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Epidural hematoma

Last updated: September 20, 2021

Summarytoggle arrow icon

Intracranial epidural hematoma (EDH) refers to bleeding between the dura mater and the calvarium. Most cases of EDH are traumatic, resulting from a head injury with an associated skull fracture that ruptures or tears the middle meningeal artery, which lies in close proximity to the skull and dura mater. EDH is more common in individuals 20–30 years of age, as the dura mater is not yet densely adherent to the calvarium at this age. The classic manifestation of EDH is an initial loss of consciousness, followed by a lucid interval in which the patient gains normal or near-normal consciousness, followed by rapid neurological decline. An ipsilateral dilated pupil (anisocoria) and contralateral hemiparesis are manifestations of transtentorial uncal herniation and signal imminent neurological decline. Neuroprotective measures to prevent secondary brain injury take precedence over diagnostic tests. Diagnosis is confirmed on a noncontrast CT head, on which EDH appears as a biconvex, hyperdense lesion, typically in the temporal or temporoparietal region. Surgical decompression with craniotomy is indicated in patients with large EDH, GCS ≤ 8, and evidence of neurological deterioration. Small, asymptomatic EDH in patients with GCS > 8 can be managed conservatively with close observation and serial CT scanning. The prognosis depends on several factors, including the GCS at presentation, size of the EDH, and, crucially, the time from the onset of brain herniation to decompressive surgery. Early intervention in patients with signs of brain herniation is associated with good neurological outcomes and lower mortality rates.

For epidural hematoma limited to the spine, see “Spinal epidural hematoma.”

  • Incidence: occurs in approx. 10% of patients with moderate to severe traumatic brain injury (TBI) [3][4]
  • Sex: > (4:1)
  • Age [4]
    • Most commonly seen in individuals between 20–30 years
    • Uncommon in individuals older than 50 years of age

Epidemiological data refers to the US, unless otherwise specified.

Inciting event

  • Traumatic EDH
    • Head injury (most common; e.g., due to motor vehicle accidents, falls, assault) [2]
    • Traumatic removal of epidural catheter (especially in patients taking on anticoagulation medication)
  • Nontraumatic EDH (rare) [5][6]

Source of hemorrhage [2][7]

The features of EDH depend on the size and location of the hematoma. The majority of patients have an associated skull fracture.

A lucid interval is seen in up to 50% of patients with EDH. [11][12]

The majority (70–95%) of patients with EDH have an associated skull fracture. [2][8]

Neurological decline following a lucid interval can be rapid and fatal without urgent intervention. [14][15]

General principles [1][3]

  • Follow trauma protocols for patients with traumatic EDH
  • CT head without IV contrast is the first-line imaging modality for all patients with suspected EDH.
  • Imaging should not delay transfer for neurosurgical care in patients who already meet the criteria for intervention. [3]
  • In cases of rapidly declining neurological status or evidence of brain herniation, consider emergency temporizing surgery even in the absence of confirmatory imaging (see “Definitive management of EDH” below). [14][16]

Imaging [7][17]

CT head without IV contrast

  • Indications: first-line imaging in patients with suspected acute EDH
  • Characteristic findings
    • Biconvex (lenticular shaped), sharply demarcated extraaxial lesion
    • Typically hyperdense in appearance [7][18][19]
    • Limited by suture lines
    • Common locations
    • Evidence of skull fracture, if present
    • Initial CT scan may be normal in patients with delayed EDH and small lesions can quickly expand in size [21]

Noncontrast CT of the head is essential for diagnosing epidural hematoma.
The initial CT scan may be normal if the bleed is slow (e.g., small arterial EDH in the middle cranial fossa, venous EDH). Neuroimaging should be repeated if there are any signs of clinical deterioration in patients with neuroimaging that is initially normal.

MRI head without IV contrast [7][17]

  • Indications
    • Stable patients with suspected small EDH (i.e., normal or near-normal initial CT scan)
    • Follow-up neuroimaging in stable patients with neurological deterioration not explained by CT findings.
    • Difficulty distinguishing EDH from SDH on CT scan
  • Characteristic findings

Additional imaging

Laboratory studies

Epidural hematoma Subdural hematoma Subarachnoid hemorrhage Intracerebral hemorrhage Ischemic stroke
Etiology
Clinical features
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
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.

General principles

EDH is a neurosurgical emergency, as hematoma expansion can rapidly lead to brain herniation and death.

Expect rapid neurological deterioration following a lucid interval and do not delay initiation of therapy and patient transfer to a trauma center or neurocritical care unit. [4]

All patients with EDH require emergency neurosurgical consultation. If a neurosurgeon is not available on site, then transfer for definitive care is indicated.

