Laboratory Studies

See the list below:

Complete blood count (CBC) with platelets - To monitor for infection and assess hematocrit and platelets for further hemorrhagic risk.
Prothrombin time (PT)/activated partial thromboplastin time (aPTT) - To identify bleeding diathesis.
Serum chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, and glucose - To characterize metabolic derangements that may complicate clinical course.
Toxicology screen and serum alcohol level - To identify associated causes of head trauma and establish need for surveillance with regard to withdrawal symptoms.
Type and hold an appropriate amount of blood - To prepare for necessary transfusions needed because of blood loss or anemia.

Imaging Studies

Plain radiography of the head (skull radiography) may reveal skull fractures, though CT scanning has largely replaced the use of skull radiography because the diagnostic information is so much greater with CT. Cervical spine radiographs with anteroposterior, lateral, and odontoid views are useful to identify associated traumatic fractures. Plain radiographs of the vertebral column may identify a cavernous angioma.

Myelography outlines the epidural space and may illustrate a space-occupying mass. CT myelography may be used when MRI is unavailable or if the patient cannot tolerate MRI.

Noncontrast CT scanning of the head not only visualizes skull fractures but also directly images an epidural hematoma.

Acute epidural hematoma may appear as a hyperdense lenticular-shaped mass situated between the brain and the skull, though regions of hypodensity may be seen with serum or fresh blood. On rare occasion, an acute epidural may appear completely isointense with respect to brain. Planoconvex or crescent-shaped epidural hematoma must be differentiated from subdural hemorrhage. Subdural hematomas may rarely appear convex and mimic epidural hematomas. Subacute lesions are homogenously hyperdense.
Chronic epidural hematoma may have a heterogeneous appearance due to neovascularization and granulation, with peripheral enhancement on contrast administration.
CT scanning may also depict air collections and displacement of brain parenchyma.
Clinical deterioration should prompt repeat imaging with CT scanning.
A "swirl" sign within the hematoma may indicate a worse prognosis.^[6]

MRI also demonstrates the evolution of an epidural hematoma, though this imaging modality may not be appropriate for patients in unstable condition.

Spinal MRI may delineate the location of an epidural hematoma and identify an associated vascular malformation.
Spinal cord enhancement may be apparent and should be distinguished from inflammation or neoplasia.
Diffusion-weighted imaging with the use of periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) MRI may be used for improved detection of acute spinal epidural hematoma.^[7]
Gadolinium-enhanced magnetic resonance arteriography (MRA) may further define the extent of an arteriovenous malformation.

Conventional angiography may be required to demonstrate definitively the presence of a vascular malformation.

Other Tests

Functional studies of the spinal cord, such as somatosensory evoked potentials, may be used for intraoperative monitoring or for prognostication following surgery.

Procedures

Emergent decompression with placement of a burr hole may be necessary when neurosurgical consultation is unavailable. For patients showing rapid deterioration with clinical signs of impending herniation, place a burr hole on the side of the dilating pupil. In the absence of a CT scan, place the burr hole 2 finger widths anterior to the tragus of the ear and 3 finger widths above the tragus of the ear.^[8]

Lumbar puncture provides little additional information and may exacerbate neurologic damage.

Treatment & Management

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Media Gallery

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

of 2

Author

David S Liebeskind, MD, FAAN, FAHA, FANA Professor of Neurology and Director, Neurovascular Imaging Research Core, Director, Vascular Neurology Residency Program, Department of Neurology, University of California, Los Angeles, David Geffen School of Medicine; Director, UCLA Outpatient Stroke and Neurovascular Programs; Director, UCLA Cerebral Blood Flow Laboratory; Associate Neurology Director, UCLA Stroke Center

David S Liebeskind, MD, FAAN, FAHA, FANA 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, Stroke Council of the American Heart 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; Physician Advisory Board for Coherex Medical; National Leader and Steering Committee Clinical Trial, Bristol Myers Squibb; Abbott Laboratories, advisory group.

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, The Scientific Research Honor Society, Southern Clinical Neurological Society

Disclosure: Nothing to disclose.