂, mannitol or hypertonic saline to lower intracranial pressure, and reversal of any blood-thinning medication. These are a bridge to theatre — not a substitute for it.
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What happens after surgery?
Neuro-ICU: sedation, ICP monitoring, controlled ventilation, seizure prophylaxis and a repeat CT at around 24 hours. Rehabilitation — physiotherapy, occupational therapy, neuropsychology — starts as soon as it is safe.
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What is the prognosis?
Excellent if the operation is done promptly on a patient who is still talking or only mildly obtunded, with many people returning to full function. Prognosis is worse with delayed presentation, fixed dilated pupils, associated brain injury or coagulopathy.
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When should I call 999?
Any head injury followed by worsening headache, vomiting, confusion, drowsiness, weakness, a seizure, a dilating pupil, or loss of consciousness — even a brief one. This is not a call-your-GP situation.
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In practice, in London
Why private craniotomy for extradural haemotoma moves differently in London
For craniotomy for extradural haemotoma, the private London route is mostly about consultant fit and hospital choice rather than raw waiting time. The NHS route for craniotomy for extradural haemotoma is thorough, but the queue is real. Most patients we speak with have been told to expect anywhere from a handful of weeks to several months, depending on their local trust and how the referral is graded. Going private in London usually collapses that window to a matter of days — often the same week if the diary allows. It isn’t about jumping a queue so much as buying time back while you still have the flexibility to plan around it.
The mechanics are straightforward: a consultant appointment, any tests done at a nearby CQC-registered site, and a written report back within a few days. London’s density of private diagnostics — Marylebone, the City, Chelsea, Canary Wharf — means most patients can find something that fits around work without a cross-town trek. For craniotomy for extradural haemotoma in particular, we bias towards consultants who do this every week rather than every month.
There are a lot of consultants in London who can technically handle craniotomy for extradural haemotoma. Fewer who do it week in, week out for the exact question you’re bringing. We spend most of our time working out which is which — and being straight when a different test or a different specialist would serve you better. Everything runs to CQC, GMC and Royal College standards; the choice is about fit, not floor.