Definitive management of EDH

Surgery [9]

Skull trephination should only be considered if there is evidence of brain herniation or coma attributable to an EDH and access to definitive neurosurgical care is delayed.

Conservative management

  • Indications: Absence of all indications for surgery (see above) [9][34][35]
  • Procedure
    • Admission to neuro-ICU or ICU [36]
    • Frequent GCS monitoring and neurological checks for at least 72 hours [3][36]
    • Serial CT scans to monitor for early hematoma expansion [37][37][38]
      • If clinically stable: Repeat within 4–6 hours.
      • Clinical deterioration or new neurologic deficits: Repeat immediately.
  • Failure of conservative management (EDH progression during observation): Perform craniotomy and hematoma evacuation. [34][36][37][38]
  • In patients with no other associated brain injury, early decompression is associated with good neurological outcomes, including full recovery. [30]
  • Factors associated with a worse prognosis [2][14][39]
    • GCS ≤ 8 at presentation
    • Pupillary abnormalities (especially fixed dilated pupil) at presentation
    • Prolonged period of time between onset of brain herniation and decompressive surgery
    • Age > 75 years [40]
    • Large volume EDH causing significant midline shift
    • Associated brain injuries

Every hour of delay from the onset of signs of brain herniation to decompressive surgery worsens the neurological outcome and increases the mortality rate. [14]

