• Clinical science

Epidural hematoma

Abstract

Epidural hematoma occurs as a result of head trauma and subsequent acute hemorrhage, primarily from the middle meningeal artery between the skull and the dura mater. Typical symptoms are due to compression of the brain and appear after a lucid interval that follows an initial loss of consciousness. Increased intracranial pressure leads to a decline in mental status and anisocoria, in which the ipsilateral pupil is dilated. Diagnosis is confirmed by CT (biconvex, hyperdense, sharply demarcated mass). Emergency treatment is necessary and involves neurosurgical opening of the skull and hematoma evacuation.

For epidural hematoma limited to the spine, see spinal epidural hematoma.

Epidemiology

  • Sex: > (4:1)
  • Peak incidence: 20–30 years

References:[1][2]

Epidemiological data refers to the US, unless otherwise specified.

Pathophysiology

References:[2][3]

Clinical features

  • Typical clinical course
    1. Initial loss of consciousness following head trauma
    2. Temporary recovery of consciousness (lucid interval)
    3. Renewed decline in mental status
  • Elevated intracranial pressure
  • Clinical signs of skull fracture (e.g., local hematoma, swelling, laceration)

Symptoms may appear directly after trauma or after a lucid interval!
References:[2][1][4][5]

Diagnostics

  • Imaging of choice: noncontrast head CT scan
    • Biconvex; , hyperdense lesion
    • Most epidural hematomas are located in the temporoparietal junction and are sharply demarcated.
    • Hematomas are limited by suture lines.
    • In some cases, an accompanying cranium fracture may be seen.

Noncontrast head CT scan is key for the diagnosis of epidural hematoma!

References:[3][2][1][6][7][8][9]

Differential diagnoses

Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intracerebral hemorrhage Ischemic stroke
Etiology
  • Traumatic rupture of middle meningeal artery
  • Most cases secondary to rupture of a saccular aneurysm or arteriovenous malformation (AVM)
  • Trauma
  • Most cases secondary to hypertension
  • Rupture of AVM
  • Trauma
  • Commonly due to embolisms, thrombi, or microangiopathic changes
  • Arterial hypertension and increasing age are the most important risk factors
Clinical features
  • Lucid interval, then loss of consciousness
  • Headache
  • Hemiplegia
  • Increasing headache over days or weeks
  • Changes in mental status
  • Less frequently: lucid interval
  • Sudden, severe headache
  • Loss of consciousness
  • Headache
  • Focal neurologic deficits
  • Loss of consciousness
  • Headache
  • Focal neurologic deficits
  • Loss of consciousness
CT findings
  • Biconvex, hyperdense lesion located between the brain and the calvarium, limited by suture lines
  • Crescent-shaped, homogenous lesion between the brain and the calvarium, not limited by suture lines
  • Extensive area of hyperdense signals around the circle of Willis (most common location)
Management
  • Surgical drainage
  • Surgical drainage
  • Medical therapy to reduce vasospasm
  • Surgical intervention: clipping or endovascular repair
  • Supportive care
  • Surgical clot removal (depends on the location and extent of the hemorrhage)

The differential diagnoses listed here are not exhaustive.

Treatment

Epidural hematoma is a medical emergency in which emergency craniotomy is essential!
References:[2][6][1][10]

Prognosis

  • Mortality rate: depends on preoperative condition of patient
    • Almost zero in patients without severe neurological impairment (GCS > 8)
    • Obtunded patients: ∼ 10%
    • Patients in deep coma: ∼ 20%
  • Factors associated with a worse prognosis
    • Low Glasgow Coma Scale scores before surgical intervention
    • Delay in treatment
    • Age > 75 years

References:[6][11][2][12]

  • 1. Liebeskind DS. Epidural Hematoma. In: Lutsep HL. Epidural Hematoma. New York, NY: WebMD. http://emedicine.medscape.com/article/1137065. Updated April 8, 2014. Accessed February 3, 2017.
  • 2. McBride W. Intracranial epidural hematoma in adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/intracranial-epidural-hematoma-in-adults. Last updated June 6, 2016. Accessed February 3, 2017.
  • 3. Granacher RP Jr. Traumatic Brain Injury: Methods for Clinical and Forensic Neuropsychiatric Assessment. CRC Press; 2007.
  • 4. Ganz JC. The lucid interval associated with epidural bleeding: evolving understanding. J Neurosurg. 2013; 118(4): pp. 739–745. doi: 10.3171/2012.12.JNS121264.
  • 5. Liferidge A. Cushings Reflex and Triad. https://umem.org/educational_pearls/133/. Updated February 3, 2017. Accessed February 3, 2017.
  • 6. Price DD. Epidural Hematoma in Emergency Medicine. In: Mills TJ. Epidural Hematoma in Emergency Medicine. New York, NY: WebMD. http://emedicine.medscape.com/article/824029. Updated October 27, 2016. Accessed February 3, 2017.
  • 7. Gentry LR, Godersky JC, Thompson B, Dunn VD. Prospective comparative study of intermediate-field MR and CT in the evaluation of closed head trauma. AJR Am J Roentgenol. 1988; 150(3): pp. 673–682. doi: 10.2214/ajr.150.3.673.
  • 8. Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol. 2002; 12(6): pp. 1237–1252. doi: 10.1007/s00330-002-1355-9.
  • 9. Mazzoni P, Pearson T, Rowland LP. Merritt's Neurology Handbook. Lippincott Williams & Wilkins; 2006.
  • 10. Nelson JA. Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma. Acad Emerg Med. 2011; 18(1): pp. 78–85. doi: 10.1111/j.1553-2712.2010.00949.x.
  • 11. Bricolo AP, Pasut LM. Extradural hematoma: toward zero mortality: A prospective study. Neurosurgery. 1984; 14(1): pp. 8–12. pmid: 6694798.
  • 12. Le roux AA, Nadvi SS. Acute extradural haematoma in the elderly. Br J Neurosurg. 2009; 21(1): pp. 16–20. doi: 10.1080/02688690601170692.
last updated 10/04/2018
{{uncollapseSections(['fpakKl', 'SpayKl', '_gc5Bb0', 'ipaJ6l', 'PpaWpl', 'kpampl', 'OpaIpl', 'Npa-pl'])}}