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Epidural Hematoma Treatment & Management

  • Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD  more...
 
Updated: Apr 08, 2014
 

Medical Care

Initial resuscitation efforts should include assessment and stabilization of airway patency, breathing, and circulation. A thorough trauma evaluation is mandatory, including inspection for skull fractures and appreciation of the force and location of impact. Immobilization of the spine should be followed by emergent transfer of the patient to the nearest level I trauma center supported with neurosurgical consultation.

  • Triage and initial management of a patient with epidural hematoma may be tailored to the degree of neurological impairment at presentation. Alert patients may be evaluated with a CT scan following a brief neurologic examination.
  • A patient with a small epidural hematoma may be treated conservatively, though close observation is advised, as delayed, yet sudden, neurological deterioration may occur.
  • Trauma patients may require diagnostic peritoneal lavage and radiographs of the chest, pelvis, and cervical spine.
  • While neurosurgical consultation is requested, administer intravenous fluids to maintain euvolemia and to provide adequate cerebral perfusion pressure.
  • Patients with elevated intracranial pressure may be treated with osmotic diuretics and hyperventilation, with elevation of the head of the bed at an angle of 30 degrees. Patients who are intubated may be hyperventilated with intermittent mandatory ventilation at a rate of 16-20 breaths per minute and tidal volume of 10-12 mL/kg. A carbon dioxide partial pressure of 28-32 mm Hg is ideal, as severe hypocapnia (< 25 mm Hg) may induce cerebral vasoconstriction and ischemia.
  • Coagulopathy or persistent bleeding may require administration of vitamin K, protamine sulfate, fresh frozen plasma, platelet transfusions, or clotting factor concentrates.
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Surgical Care

Although several recent reports have described successful conservative management of epidural hematoma, surgical evacuation constitutes definitive treatment of this condition (see the image below). Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the bone and, occasionally, epidural drains are employed for as long as 24 hours.

CT scanning performed before and after surgical evCT scanning performed before and after surgical evacuation of an intracranial epidural hematoma.

See the list below:

  • Minimally invasive surgical procedures, including the use of burr holes and negative pressure drainage, may be used in selected cases.
  • Novel therapeutic approaches
    • Endovascular embolization to minimize bleeding during the acute stage
    • Thrombolytic evacuation using closed suction drain
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Consultations

See the list below:

  • Neurosurgeon (for potential emergent evacuation of the hematoma)
  • Neurologist
  • Rehabilitation specialist
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Diet

The hypermetabolic and catabolic phenomena associated with severe head injury necessitate caloric supplementation. Initiate enteral feedings as soon as possible.

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Activity

Patients who are treated conservatively should undergo close observation and should avoid strenuous activity. Inpatients should remain on bedrest during the initial phase; this can be followed by a progressive increase in activity.

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Contributor Information and Disclosures
Author

David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California, Los Angeles, David Geffen School of Medicine; 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, Stroke Council of the American Heart Association, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Neurological Association, American Society of Neurorehabilitation, American Academy of Neurology, American Heart Association, American Medical Association, National Stroke Association, Phi Beta Kappa, Tennessee Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, OHSU Stroke Center

Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology, American Stroke Association

Disclosure: Medscape Neurology Editorial Advisory Board for: Stroke Adjudication Committee, CREST2.

Additional Contributors

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, Society for Neuroscience, American Society for Biochemistry and Molecular Biology, American Academy of Neurology, American Neurological Association, Phi Beta Kappa, Sigma Xi, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.

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CT scanning performed before and after surgical evacuation of an intracranial epidural hematoma.
This MRI demonstrates spinal epidural hematoma.
 
 
 
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