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Epidural Hematomas Workup

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

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. Presence of coagulopathy may be associated with worse outcomes.[9]

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.[10, 11, 5]

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, bi 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 CT bone window image of same patient in Media file 2 that demonstrates a large midline fracture.
Coronal CT scan reconstruction that further clarif 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 defin Sagittal 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.[12]

Gean et al reported a series of 21 patients with anterior temporal tip epidural hematomas.[4] These lesions were usually limited by the orbital fissure medially and by the sphenotemporal suture laterally and were confined to the anterior temporal fossa without expansion on subsequent imaging.

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.[5]

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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, 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
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  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].

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  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].

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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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