The Swirl Sign and Its Relationship to Patient Outcomes in Extradural Hematomas: A Retrospective Investigation


  • Muhammad Ammad Ul Haq Neurosurgery
  • Muhammad Jazib Ijaz
  • Anam Ali
  • Sania Bhatti
  • Maheen Sabah
  • Eesha Yaqoob
  • Saad Javed



Introduction:" Swirl sign" is a relatively uncommon sign, seen on non-contrast CT scans in patients with head trauma who develop extradural hematoma the prognostic significance of which is controversial. This research aims to evaluate the predictive significance of the swirl sign in patients with an extradural hemorrhage.

Material and Methods:  It was a retrospective study and included 145 patients, with traumatic brain injury, who underwent surgical treatment at the Department of Neurosurgery Holy Family Hospital, Rawalpindi, Pakistan, between January 2022 and January 2023 and had traumatic EDH identified by computed tomography scan. Patients who did not undergo surgery or had combined or open craniocerebral injuries were eliminated. A Glasgow Outcome Scale score was used to evaluate outcomes after three months of traumatic brain injury. Mann-Whitney U test, the Chi-square test, and multivariate logistic regression were applied for descriptive and inferential analysis.

Results:  A total of 145 cases were evaluated, 19 (13.1%) demonstrated the sign on a CT scan of the brain. Analysis displayed a notable association between the incidence of the swirl sign and pupillary size, preoperative Glasgow Coma Scale score, time between trauma and first CT scan, and volume of hematoma measured intraoperatively. Patients displaying the swirl sign showed an increased mortality rate (25%) compared to patients without the swirl sign (5%) and worse outcomes at 3 months.

Conclusion:  The presence of the swirl sign on the CT scan had a significant association with worse outcomes. Early detection and prompt surgical evacuation are important for patients with this sign.


Nasi D, Iaccarino C, Romano A, De Bonis P, Farneti M, Servadei F, Ghadirpour R. Surgical management of traumatic supra and infratentorial extradural hematomas: our experience and systematic literature review. Neurosurgical Review. 2020 Jun;43(3):893-901.

Khairat A, Waseem M. Epidural hematoma. 2022 Jan

Yao YX, Li MX, Sun LJ. Good outcomes after the delayed removal of an epidural hematoma: a case report. Medicine (Baltimore). 2018 Apr. 97 (14):e0341.

Gutowski P, Meier U, Rohde V, et al. Clinical outcome of epidural hematoma treated surgically in the era of modern resuscitation and trauma care. World Neurosurg. 2018 Oct. 118:e166-e174.

Guo C, Liu L, Wang B, Wang Z. Swirl sign in traumatic acute epidural hematoma: prognostic value and surgical management. Neurological Sciences. 2017 Dec;38(12):2111-6.

Al-Nakshabandi NA. The swirl sign. Radiology. 2001 Feb;218(2):433-.

Gupta VK, Seth A. “Swirl sign” in extradural hematoma. World Neurosurgery. 2019 Jan 1;121:95-6.

Selariu E, Zia E, Brizzi M, Abul-Kasim K. Swirl sign in intracerebral haemorrhage: definition, prevalence, reliability and prognostic value. BMC neurology. 2012 Dec;12(1):1-6.

Beniwal HK, Reddy MS, Rao GP, Srikrishnaditya M, Beniwal A. Prognostic value of swirl sign in acute epidural hemorrhage. Asian J Neurosurg [Internet]. 2022;17(04):584–7. Available from:

Greenberg J, Cohen WA, Cooper PR. The “hyperacute” extraaxial intracranial hematoma: Computed tomographic findings and clinical significance. Neurosurgery [Internet]. 1985 [cited 2022 Dec 30];17(1):48–56. Available from:

Lee EJ, Hung YC, Wang LC, Chung KC, Chen HH. Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery. J Trauma [Internet]. 1998 [cited 2022 Dec 31];45(5):946–52. Available from:

Ono J, Yamaura A, Kubota M, Okimura Y, Isobe K. Outcome prediction in severe head injury: analyses of clinical prognostic factors. J Clin Neurosci [Internet]. 2001 [cited 2022 Dec 31];8(2):120–3. Available from:

Chen H, Guo Y, Chen S-W, Wang G, Cao H-L, Chen J, et al. Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors. Emerg Med Int [Internet]. 2012 [cited 2023 Jan 2];2012:134905. Available from:

Selariu E, Zia E, Brizzi M, Abul-Kasim K. Swirl sign in intracerebral haemorrhage: definition, prevalence, reliability and prognostic value. BMC Neurol [Internet]. 2012;12(1):109. Available from:

Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, et al. Surgical management of acute epidural hematomas. Neurosurgery [Internet]. 2006 [cited 2023 Jan 2];58(3 Suppl):S7-15; discussion Si-iv. Available from:

Araujo JLV, Aguiar U do P, Todeschini AB, Saade N, Veiga JCE. Análise epidemiológica de 210 casos de hematoma extradural traumático tratados cirurgicamente. Rev Col Bras Cir [Internet]. 2012 [cited 2023 Jan 2];39(4):268–71. Available from:

Paiva WS, Andrade AF de, Mathias Júnior L, Guirado VM de P, Amorim RL, Magrini NN, et al. Management of supratentorial epidural hematoma in children: report on 49 patients. Arq Neuropsiquiatr [Internet]. 2010 [cited 2023 Jan 2];68(6):888–92. Available from:

Yilmazlar S, Kocaeli H, Dogan S, Abas F, Aksoy K, Korfali E, et al. Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases. Acta Neurochir (Wien) [Internet]. 2005 [cited 2023 Jan 1];147(12):1241–8; discussion 1248. Available from:

Bezircioglu H, Ersahin Y, Demircivi F, Yurt I, Donertas K, Tektas S. Nonoperative treatment of acute extradural hematomas: Analysis of 80 cases. The Journal of Trauma: Injury, Infection, and Critical Care [Internet]. 1996 [cited 2023 Jan 2];41(4):696–8. Available from:

Leach P, Childs C, Evans J, Johnston N, Protheroe R, King A (2007) Transfer times for patients with extradural and subdural haematomas to neurosurgery in Greater Manchester. Br J Neurosurg 21:11–15

Tian HL, Chen SW, Xu T et al (2008) Risk factors related to hospital mortality in patients with isolated traumatic acute subdural haematoma: analysis of 308 patients undergone surgery. Chin Med J 121:1080–1084

Ng D, Churilov L, Mitchell P, Dowling R, Yan B. The CT swirl sign is associated with hematoma expansion in intracerebral hemorrhage. AJNR Am J Neuroradiol [Internet]. 2018;39(2):232–7. Available from:

Park BK, Kwak HS, Chung GH, Hwang SB. Diagnostic value of swirl sign on noncontrast computed tomography and spot sign on computed tomographic angiography to predict intracranial hemorrhage expansion. Clin Neurol Neurosurg [Internet]. 2019;182:130–5. Available from:






Original Articles