CV

Epidural Hematoma

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Epidural Hematoma, Epidural Hemorrhage

  • See Also
  1. Head Injury
  2. Management of Severe Head Injury
  3. Increased Intracranial Pressure in Closed Head Injury
  4. Brainstem Herniation
  5. Neurovascular Anatomy
  6. Subarachnoid Hemorrhage
  7. Subdural Hematoma
  8. Intracerebral Hemorrhage
  • Epidemiology
  1. Ages 2 to 60 years
    1. Dura matter adheres more tightly to skull outside these age ranges, and prevents blood accumulation
  • 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 most cases
  2. Hemorrhage is typically from the meningeal arteries (85%), but may also arise from venous sinuses
  3. Middle Meningeal Artery rupture
    1. middleMeningealArtery.jpg
  • 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
  • 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
  • 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
  1. Focal bleeding in territory of middle meningeal artery (contrast with subdural which can extend fully anterior to posterior)
  2. Convex "lens" (biconvex) 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
    1. Mortality is 5 fold higher in delayed diagnosis
  • Evaluation
  1. See Trauma Evaluation
  2. See Head Injury
  • 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]
  • References
  1. Abuguyan (2024) Crit Dec Emerg Med 38(7): 4-11
  2. Dreis (2020) Crit Dec Emerg Med 34(7):3-21