Epidural Hematoma


Epidural Hematoma, Epidural Hemorrhage

  • Pathophysiology
  1. Middle Meningeal Artery rupture
    1. middleMeningealArtery.jpg
  2. Results in blood accumulation between skull and dura
  3. Associated with a temporal bone Skull Fracture in most cases
  • Symptoms
  • Signs
  • Pathognomonic Presentation
  1. Loss of consciousness
  2. 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
  3. Loss of consciousness
  • Signs
  • Transtentorial bleed findings
  1. Contralateral Hemiparesis
  2. Ipsilateral fixed and dilated pupil (Cranial Nerve III palsy) in 85% of cases
    1. Heralds impending Cerebral Herniation
  1. Focal bleeding in territory of middle meningeal artery (contrast with subdural which can extend fully anterior to posterior)
  2. Convex "lens" appearance on CT (contrast with concave crescent in Subdural Hematoma)
    1. Outside the dura, and therefore follows the inner skull surface
    2. Blood dissects between the skull and the tightly adherent dura
  • Precautions
  1. Epidural Hemorrhage may be rapidly fatal
  • Evaluation
  • 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
    3. Midline shift >5 mm
    4. Poor mental status (GCS <8)
    5. Bullock (2006) Neurosurgery 58(3 suppl): S7-15 [PubMed]
  • References
  1. Dreis (2020) Crit Dec Emerg Med 34(7):3-21