• Clinical science
  • Physician

Epidural hematoma

Summary

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

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
  • Commonly due to embolisms, thrombi, or microangiopathic changes
  • Arterial hypertension and increasing age are the most important risk factors
Clinical features
  • 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]

Acute management checklist

  • Urgent neurosurgery consult for consideration of surgical intervention and ICP monitoring
  • Airway management: anesthesiology consult
  • Establish IV access.
  • Identify and treat any underlying coagulopathy.
  • Identify and treat any complications (e.g., elevated ICP, seizures)
  • Euthermia: antipyretics for fever
  • Euglycemia
  • Euvolemia: IV fluids for hypovolemia
  • Identify and treat the underlying cause.
  • Close observation and GCS monitoring
  • Admit to neurosurgical ICU.
  • Repeat CT head [13]
    • If clinically stable: Repeat within 4–8 hours.
    • In the case of clinical deterioration or new neurologic deficits: Repeat immediately.

Prognosis

  • Mortality rate: depends on preoperative condition of patient
    • Almost zero in patients without severe neurological impairment (GCS > 8)
    • 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][14][2][15]

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  • 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.
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last updated 03/30/2020
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