Aim:Traumatic posterior fossa extradural hematoma (PFEDH) is a relatively rare entity with non-specific clinical presentation and management. The aim of this study is to perform a comparative analysis of conservative management with surgical decompression.Material and Methods:Between 2018 and 2022, 51 patients were admitted with PFEDH. Management decision was tailored by clinicoradiological findings. We did a prospective analysis of patient characteristics, radiology, clinical presentation, management, and outcome at discharge and one-month. Results:45/51(88.2%) were male, with mean age 31.2 years (2-77 years). 26 patients needed surgical evacuation, while 25 were managed conservatively. There was one crossover patient from the conservative to surgical arm. Road traffic accidents (RTA) were the most common cause of injury (n=35;68.6%), followed by falls from height (n=16;31.4%). Most patients presented with vomiting and loss of consciousness. At presentation, 30 patients(58.5%) had a GCS of 15. Seven patients(13.7%) presented with a GCS of 9-14, and 14 patients(27.5%) with GCS ≤ 8.Mean EDH volume in conservatively and surgically managed patients was 14.1 and 25.1cc, respectively. Five patients(9.8%) had significant midline shift with obliteration of basal cisterns, 15 patients(29.4%) had effacement of the fourth ventricle, and 11 patients(21.5%) had the presence of hydrocephalus. 24/ 25(96%) conservatively managed patients had favorable GOS scores at discharge.16/26(61.5%) surgically treated patients had a good outcome at discharge (GOS=4-5),while ten patients(38.4%) had adverse outcomes(GOS <4). Initial EDH volume was inversely correlated with presenting GCS and GOS with a mean volume of 21.5 ± 8.5 cc in patients presenting with a GCS ≤8. Conclusion:In patients with a clot volume of <15 cm3 and GCS of 15 at presentation with no mass effect and absence of TPF, a conservative trial under strict clinicoradiological monitoring in a neuro-critical multidisciplinary setting can be offered with good results. In cases of altered GCS, findings of a TPF, or clinicoradiological deterioration, immediate surgery is warranted.