eMedicine Specialties > Neurology > Critical Care Neurology

Epidural Hematoma: Differential Diagnoses & Workup

Author: David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center
Contributor Information and Disclosures

Updated: Mar 10, 2009

Differential Diagnoses

Alcohol (Ethanol) Related Neuropathy
Intracranial Hemorrhage
Anisocoria
Posttraumatic Epilepsy
Ankylosing Spondylitis
Spinal Cord Hemorrhage
Cervical Spondylosis: Diagnosis and Management
Spinal Epidural Abscess
Foix-Alajouanine Syndrome
Head Injury
Intracranial Epidural Abscess

Other Problems to Be Considered

Back pain
Spinal Cord Disease

Workup

Laboratory Studies

  • Complete blood count (CBC) with platelets - To monitor for infection and assess hematocrit and platelets for further hemorrhagic risk.
  • Prothrombin time (PT)/activated partial thromboplastin time (aPTT) - To identify bleeding diathesis.
  • Serum chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, and glucose - To characterize metabolic derangements that may complicate clinical course.
  • Toxicology screen and serum alcohol level - To identify associated causes of head trauma and establish need for surveillance with regard to withdrawal symptoms.
  • Type and hold an appropriate amount of blood - To prepare for necessary transfusions needed because of blood loss or anemia.

Imaging Studies

  • Plain radiography of the head (skull radiography) may reveal skull fractures, though CT scanning has largely replaced the use of skull radiography because the diagnostic information is so much greater with CT. Cervical spine radiographs with anteroposterior, lateral, and odontoid views are useful to identify associated traumatic fractures. Plain radiographs of the vertebral column may identify a cavernous angioma.
  • Myelography outlines the epidural space and may illustrate a space-occupying mass. CT myelography may be used when MRI is unavailable or if the patient cannot tolerate MRI.
  • Noncontrast CT scanning of the head not only visualizes skull fractures but also directly images an epidural hematoma.
    • Acute epidural hematoma may appear as a hyperdense lenticular-shaped mass situated between the brain and the skull, though regions of hypodensity may be seen with serum or fresh blood. On rare occasion, an acute epidural may appear completely isointense with respect to brain. Planoconvex or crescent-shaped epidural hematoma must be differentiated from subdural hemorrhage. Subacute lesions are homogenously hyperdense.
    • Chronic epidural hematoma may have a heterogeneous appearance due to neovascularization and granulation, with peripheral enhancement on contrast administration.
    • CT scanning may also depict air collections and displacement of brain parenchyma.
    • Clinical deterioration should prompt repeat imaging with CT scanning.
  • MRI also demonstrates the evolution of an epidural hematoma, though this imaging modality may not be appropriate for patients in unstable condition.
    • Spinal MRI may delineate the location of an epidural hematoma and identify an associated vascular malformation.
    • Spinal cord enhancement may be apparent and should be distinguished from inflammation or neoplasia.
    • Diffusion-weighted imaging with the use of periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) MRI may be used for improved detection of acute spinal epidural hematoma.3
    • Gadolinium-enhanced magnetic resonance arteriography (MRA) may further define the extent of an arteriovenous malformation.
  • Conventional angiography may be required to demonstrate definitively the presence of a vascular malformation.

Other Tests

Functional studies of the spinal cord, such as somatosensory evoked potentials, may be used for intraoperative monitoring or for prognostication following surgery.

Procedures

  • Emergent decompression with placement of a burr hole may be necessary when neurosurgical consultation is unavailable. For patients showing rapid deterioration with clinical signs of impending herniation, place a burr hole on the side of the dilating pupil. In the absence of a CT scan, place the burr hole 2 finger widths anterior to the tragus of the ear and 3 finger widths above the tragus of the ear.4
  • Lumbar puncture provides little additional information and may exacerbate neurologic damage.

More on Epidural Hematoma

Overview: Epidural Hematoma
Differential Diagnoses & Workup: Epidural Hematoma
Treatment & Medication: Epidural Hematoma
Follow-up: Epidural Hematoma
Multimedia: Epidural Hematoma
References
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References

  1. Huisman TA, Tschirch FT. Epidural hematoma in children: Do cranial sutures act as a barrier?. J Neuroradiol. Aug 11 2008;[Medline].

  2. Gouveia LO, Castanho P, Ferreira JJ, Guedes MM, Falcao F, e Melo TP. Chiropractic manipulation: reasons for concern?. Clin Neurol Neurosurg. Dec 2007;109(10):922-5. [Medline].

  3. Fujiwara H, Oki K, Momoshima S. PROPELLER diffusion-weighted magnetic resonance imaging of acute spinal epidural hematoma. Acta Radiol. Aug 2005;46(5):539-42. [Medline].

  4. Liu JT, Tyan YS, Lee YK. Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report. Acta Neurochir (Wien). Mar 2006;148(3):313-7. [Medline].

