Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Epidural Hematomas Treatment & Management

  • Author: Jamie S Ullman, MD; Chief Editor: Brian H Kopell, MD  more...
 
Updated: Apr 14, 2016
 

Medical Therapy

Treatment of the epidural hematoma depends on various factors. The adverse effect on brain tissue is mainly from mass effect causing structural distortion, life-threatening brain herniation, and increased intracranial pressure.

The 2 treatment options for these patients are (1) immediate surgical intervention and (2) initial, conservative, close clinical observation with possible delayed evacuation. Note that EDHs tend to expand in volume more rapidly than subdural hematomas, and patients require very close observation if the conservative route is taken.

Not all cases of acute EDH require immediate surgical evacuation.[13, 14] If a lesion is small and the patient is in good neurological condition, observing the patient with frequent neurological examinations is reasonable. Acute anterior temporal tip EDH are one subset of this entity which runs a benign course and can usually be followed with imaging and observation. The likely venous origin of these EDH contributes to slow expansion and eventual tamponade of the bleeding source.[4]

In a retrospective review over a 5-year period of EDH patients who were initially triaged for conservative management, only 11.2% required surgery. Statistical comparison showed that younger age and coagulopathy were the only significant factors for conversion to surgery.[15]

Although conservative management is often left to clinical judgment, the "Guidelines for the Surgical Management of Traumatic Brain Injury" recommended that patients who exhibit an EDH that is less than 30 mL, less than 15-mm thick, and less than 5-mm midline shift, without a focal neurological deficit and GCS greater than 8 can be treated nonoperatively.[16] Early follow-up scanning should be used to assess a further increase in hematoma size prior to deterioration. Delayed epidural formation has been reported. If a rapid size increase is noted and/or the patient develops anisocoria or a neurological deficit, then surgery is indicated. Middle meningeal artery embolization has been described in the early stages of EDH, especially when angiographic dye extravasation has been observed (see Future and Controversies).

When treating patients with spontaneous EDH, the underlying primary disease process must be addressed in addition to the fundamental principles discussed above.

Next

Surgical Therapy

According to the "Guidelines for the Management of Traumatic Brain Injury,"[16] EDH with volume greater than 30 mL should undergo surgical evacuation, regardless of GCS.[16] This criterion becomes especially important when the EDH exhibits thickness of 15 mm or more, and a midline shift beyond 5 mm. Most patients with such an EDH experience a worsening of the conscious state and/or exhibit lateralizing signs.

Location is also an important factor in the surgical decision. Temporal hematomas, if they are large or expanding, may lead to uncal herniation and more rapid deterioration. EDH in the posterior fossa, which is often related to interruption of the lateral venous sinus, often requires prompt evacuation because of the limited space available compared with the supratentorial compartment (see the images below).[17]

CT image of a pre-adolescent male with a left post CT image of a pre-adolescent male with a left posterior fossa epidural hemorrhage (EDH). Such hemorrhages need to be watched carefully, and the surgical team should have a low threshold for surgical intervention because this region has less room to accommodate mass lesions.
Bone window of the same patient as Media file 6 th Bone window of the same patient as Media file 6 that reveals a diastasis (separation) of the left mastoid suture.

Before the advent of CT scanning, drilling exploratory burholes was commonplace, especially when the patient demonstrated lateralizing signs or rapid deterioration. Currently, with fast-scan techniques, this type of exploration is rarely required.

Currently, drilling exploratory burholes is reserved for the following patients:

  • Patients with definitive localizing signs and clinical evidence of intracranial hypertension who are unable to tolerate a CT scan because of severe hemodynamic instability
  • Patients who require immediate surgical intervention for systemic injuries

Reports have emerged that discuss burholes with negative pressure drainage as a primary mode of EDH treatment in select patients (ie, those patients awaiting transfer to a higher level trauma facility or patients with hemorrhages of nonarterial origin; see Future and Controversies).[18] However, despite these reports, craniotomy remains the standard.