  1. Walls R, Hockberger R, Gausche-Hill M. Rosen's Emergency Medicine. Elsevier Health Sciences ; 2018
  2. Turtz AR, Goldman HW. Head Injury. Elsevier ; 2008 : p. 1385-1422
  3. American College of Surgeons and the Committee on Trauma. ATLS Advanced Trauma Life Support. American College of Surgeons ; 2018
  4. Johns P. Head injury. Elsevier ; 2014 : p. 105-114
  5. Saha B, Saha A. Spontaneous Epidural Hemorrhage in Sickle Cell Disease, Are They All the Same? A Case Report and Comprehensive Review of the Literature.. Case reports in hematology. 2019; 2019 : p.8974580. doi: 10.1155/2019/8974580 . | Open in Read by QxMD
  6. Moonis G, Granados A, Simon SL. Epidural hematoma as a complication of sphenoid sinusitis and epidural abscess: a case report and literature review.. Clin Imaging. undefined; 26 (6): p.382-5. doi: 10.1016/s0899-7071(02)00454-0 . | Open in Read by QxMD
  7. Mutch CA, Talbott JF, Gean A. Imaging Evaluation of Acute Traumatic Brain Injury.. Neurosurg Clin N Am. 2016; 27 (4): p.409-39. doi: 10.1016/j.nec.2016.05.011 . | Open in Read by QxMD
  8. Irie F, Le Brocque R, Kenardy J, Bellamy N, Tetsworth K, Pollard C. Epidemiology of traumatic epidural hematoma in young age.. J Trauma. 2011; 71 (4): p.847-53. doi: 10.1097/TA.0b013e3182032c9a . | Open in Read by QxMD
  9. Ganz JC. The lucid interval associated with epidural bleeding: evolving understanding. J Neurosurg. 2013; 118 (4): p.739-745. doi: 10.3171/2012.12.JNS121264 . | Open in Read by QxMD
  10. Levine Z. Mild traumatic brain injury: part 1: determining the need to scan.. Can Fam Physician. 2010; 56 (4): p.346-9.
  11. Zangbar B, Serack B, Rhee P, et al. Outcomes in Trauma Patients with Isolated Epidural Hemorrhage: A Single-Institution Retrospective Cohort Study.. Am Surg. 2016; 82 (12): p.1209-1214.
  12. Cushings Reflex and Triad. https://umem.org/educational_pearls/133/. Updated: February 3, 2017. Accessed: February 3, 2017.
  13. Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas.. Neurosurgery. 2006; 58 (3 Suppl): p.S7-15; discussion Si-iv.
  14. Nelson JA. Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma. Acad Emerg Med. 2011; 18 (1): p.78-85. doi: 10.1111/j.1553-2712.2010.00949.x . | Open in Read by QxMD
  15. Ramsay DA. Deaths: Trauma, Head and Spine – Pathology. Elsevier ; 2016 : p. 153-161
  16. Wilson MH, Wise D, Davies G, Lockey D. Emergency burr holes: "How to do it".. Scandinavian journal of trauma, resuscitation and emergency medicine. 2012; 20 : p.24. doi: 10.1186/1757-7241-20-24 . | Open in Read by QxMD
  17. Shetty VS, Reis MN, et al. ACR Appropriateness Criteria Head Trauma. Journal of the American College of Radiology. 2015 .
  18. Aguilar MI, Brott TG. Update in intracerebral hemorrhage.. The Neurohospitalist. 2011; 1 (3): p.148-59. doi: 10.1177/1941875211409050 . | Open in Read by QxMD
  19. Siddiqui FM, Bekker SV, Qureshi AI. Neuroimaging of hemorrhage and vascular defects.. Neurotherapeutics. 2011; 8 (1): p.28-38. doi: 10.1007/s13311-010-0009-x . | Open in Read by QxMD
  20. Douglas DB, Ro T, Toffoli T, et al. Neuroimaging of Traumatic Brain Injury.. Medical sciences (Basel, Switzerland). 2018; 7 (1). doi: 10.3390/medsci7010002 . | Open in Read by QxMD
  21. Summers LE, Mascott CR. Delayed epidural hematoma: presentation in a pediatric patient.. J La State Med Soc. 2001; 153 (2): p.81-4.
  22. Shankar JJ, Lum C, Chakraborty S, Dos Santos M. Cerebral vascular malformations: Time-resolved CT angiography compared to DSA.. The neuroradiology journal. 2015; 28 (3): p.310-5. doi: 10.1177/1971400915589682 . | Open in Read by QxMD
  23. Biswas S, Chandran A, Radon M, et al. Accuracy of four-dimensional CT angiography in detection and characterisation of arteriovenous malformations and dural arteriovenous fistulas.. The neuroradiology journal. 2015; 28 (4): p.376-84. doi: 10.1177/1971400915604526 . | Open in Read by QxMD
  24. Khoo YH. Non-Traumatic, Spontaneous Extra-Dural Haemorrhage: A Rare Neurosurgical Emergency of Beta-Thalassemia Major. Journal of Head Neck & Spine Surgery. 2019; 3 (5). doi: 10.19080/jhnss.2019.03.555625 . | Open in Read by QxMD
  25. Ng WH, Yeo TT, Seow WT. Non-traumatic spontaneous acute epidural haematoma -- report of two cases and review of the literature.. J Clin Neurosci. 2004; 11 (7): p.791-3. doi: 10.1016/j.jocn.2003.12.002 . | Open in Read by QxMD
  26. Thomas S, Makris M. The reversal of anticoagulation in clinical practice .. Clin Med. 2018; 18 (4): p.314-319. doi: 10.7861/clinmedicine.18-4-314 . | Open in Read by QxMD
  27. Puckett Y, Zhang K, Blasingame J, et al. Safest Time to Resume Oral Anticoagulation in Patients with Traumatic Brain Injury.. Cureus. 2018; 10 (7): p.e2920. doi: 10.7759/cureus.2920 . | Open in Read by QxMD
  28. Murthy SB, Wu X, Diaz I, et al. Non-Traumatic Subdural Hemorrhage and Risk of Arterial Ischemic Events.. Stroke. 2020; 51 (5): p.1464-1469. doi: 10.1161/STROKEAHA.119.028510 . | Open in Read by QxMD