  5. Chang FC, Lirng JF, Luo CB. Evaluation of clinical and MR findings for the prognosis of spinal epidural haematomas. Clin Radiol. Jul 2005;60(7):762-70. [Medline].

  6. Arrese I, Lobato RD, Gomez PA. Hyperacute epidural haematoma isodense with the brain on computed tomography. Acta Neurochir (Wien). Feb 2004;146(2):193-4. [Medline].

  7. Awad JN, Kebaish KM, Donigan J. Analysis of the risk factors for the development of post-operative spinal epidural haematoma. J Bone Joint Surg Br. Sep 2005;87(9):1248-52. [Medline].

  8. Bejjani GK, Donahue DJ, Rusin J, Broemeling LD. Radiological and clinical criteria for the management of epidural hematomas in children. Pediatr Neurosurg. Dec 1996;25(6):302-8. [Medline].

  9. Berry C, Sandberg DI, Hoh DJ, Krieger MD, McComb JG. Use of cranial fixation pins in pediatric neurosurgery. Neurosurgery. Apr 2008;62(4):913-8; discussion 918-9. [Medline].

  10. Bezircioglu H, Ersahin Y, Demircivi F, et al. Nonoperative treatment of acute extradural hematomas: analysis of 80 cases. J Trauma. Oct 1996;41(4):696-8. [Medline].

  11. Borovich B, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg. Jul 1985;63(1):30-4. [Medline].

  12. Bozbuga M, Izgi N, Polat G, Gurel I. Posterior fossa epidural hematomas: observations on a series of 73 cases. Neurosurg Rev. 1999;22(1):34-40. [Medline].

  13. Cohen JE, Montero A, Israel ZH. Prognosis and clinical relevance of anisocoria-craniotomy latency for epidural hematoma in comatose patients. J Trauma. Jul 1996;41(1):120-2. [Medline].

  14. de Andrade AF, Figueiredo EG, Caldas JG, Paiva WS, De Amorim RL, Puglia P, et al. Intracranial vascular lesions associated with small epidural hematomas. Neurosurgery. Feb 2008;62(2):416-20; discussion 420-1. [Medline].

  15. De Souza M, Moncure M, Lansford T, Albaugh G, Tarnoff M, Goodman M, et al. Nonoperative management of epidural hematomas and subdural hematomas: is it safe in lesions measuring one centimeter or less?. J Trauma. Aug 2007;63(2):370-2. [Medline].

  16. Durand P, Adamson GJ. On-the-field management of athletic head injuries. J Am Acad Orthop Surg. May-Jun 2004;12(3):191-5. [Medline].

  17. Fukui MB, Swarnkar AS, Williams RL. Acute spontaneous spinal epidural hematomas. Am J Neuroradiol. Aug 1999;20(7):1365-72. [Medline].

  18. Guay J. Estimating the incidence of epidural hematoma - is there enough information?. Can J Anaesth. May 2004;51(5):514-5. [Medline].

  19. Heyman R, Heckly A, Magagi J. Intracranial epidural hematoma in newborn infants: clinical study of 15 cases. Neurosurgery. Nov 2005;57(5):924-9; discussion 924-9. [Medline].

  20. Holtas S, Heiling M, Lonntoft M. Spontaneous spinal epidural hematoma: findings at MR imaging and clinical correlation. Radiology. May 1996;199(2):409-13. [Medline].

  21. Ibanez J, Arikan F, Pedraza S. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. May 2004;100(5):825-34. [Medline].

  22. Knopman J, Tsiouris AJ, Souweidane MM. Atraumatic epidural hematoma secondary to a venous sinus thrombosis: a novel finding. J Neurosurg Pediatrics. Dec 2008;2(6):416-9. [Medline].

  23. Koch BL, Moosbrugger EA, Egelhoff JC. Symptomatic spinal epidural collections after lumbar puncture in children. AJNR Am J Neuroradiol. Oct 2007;28(9):1811-6. [Medline].

  24. Koenig MA, Bryan M, Lewin JL 3rd, Mirski MA, Geocadin RG, Stevens RD. Reversal of transtentorial herniation with hypertonic saline. Neurology. Mar 25 2008;70(13):1023-9. [Medline].

  25. Layton KF, Kallmes DF, Horlocker TT. Recommendations for anticoagulated patients undergoing image-guided spinal procedures. AJNR Am J Neuroradiol. Mar 2006;27(3):468-70. [Medline].

  26. Lee EJ, Hung YC, Wang LC, et al. Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery. J Trauma. Nov 1998;45(5):946-52. [Medline].

  27. Liu W, Ma L, Wen L, Shen F, Sheng H, Zhou B, et al. Drilling skull plus injection of urokinase in the treatment of epidural haematoma: a preliminary study. Brain Inj. Feb 2008;22(2):199-204. [Medline].