Previous
Next

Preoperative Details

Patients are brought to the operating room as quickly as possible after CT scanning. The body is supine, and the head is placed on a donut or horseshoe head holder. Three-point head clamps that are often used for intracranial surgery are not routinely used by the authors because they may propagate existing skull fractures.

Occipital or posterior fossa EDH requires positioning in the lateral, semiprone, or prone position. Three-point head clamps are then used for stable head fixation and are applied with care.

If the cervical spine is not adequately cleared for fracture or instability in patients with trauma, a hard cervical collar is kept in place.

Previous
Next

Intraoperative Details

Surgical treatment of epidural hematomas involves opening the calvaria over the site of the hemorrhage. The EDH is readily apparent after elevating the bone flap, and it is removed. Coagulation of bleeding dural vessels is usually performed. Epidural tack-up sutures are placed from the dura to the craniotomy bone edge and to the center of the craniotomy flap to tamponade epidural bleeding from areas beyond the craniotomy edges and to prevent recurrence. Dural venous sinus bleeding is controlled with tamponade by gelatin sponges and cotton strips and head-of-the-bed elevation, taking care to avoid venous air embolism. The utmost care should be taken when elevating depressed bone fragments on or near the dural venous sinuses. If present, the Cushing response remains untreated until it resolves spontaneously as the mass effect is relieved.

If the patient presents with a dilated pupil or clinical signs of intracranial hypertension, a small incision is first made in an area considered to be over the hematoma. A rapid burhole is made, and the epidural is partially evacuated. This maneuver often allows for some initial pressure relief until the entire epidural blood clot can be evacuated.

If other significant intracranial injuries (eg, subdural hematoma, intracerebral hematoma) are apparent after imaging or upon direct visualization, they are surgically evacuated as needed. Intraoperative ultrasound is sometimes helpful in identifying such lesions. Occasionally, the bone flap (decompressive craniectomy) may not be reattached to the skull and is instead stored in a freezer, discarded, or preserved in the abdominal fat layer. This occurs when significant intracerebral swelling or injury is noted on the initial CT scan or encountered during the operation or if intractable intracranial hypertension develops in the postoperative period. Such decompression can allow for further brain expansion.

Previous
Next

Postoperative Details

Patients are usually treated in the ICU or a monitored setting until they improve. Associated intracranial or systemic injuries are managed as needed. Depending on their neurological condition and radiographic findings, some patients may require intracranial pressure monitoring.

Previous
Next

Follow-up

Follow-up CT scans are performed to determine the extent of clot evacuation. These scans can also help evaluate for delayed hematomas.

Previous
Next

Complications

Many of the complications from EDH occur when the pressure they exert results in significant brain shifting. When the brain is subject to subfalcine herniation, the anterior and posterior cerebral arteries may occlude, resulting in cerebral infarction.

Downward herniation of the brain stem can result in Duret hemorrhages within the brainstem, mostly in the pons.

Transtentorial herniation may result in an ipsilateral cranial nerve III palsy, which often takes many months to resolve once the pressure is relieved. Cranial nerve III palsy manifests as ptosis, pupillary dilation, and the inability to move the eye in medial, upward, and downward directions.

In children younger than 3 years, a skull fracture may result in a leptomeningeal cyst or a growing fracture. These cysts are believed to occur when brain pulsation and growth do not allow the fracture to heal, thus expanding a dural tear and enlarging the edge of the fracture. Patients with a leptomeningeal cyst usually develop a pulsatile scalp mass.

Previous
Next

Outcome and Prognosis

Although the ultimate goal is to achieve 0% mortality and 100% good functional outcomes, the overall mortality in most series of patients with EDH ranges from 9.4-33%, averaging approximately 10%. In general, the preoperative motor examination, the Glasgow Coma Scale score, and pupillary reactivity are significantly correlated to the functional outcome of patients with acute epidural hematomas when they survive. Because many isolated epidural hematomas do not involve underlying structural brain damage, the overall outcome is excellent if prompt surgical evacuation is undertaken.

