The swirl sign is identified as a small area of low attenuation within an 
intracranial hyperattenuating clot on non-enhanced computed tomography (CT) 
scans of the brain, which represents active bleeding. The purpose of this study 
was to evaluate the incidence of the swirl sign among patients with acute 
epidural hematoma (AEDH) and to identify its prognostic value and impact on 
surgical treatment. A retrospective review was performed of patients with a 
diagnosis of traumatic EDH by CT scan who were surgically treated at the 
Department of Neurosurgery of the First People's Hospital of Jingmen between 
January 2010 and January 2014. Patients with combined or open craniocerebral 
injuries and those who did not undergo surgical treatment were excluded. Of the 
147 patients evaluated, 21 (14%) exhibited the swirl sign on non-enhanced CT 
scans of the brain. Univariate analysis revealed a significant correlation 
between the occurrence of the swirl sign and preoperative Glasgow coma scale 
scores, preoperative mydriasis, time from injury to CT scan, and intraoperative 
hematoma volume. Compared with patients without this sign, those exhibiting the 
swirl sign had a higher mortality rate (24 vs. 6%, respectively; P = 0.028) and 
a worse outcome (Glasgow Outcome Scale score ≤ 3: 38 vs. 15%, respectively; 
P = 0.027) at 3 months. An adjusted analysis showed that the occurrence of the 
swirl sign was an independent predictor of poor outcome (death: odds ratio 
(OR) = 4.61; 95% confidence interval (CI): 1.34-15.82; P < 0.05; 3-month Glasgow 
Outcome Scale score ≤ 3: OR = 3.47; 95% CI: 1.27-9.49; P < 0.05). In conclusion, 
the occurrence of the swirl sign on the head CT scan of patients with AEDH was 
found to be significantly associated with poor outcome. Therefore, early 
identification of this sign and aggressive management with early surgical 
evacuation is crucial for improving patient outcome.