Epidural Hematoma

Aka: Epidural Hematoma, Epidural Hemorrhage

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II. Epidemiology

  1. Ages 2 to 60 years
    1. Dura matter adheres more tightly to skull outside these age ranges, and prevents blood accumulation
  2. Epidural Hematoma occurs in ~8% of Traumatic Brain Injury (worldwide)
    1. Often coexists with other CNS Hemorrhage (e.g. Traumatic Subarachnoid Hemorrhage, Subdural Hematoma)

III. Pathophysiology

  1. Epidural Hematoma results from Hemorrhage and blood accumulation between the skull and Dura Mater
    1. Associated with a Temporal Bone or parietal bone Skull Fracture in 75% of cases
  2. Involved vessels
    1. Middle meningeal artery accounts for 50% of surrgical cases
      1. Middle Meningeal Artery rupture
        1. middleMeningealArtery.jpg
    2. Other sources
      1. Dural venous sinuses (40% of surgical cases)

IV. Symptoms

  1. Timing of presentation depends on bleeding source (most present <24 hours)
    1. Arterial Epidural Hematomas (e.g. middle meningeal artery) develop rapidly (within hours)
    2. Dural Sinus Epidural Hematomas develop more slowly
  2. Headache
  3. Nausea and Vomiting
  4. Nuchal Rigidity

V. Signs: Pathognomonic Presentation

  1. Classic presentation occurs in only 20% of patients
  2. Loss of consciousness
  3. Period of lucency interspersed between 2 distinct periods of LOC
    1. Variably present and variable timing
    2. Absent in most cases, in which patient remains comatose without period of lucidity
  4. Loss of consciousness

VI. Signs: Transtentorial bleed findings

  1. Contralateral Hemiparesis
  2. Loss of consciousness eventually occurs
  3. Ipsilateral fixed and dilated pupil (Cranial Nerve III palsy) in 85% of cases
    1. Heralds impending Cerebral Herniation

VII. Imaging: CT Head

  1. Focal bleeding that does not typically cross Sutures
    1. Contrast with subdural which can extend fully anterior to posterior)
    2. Often in territory of middle meningeal artery (50% of cases)
  2. Convex "lens" (biconvex) appearance on CT
    1. Contrast with Subdural Hematoma with concave crescent facing inward (and convexity facing externally)
    2. Outside the dura, and therefore follows the inner skull surface
    3. Blood dissects between the skull and the tightly adherent dura
  3. Findings of continued bleeding
    1. Swirl sign or active extravasation may be seen when IV contrast is used
  4. Approximate Hematoma Volume calculation (ABC/2, elipse volume calculation)
    1. Precaution
      1. More accurate volume calculations may be done with manual tracing of the Hematoma
    2. Axial Slice (Transverse Plane): Identify CT slice in which Epidural Hematoma size is maximal
      1. A = Maximum Hematoma length (in cm)
      2. B = Maximum Hematoma width (in cm, along line perpendicular to A)
    3. Coronal Slice (Coronal Plane): Identify CT slice in which Epidural Hematoma size is maximal
      1. C = Maximum Hematoma height (in cm)
      2. If only axial slices are available
        1. C= SliceWidth x Number of axial CT slices on which Hematoma is visible
    4. Volume calculation
      1. Elipse volume = A * B * C /2
  5. Location of Epidural Hematoma
    1. Supratentorial
      1. Superior to the tentorium cerebelli (dural fold marking the upper border of the potserior fossa)
    2. Infratentorial
      1. Smaller confined space at higher risk of Brainstem Herniation than supratentorial Hematomas
      2. Surgical evacuation is performed at lower Hematoma volumes than supratentorial
  6. Other important characteristics of Epidural Hematomas
    1. Maximum thickness of Epidural Hematoma
    2. Midline shift
    3. Mass effect on adjacent structures

VIII. Precautions

  1. Epidural Hemorrhage may be rapidly fatal
    1. Mortality is 5 fold higher in delayed diagnosis

IX. Evaluation

  1. See Trauma Evaluation
  2. See Head Injury

X. Management

  1. See ABC Management
  2. See Management of Severe Head Injury
  3. See Increased Intracranial Pressure in Closed Head Injury
  4. Rapid assessment and management is key
  5. Emergent Neurosurgical Consultation
  6. Emergent decompression in the Emergency Department
    1. Indicated in imminent Cerebral Herniation (Ipsilateral fixed and dilated pupil) and delay to neurosurgery
    2. See Skull Trephination
  7. Neurosurgical decompression indications
    1. Epidural Hematoma width >15 mm
    2. Epidural Hematoma volume >30 ml (cm^3)
    3. Midline shift >5 mm
    4. Poor mental status (GCS <8)
    5. Impending brain Herniation
    6. Bullock (2006) Neurosurgery 58(3 suppl): S7-15 [PubMed]

XI. References

  1. Abuguyan (2024) Crit Dec Emerg Med 38(7): 4-11
  2. Broder and Lee (2026) Crit Dec Emerg Med 40(6): 24-7
  3. Dreis (2020) Crit Dec Emerg Med 34(7):3-21

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