  29. Abdelmalik PA, Draghic N, Ling GSF. Management of moderate and severe traumatic brain injury. Transfusion (Paris). 2019; 59 (S2): p.1529-1538. doi: 10.1111/trf.15171 . | Open in Read by QxMD
  30. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics.. PLoS Med. 2008; 5 (8): p.e165; discussion e165. doi: 10.1371/journal.pmed.0050165 . | Open in Read by QxMD
  31. Barker FG. Efficacy of Prophylactic Antibiotics Against Meningitis after Craniotomy: A Meta-Analysis. Neurosurgery. 2007; 60 (5): p.887-894. doi: 10.1227/01.neu.0000255425.31797.23 . | Open in Read by QxMD
  32. Alotaibi AF, Mekary RA, Zaidi HA, Smith TR, Pandya A. Safety and Efficacy of Antibacterial Prophylaxis After Craniotomy: A Decision Model Analysis.. World neurosurgery. 2017; 105 : p.906-912.e5. doi: 10.1016/j.wneu.2017.05.126 . | Open in Read by QxMD
  33. Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly.. J Emerg Med. 2010; 39 (3): p.377-83. doi: 10.1016/j.jemermed.2009.04.062 . | Open in Read by QxMD
  34. Chughtai KA, Nemer OP, Kessler AT, Bhatt AA. Post-operative complications of craniotomy and craniectomy. Emerg Radiol. 2018; 26 (1): p.99-107. doi: 10.1007/s10140-018-1647-2 . | Open in Read by QxMD
  35. Winn HR. Youmans and Winn Neurological Surgery. Elsevier ; 2016
  36. Gerard C, Busl KM. Treatment of Acute Subdural Hematoma. Curr Treat Options Neurol. 2013; 16 (1). doi: 10.1007/s11940-013-0275-0 . | Open in Read by QxMD
  37. Piepmeier JM, Wagner FC Jr. Delayed post-traumatic extracerebral hematomas.. J Trauma. 1982; 22 (6): p.455-60. doi: 10.1097/00005373-198206000-00003 . | Open in Read by QxMD
  38. Lewis A, Sen R, Hill TC, et al. Antibiotic prophylaxis for subdural and subgaleal drains.. J Neurosurg. 2017; 126 (3): p.908-912. doi: 10.3171/2016.4.JNS16275 . | Open in Read by QxMD
  39. Hamou HA, Kotliar K, Tan SK, et al. Surgical nuances and placement of subgaleal drains for supratentorial procedures—a prospective analysis of efficacy and outcome in 150 craniotomies. Acta Neurochir (Wien). 2020 : p.1-8. doi: 10.1007/s00701-019-04196-6 . | Open in Read by QxMD
  40. Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J. Epidural Hematoma Treated Conservatively: When to Expect the Worst. Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques. 2015; 43 (1): p.74-81. doi: 10.1017/cjn.2015.232 . | Open in Read by QxMD
  41. Maugeri R, Anderson DG, Graziano F, Meccio F, Visocchi M, Iacopino DG. Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature. American Journal of Case Reports. 2015; 16 : p.811-817. doi: 10.12659/ajcr.895231 . | Open in Read by QxMD
  42. Offner PJ, Pham B, Hawkes A. Nonoperative management of acute epidural hematomas: A “no-brainer”. The American Journal of Surgery. 2006; 192 (6): p.801-805. doi: 10.1016/j.amjsurg.2006.08.047 . | Open in Read by QxMD
  43. Oertel M, Kelly DF, McArthur D, et al. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury.. J Neurosurg. 2002; 96 (1): p.109-16. doi: 10.3171/jns.2002.96.1.0109 . | Open in Read by QxMD
  44. Jeong YH, Oh JW, Cho S. Clinical Outcome of Acute Epidural Hematoma in Korea: Preliminary Report of 285 Cases Registered in the Korean Trauma Data Bank System. Korean Journal of Neurotrauma. 2016; 12 (2): p.47. doi: 10.13004/kjnt.2016.12.2.47 . | Open in Read by QxMD
  45. Chen H, Guo Y, Chen SW, et al. Progressive epidural hematoma in patients with head trauma: incidence, outcome, and risk factors.. Emergency medicine international. 2012; 2012 : p.134905. doi: 10.1155/2012/134905 . | Open in Read by QxMD
  46. Haselsberger K, Pucher R, Auer LM. Prognosis after acute subdural or epidural haemorrhage.. Acta Neurochir (Wien). 1988; 90 (3-4): p.111-6. doi: 10.1007/bf01560563 . | Open in Read by QxMD
  47. Le roux AA, Nadvi SS. Acute extradural haematoma in the elderly. Br J Neurosurg. 2009; 21 (1): p.16-20. doi: 10.1080/02688690601170692 . | Open in Read by QxMD
  48. Vella MA, Crandall ML, Patel MB. Acute Management of Traumatic Brain Injury. Surg Clin North Am. 2017; 97 (5): p.1015-1030. doi: 10.1016/j.suc.2017.06.003 . | Open in Read by QxMD
  49. Makris M, Van Veen JJ, Tait CR, Mumford AD, Laffan M. Guideline on the management of bleeding in patients on antithrombotic agents. Br J Haematol. 2012; 160 (1): p.35-46. doi: 10.1111/bjh.12107 . | Open in Read by QxMD
  50. Frontera JA, Lewin III JJ, Rabinstein AA, et al. Guideline for Reversal of Antithrombotics in Intracranial Hemorrhage. Neurocrit Care. 2015; 24 (1): p.6-46. doi: 10.1007/s12028-015-0222-x . | Open in Read by QxMD
  51. Kaufman RM, Djulbegovic B, Gernsheimer T. Platelet Transfusion: A Clinical Practice Guideline From the AABB. Ann Intern Med. 2015; 162 (3): p.205-213. doi: 10.7326/M14-1589 . | Open in Read by QxMD
  52. Stolla M, Zhang F, Meyer MR, Zhang J, Dong J. Current state of transfusion in traumatic brain injury and associated coagulopathy. Transfusion (Paris). 2019; 59 (S2): p.1522-1528. doi: 10.1111/trf.15169 . | Open in Read by QxMD
  53. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018