Previous
Next

Future and Controversies

Epidural hematoma is an emergent neurosurgical disease that can be managed with close clinical and radiographic observation or surgical evacuation. Most cases involve skull fractures over the lateral convexities of the hemispheres, with rupture of middle meningeal artery branches. Prompt diagnosis and appropriate management have resulted in low mortality and excellent functional outcomes.

With growing interest and experience in minimally invasive techniques, the value of burhole evacuation with negative pressure may need to be further investigated.[18] In addition, endovascular approaches may be a new avenue for investigation. In 2004, Suzuki et al reported on 9 patients undergoing embolization of the middle meningeal artery during the early stages of epidural hematoma formation to arrest further expansion. This therapy was reserved for patients who demonstrated contrast dye extravasation on CT scans. The desired result was achieved in all 9 patients.

Previous
 
Contributor Information and Disclosures
Author

Jamie S Ullman, MD Associate Professor, Department of Neurosurgery, Mount Sinai School of Medicine; Director, Department of Neurosurgery, Elmhurst Hospital Center

Jamie S Ullman, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Anthony Sin, MD, MD 

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.

Ryszard M Pluta, MD, PhD Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Polish Society of Neurosurgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

References
  1. Maugeri R, Anderson DG, Graziano F, Meccio F, Visocchi M, Iacopino DG. Conservative vs. Surgical Management of Post-Traumatic Epidural Hematoma: A Case and Review of Literature. Am J Case Rep. 2015 Nov 14. 16:811-7. [Medline].

  2. Bir SC, Maiti TK, Ambekar S, Nanda A. Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States. Clin Neurol Neurosurg. 2015 Nov. 138:99-103. [Medline].

  3. Hamlat A, Heckly A, Adn M, Poulain P. Pathophysiology of intracranial epidural haematoma following birth. Med Hypotheses. 2006. 66(2):371-4. [Medline].

  4. Gean AD, Fischbein NJ, Purcell DD, et al. Benign anterior temporal epidural hematoma: indolent lesion with a characteristic CT imaging appearance after blunt head trauma. Radiology. 2010 Oct. 257(1):212-8. [Medline].

  5. Singh S, Ramakrishnaiah RH, Hegde SV, Glasier CM. Compression of the posterior fossa venous sinuses by epidural hemorrhage simulating venous sinus thrombosis: CT and MR findings. Pediatr Radiol. 2016 Jan. 46 (1):67-72. [Medline].

  6. Ullman JS. Cerebrovascular pathophysiology and monitoring in the neurosurgical intensive care unit. Andrews BT. Intensive Care in Neurosurgery. New York: Thieme; 2003. 29-46.

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

  8. Fishpool SJ, Suren N, Roncaroli F, Ellis H. Middle meningeal artery hemorrhage: an incorrect name. Clin Anat. 2007 May. 20(4):371-5. [Medline].

  9. Mayr R, Troyer S, Kastenberger T, et al. The impact of coagulopathy on the outcome of traumatic epidural hematoma. Arch Orthop Trauma Surg. 2012 Jun 8. [Medline].

  10. Al-Nakshabandi NA. The swirl sign. Radiology. 2001 Feb. 218(2):433. [Medline].

  11. Arrese I, Lobato RD, Gomez PA, Nunez AP. Hyperacute epidural haematoma isodense with the brain on computed tomography. Acta Neurochir (Wien). 146(2):193-194. [Medline].

  12. Park HK, Joo WI, Chough CK, Cho CB, Lee KJ, Rha HK. The clinical efficacy of repeat brain computed tomography in patients with traumatic intracranial haemorrhage within 24 hours after blunt head injury. Br J Neurosurg. 2009 Dec. 23(6):617-21. [Medline].

  13. Chen TY, Wong CW, Chang CN. The expectant treatment of "asymptomatic" supratentorial epidural hematomas. Neurosurgery. 32(2):176-179; discussion 179. [Medline].

