History
Most epidural hematomas are traumatic in origin, often involving a blunt impact to the head. Patients may have external evidence of head injuries such as scalp lacerations, cephalohematoma, or contusions. Systemic injuries may also be present. Depending on the force of impact, patients may present with no loss of consciousness, brief loss of consciousness, or prolonged loss of consciousness.
The classic lucid interval occurs in 20-50% of patients with EDH. Initially, the concussive force that caused the head injury results in an alteration of consciousness. After consciousness is recovered, the EDH continues to expand until the mass effect of the hemorrhage itself results in increased intracranial pressure, a decreased level of consciousness, and a possible herniation syndrome.
With severe intracranial hypertension, a Cushing response may occur. The classic Cushing triad involves systemic hypertension, bradycardia, and respiratory depression. This response usually occurs when cerebral, particularly brainstem, perfusion is compromised by increased intracranial pressure. Antihypertensive therapy during this time may lead to critical cerebral ischemia and cell death. [13] Evacuation of the mass lesion alleviates the Cushing response.
Neurologic assessment is essential. Attention should be paid to level of consciousness, motor activity, eye opening, verbal output, pupillary reactivity and size, and lateralizing signs such as hemiparesis or plegia. The Glasgow Coma Scale score (GCS) is essential in assessing the current clinical condition (see the Glasgow Coma Scale calculator). The GCS has been positively correlated with outcome. In awake patients with a mass lesion, the pronator drift phenomenon might help to assess clinical significance. Drifting of the extremity when the patient is asked to hold both arms outstretched with palms facing upward indicates subtle but significant mass effect.
Symptomatic postoperative EDH is rare, with an incidence of 0.10-0.69%. Many studies have reported advanced age, preoperative or postoperative coagulopathy, and multilevel laminectomy as risk factors. Symptomatic postoperative epidural hematomas usually present within the first 24-48 hours after surgery but can present later. Patients first report a marked increase in axial pain, followed by radicular symptoms in the extremities, then motor weakness and sphincter dysfunction. Magnetic resonance imaging (MRI) should be conducted, and if it confirms a compressive hematoma, surgical evacuation should be carried out as quickly as possible. The prognosis for neurologic improvement after evacuation depends on the time delay and the degree of neurologic impairment before evacuation. [14]
Several case reports have described emergency hematoma evacuation after epidural steroid injection. Spinal epidural hematoma is a rare condition that can rapidly lead to severe neurologic deficits. The pathophysiology of this development remains unclear. [15]
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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.
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Axial CT scan that demonstrates a large vertex, bifrontoparietal epidural hemorrhage (EDH). Air bubbles are within the hematoma.
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CT bone window image of same patient in Media file 2 that demonstrates a large midline fracture.
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Coronal CT scan reconstruction that further clarifies the thickness and mass effect associated with this vertex epidural hemorrhage (EDH).
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Sagittal CT scan reconstruction that further defines the anterior-posterior extent of the vertex epidural hemorrhage (EDH).
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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.
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Bone window of the same patient as Media file 6 that reveals a diastasis (separation) of the left mastoid suture.
