eMedicine Specialties > Neurology > Critical Care Neurology

Epidural Hematoma: Follow-up

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

Follow-up

Further Inpatient Care

Following initial management in the emergency department, the patient may be sent for emergent neurosurgical evacuation of the hematoma or may be transferred to the ICU for further care. Subsequent care generally includes the following:

  • Serial neurologic examinations
  • Treatment of elevated intracranial pressure
  • Avoidance of hypotension or hypertension (ie, maintain mean arterial pressure [MAP] between 70-130 mm Hg)
  • Use of isotonic solutions, such as normal saline, to minimize cerebral edema
  • Avoidance of hyperthermia
  • Treatment or prevention of posttraumatic seizures
  • Observation and potential repair of CSF leaks
  • Treatment of urinary tract infections
  • Prevention of venous thrombosis
  • Prophylaxis for gastric ulcers
  • Physical, occupational, and speech therapy
  • Repeat CT scan for clinical deterioration

Further Outpatient Care

After hospital discharge, continued physical, occupational, and speech therapy may be required.

Inpatient & Outpatient Medications

  • Mannitol or other osmotic diuretics for elevated intracranial pressure
  • Steroids for spinal cord compression
  • Acetaminophen for fever
  • Subcutaneous heparin for prevention of venous complications
  • Famotidine or other antacids for gastric ulcer prophylaxis
  • Fosphenytoin or other anticonvulsants for posttraumatic seizures
  • Anticholinergics for bladder complications
  • Baclofen, diazepam, or tizanidine for spasticity due to spinal cord damage
  • Amitriptyline, carbamazepine, or gabapentin for neuropathic pain

Transfer

Although emergent decompression of an epidural hematoma should not be delayed, trauma patients should be transferred to centers with neurosurgical expertise.

Deterrence/Prevention

  • Educate the public regarding traumatic brain injury, including appropriate use of safety equipment, precautions, and measures that may reduce the incidence of head injury.
  • Avoid lumbar puncture or epidural anesthesia in individuals on anticoagulation, following thrombolysis, or when a bleeding diathesis is suspected.

Complications

  • Neurological deficits or death may occur.
  • Posttraumatic seizures due to cortical damage may develop 1-3 months after the initial injury, with decreasing frequency over time. Alcoholism increases the risk of posttraumatic seizures.
  • Delayed effects of an epidural hematoma include the postconcussion syndrome, which is characterized by headaches, dizziness, vertigo, restlessness, emotional lability, inability to concentrate, and fatigue.
  • Spinal epidural hematoma may cause spasticity, neuropathic pain, and urinary complications.

Prognosis

  • Declines with advancing age
  • Deteriorates when associated with other intracranial injuries
  • Depends on the initial Glasgow Coma Scale score (0% mortality for awake patients, 40% mortality for comatose individuals)
  • Worsens with delays between injury and surgical intervention
  • In spinal epidural hematoma, the MRI appearance of T2-hyperintensity within the spinal cord may portend a poor clinical outcome.5

Patient Education

Educate patients regarding prevention of traumatic brain injury, with particular emphasis on sports injuries, use of safety precautions, and proper use of safety equipment.

Miscellaneous

Medicolegal Pitfalls

  • Consider epidural hematoma in all patients who have experienced head injury.
  • Alteration in the level of consciousness may be highly variable and unreliable as a clinical predictor.
  • Obtain CT scan whenever possible.
  • Skull fractures are not always present, particularly in children.
  • Delayed transfer and triage may be the principal determinant of death.
  • Close observation requires frequent neurologic evaluations.
 


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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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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