Epidural Hemorrhage Workup

  • Author: Jamie S Ullman, MD; Chief Editor: Allen R Wyler, MD   more...
 
Updated: Mar 9, 2010
 

Laboratory Studies

  • Hematocrit level, chemistries, and coagulation profile (including platelet count) are essential in the assessment of patients with EDH, whether spontaneous or traumatic.
    • Severe head injury can cause release of tissue thromboplastins, which can result in disseminated intravascular coagulation. Prior knowledge of coagulopathy is required if surgery is to be undertaken. If required, appropriate factors are administered preoperatively and intraoperatively.
    • In adults, EDH rarely causes a significant drop in the hematocrit level within the rigid skull cavity. In infants, whose blood volume is already limited, epidural bleeding within an expansile cranium with open sutures can result in significant blood loss. Such bleeding can result in hemodynamic instability; therefore, careful and frequent monitoring of the hematocrit level is required.
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Imaging Studies

  • Radiography
    • Skull radiographs often reveal a fracture crossing the vascular shadow of the middle meningeal artery branches. An occipital, frontal, or vertex fracture also might be observed.
    • The presence of a fracture does not necessarily guarantee the existence of EDH. However, more than 90% of EDH cases are associated with skull fractures. In children, this rate is less because of greater skull deformability.
  • CT scanning
    • CT scanning is the most accurate and sensitive method of diagnosing acute EDH. The findings are characteristic. The space occupied by EDH is limited by the adherence of the dura to the inner table of the skull, especially at the suture lines, contributing to the lenticular or biconvex appearance (see the image below). Hydrocephalus may be present in patients with a large posterior fossa EDH exerting a mass effect and obstructing the fourth ventricle. CT scan of an acute left-sided epidural hematoma. 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.
    • Cerebrospinal fluid is not commonly mixed with epidural hematomas; therefore, the hematoma is denser and homogenous. The quantity of hemoglobin in the hematoma determines the amount of radiation absorbed.
    • The signal density of the hematoma compared with the brain parenchyma changes over time after the injury. The acute phase is hyperdense (ie, bright signal on CT scan). The hematoma then becomes isodense at 2-4 weeks, and then it becomes hypodense (ie, dark signal) thereafter. Hyperacute blood may be observed as isodense or low-density areas, possibly indicating ongoing hemorrhage or a low serum hemoglobin level.[5, 6]
    • Another less frequently involved area is the vertex, an area in which confirming the diagnosis on CT scans may be difficult. Vertex epidural hematomas can be mistaken as artifact in traditional axial CT scan sections. Even when correctly detected, the volume and the mass effect may easily be underestimated. In some cases, coronal and sagittal reconstructions can be used to evaluate the hematoma on coronal planes (see the images below). Axial CT scan that demonstrates a large vertex, biAxial 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 fileCT bone window image of same patient in Media file 2 that demonstrates a large midline fracture. Coronal CT scan reconstruction that further clarifCoronal CT scan reconstruction that further clarifies the thickness and mass effect associated with this vertex epidural hemorrhage (EDH). Sagittal CT scan reconstruction that further definSagittal CT scan reconstruction that further defines the anterior-posterior extent of the vertex epidural hemorrhage (EDH).
    • Approximately 10-50% of EDH cases are associated with other intracranial lesions. These lesions include subdural hematomas, cerebral contusions, and intracerebral hematomas. A 2009 study by Park et al suggests that routine repeat CT scanning within 24 hours of blunt head trauma may lessen potential neurological deterioration among patients with a GCS of less than 12, epidural hematoma, or multiple lesions, as indicated on initial CT scanning.[7]
  • MRI: Acute blood on MRIs is isointense, making this modality less suited to detection of hemorrhage in acute trauma. Mass effect, however, can be observed when extant.
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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, American College of Surgeons, and Congress of Neurological Surgeons

Disclosure: Oxygen Biotherapeutics Consulting fee Consulting; Brain Trauma Foundation Honoraria Speaking and teaching

Coauthor(s)

Anthony Sin, MD  Staff Physician, Department of Neurosurgery, Louisiana State University

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael G Nosko, MD, PhD  Chief, Division of Neurosurgery, Director of Neurovascular Surgery, Medical Director of Neuroscience Unit, Associate Professor, Department of Surgery, University of Medicine and Dentistry of New Jersey

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

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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

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

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD  Former Medical Director, Northstar Neuroscience, Inc

Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons

Disclosure: Nothing to disclose.

References

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

  3. 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].

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  6. 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].

  7. 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. Dec 2009;23(6):617-21. [Medline].

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

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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.
 
 
 
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