  28. McClelland S 3rd, Won EK, Lam CH. Utilization of recombinant activated factor VII for intracranial hematoma evacuation in coagulopathic nonhemophilic neurosurgical patients with normal international normalized ratios. Neurocrit Care. 2007;7(2):136-9. [Medline].

  29. Miller DJ, Steinmetz M, McCutcheon IE. Vertex epidural hematoma: surgical versus conservative management: two case reports and review of the literature. Neurosurgery. Sep 1999;45(3):621-4; discussion 624-5. [Medline].

  30. Muench MV, Zheng M, Bilica PM, Canterino JC. Prenatal diagnosis of a fetal epidural hematoma using 2- and 3-dimensional sonography and magnetic resonance imaging. J Ultrasound Med. Sep 2008;27(9):1369-73. [Medline].

  31. Narayan RK, Wilberger JE Jr, Povlishock JT, eds. Neurotrauma. First ed. New York: McGraw Hill; 1996.

  32. Pahapill PA, Lownie SP. Conservative treatment of acute spontaneous spinal epidural hematoma. Can J Neurol Sci. May 1998;25(2):159-63. [Medline].

  33. Park J, Kim GJ, Hwang SK. Thrombolytic evacuation of post-craniotomy epidural haematomas using closed suction drains: a pilot study. Acta Neurochir (Wien). Apr 2008;150(4):359-66; discussion 366. [Medline].

  34. Rivas JJ, Lobato RD, Sarabia R, et al. Extradural hematoma: analysis of factors influencing the courses of 161 patients. Neurosurgery. Jul 1988;23(1):44-51. [Medline].

  35. Ruppen W, Derry S, McQuay HJ, Moore RA. Incidence of epidural haematoma and neurological injury in cardiovascular patients with epidural analgesia/anaesthesia: systematic review and meta-analysis. BMC Anesthesiol. Sep 12 2006;6:10. [Medline].

  36. Servadei F. Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien). 1997;139(4):273-8. [Medline].

  37. Sokolowski MJ, Garvey TA, Perl J 2nd, Sokolowski MS, Cho W, Mehbod AA, et al. Prospective study of postoperative lumbar epidural hematoma: incidence and risk factors. Spine. Jan 1 2008;33(1):108-13. [Medline].

  38. Suzuki S, Endo M, Kurata A. Efficacy of endovascular surgery for the treatment of acute epidural hematomas. AJNR Am J Neuroradiol. Aug 2004;25(7):1177-80. [Medline].

  39. Tallon JM, Ackroyd-Stolarz S, Karim SA, Clarke DB. The epidemiology of surgically treated acute subdural and epidural hematomas in patients with head injuries: a population-based study. Can J Surg. Oct 2008;51(5):339-45. [Medline].

  40. Vitali AM, Steinbok P. Depressed skull fracture and epidural hematoma from head fixation with pins for craniotomy in children. Childs Nerv Syst. Aug 2008;24(8):917-23; discussion 925. [Medline].

  41. Wester K. Decompressive surgery for "pure" epidural hematomas: does neurosurgical expertise improve the outcome?. Neurosurgery. Mar 1999;44(3):495-500; discussion 500-2. [Medline].

  42. Whedon JM. Lumbar epidural hematoma after chiropractic manipulation for lower-back pain: case report. Neurosurgery. Aug 2008;63(2):E376; author reply E376. [Medline].

  43. Wysowski DK, Talarico L, Bacsanyi J, Botstein P. Spinal and epidural hematoma and low-molecular-weight heparin. N Engl J Med. Jun 11 1998;338(24):1774-5. [Medline].

  44. Yilmazlar S, Kocaeli H, Dogan S. Traumatic epidural haematomas of nonarterial origin: analysis of 30 consecutive cases. Acta Neurochir (Wien). Dec 2005;147(12):1241-8; discussion 1248. [Medline].

  45. Yuh EL, Gean AD, Manley GT, Callen AL, Wintermark M. Computer-aided assessment of head computed tomography (CT) studies in patients with suspected traumatic brain injury. J Neurotrauma. Oct 2008;25(10):1163-72. [Medline].

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Further Reading

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Keywords

epidural hemorrhage, extradural hematoma, extradural hemorrhage, cerebral epidural hematoma, spinal epidural hematoma, EDH, SEDH, head injury, intracranial epidural hematoma

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Contributor Information and Disclosures

Author

David S Liebeskind, MD, Associate Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California at Los Angeles; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center
David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Edward L Hogan, MD, Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina
Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Howard S Kirshner, MD, Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center
Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical Association
Disclosure: Boehringer Ingelheim Honoraria Speaking and teaching; BMS/Sanofi Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD, Professor, Department of Neurology, Oregon Health and Science University; Associate Director, Oregon Stroke Center
Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association
Disclosure: Co-Axia Consulting fee Review panel membership; Talecris Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Boehringer Ingelheim Honoraria Speaking and teaching; Concentric Medical Consulting fee Review panel membership; Abbott Consulting fee Consulting; Sanofi  Consulting

 
 
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