Epidural Hematoma Workup

Updated: Jan 09, 2018
  • Author: David S Liebeskind, MD, FAAN, FAHA, FANA; Chief Editor: Helmi L Lutsep, MD  more...
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Workup

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.

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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.

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Other Tests

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

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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.

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