  14. Offner PJ, Pham B, Hawkes A. Nonoperative management of acute epidural hematomas: a "no-brainer". Am J Surg. 2006 Dec. 192(6):801-5. [Medline].

  15. Basamh M, Robert A, Lamoureux J, Saluja RS, Marcoux J. Epidural Hematoma Treated Conservatively: When to Expect the Worst. Can J Neurol Sci. 2016 Jan. 43 (1):74-81. [Medline].

  16. [Guideline] Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW. Surgical management of acute epidural hematomas. Neurosurgery. 2006 Mar. 58(3 Suppl):S7-15; discussion Si-iv. [Medline]. [Full Text].

  17. Songara A, Patil HG, Nayaran S. Traumatic posterior fossa extradural hematoma: case report and review of literature. Int Surg J. 2016. 3(1):369-71. [Full Text].

  18. Li S, Zhang H, Jiao QF, Liu Z, Mao BY. A comparative study on therapeutic method of traumatic epidural hematoma. Chin J Traumatol. 2007 Jun. 10(3):166-70. [Medline].

  19. Servadei F, Nanni A, Nasi MT. Evolving brain lesions in the first 12 hours after head injury: analysis of 37 comatose patients. Neurosurgery. 1995. 37(5):899-906; discussion 906-907. [Medline].

  20. Rocchi G, Caroli E, Raco A, Salvati M, Delfini R. Traumatic epidural hematoma in children. J Child Neurol. 2005 Jul. 20(7):569-72. [Medline].

  21. Berker M, Cataltepe O, Ozcan OE. Traumatic epidural haematoma of the posterior fossa in childhood: 16 new cases and a review of the literature. Br J Neurosurg. 17(3):226-229. [Medline].

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

  23. Chesnut RM, Servadei F. Surgical treatment of post-traumatic mass lesions. In: Marion DW, ed. Traumatic Brain Injury. 1999:81-99.

  24. Kelly DF, Nikas DL, Becker DP. Diagnosis and treatment of moderate and severe head injuries in adults. In: Youmans JR, ed. Neurological Surgery. 1996. 3:1643-1645.

  25. Lee EJ, Hung YC, Wang LC. Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery. J Trauma. 45(5):946-952. [Medline].

  26. Liau LM, Bergsneider M, Becker DP. Pathology and pathophysiology of head injury. In: Youmans JR, ed. Neurological Surgery. 4th ed. 1996:1549-1594.

  27. Liu JT, Tyan YS, Lee YK, Wang JT. Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report. Acta Neurochir (Wien). 2006 Mar. 148(3):313-7; discussion 317. [Medline].

  28. Lobato RD, Rivas JJ, Gomez PA. Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography. J Neurosurg. 75(2):256-261. [Medline].

  29. Radulovic D, Janosevic V, Djurovic B, Slavik E. Traumatic delayed epidural hematoma. Zentralbl Neurochir. 2006 May. 67(2):76-80. [Medline].

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

 
Previous
Next
 
CT scan of an acute left-sided epidural hematoma. Note the typical convex or lens-shaped appearance. The hematoma takes this shape as the dura strips from the undersurface of the cranium, limited by the suture lines. A midline shift of the ventricular system is present. This hemorrhage requires immediate surgical evacuation.
Axial CT scan that demonstrates a large vertex, bifrontoparietal epidural hemorrhage (EDH). Air bubbles are within the hematoma.
CT bone window image of same patient in Media file 2 that demonstrates a large midline fracture.
Coronal CT scan reconstruction that further clarifies the thickness and mass effect associated with this vertex epidural hemorrhage (EDH).
Sagittal CT scan reconstruction that further defines the anterior-posterior extent of the vertex epidural hemorrhage (EDH).
CT image of a pre-adolescent male with a left posterior fossa epidural hemorrhage (EDH). Such hemorrhages need to be watched carefully, and the surgical team should have a low threshold for surgical intervention because this region has less room to accommodate mass lesions.
Bone window of the same patient as Media file 6 that reveals a diastasis (separation) of the left mastoid suture.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.