Epidural Hematoma in Emergency Medicine

Updated: Dec 10, 2021
  • Author: Daniel D Price, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Overview

Practice Essentials

Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. EDH results from traumatic head injury, usually with associated skull fracture and arterial laceration. This is a life-threatening condition that may require immediate intervention and can be associated with significant morbidity and mortality if left untreated. [1]  Injuries suffered while participating in extreme sports account for numerous emergency department visits for EDH. [2]  The inciting event often is a focused blow to the head, such as that produced by a hammer or a baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of hemorrhage in the formation of an epidural hematoma. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to the patient's preoperative neurologic condition. [3, 4]

In a study of 41 patients with epidural hematoma at a level I trauma center, patient age, severity of traumatic brain injury, and neurologic status were the main factors influencing outcome. Two patients died within 24 hours, and 39 patients (95%) survived. Thirty-two patients (78%) showed good recovery at latest follow-up. [5]

In cases of rare bilateral extradural hematoma (0.5-10%), higher mortality has been reported. Approach to treatment depends on the volume of blood, the time of diagnosis, and the neurologic deficit level. Simultaneous drainage of bilateral hematomas has been demonstrated to be an effective technique. [6, 7]   Consult a neurosurgeon immediately for EDH evacuation and repair. Consult a trauma surgeon for other life-threatening injuries.

The outcome for EDH is more favorable than decades ago, most probably reflecting a well-established chain of trauma care. [8]  However, study results show that morbidity and mortality after EDH evacuation remain relatively high (with 14% remaining disabled and 6% dying). [9]  Rapid diagnosis and evacuation are important for a good outcome. [10]

Complications include neurobehavioral changes (postconcussive syndrome can last hours to months; see Postconcussive Syndrome), vegetative state, and death.

Mortality rates are essentially nil for patients not in coma preoperatively and are approximately 10% for obtunded patients and 20% for patients in deep coma. 

(See the images below.)

Right temporal epidural hematoma with midline shif Right temporal epidural hematoma with midline shift. Patient should be taken immediately to the operating room for neurosurgery. This may require emergent transport to a trauma center or other facility with a neurosurgeon available.
Brain CT scan of 90-year-old man who slipped on a Brain CT scan of 90-year-old man who slipped on a waxed floor. Witnesses reported loss of consciousness followed by a "lucid interval." Patient arrived to ED unconscious. CT scan indicates epidural hematoma. Image courtesy of Dr Dana Stearns, Massachusetts General Hospital.

 

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Pathophysiology

Epidural hematoma is most often caused by rupture of the middle meningeal artery secondary to head trauma with fracture of the temporal bone. It is a potentially fatal condition that can lead to elevated intracranial pressure, herniation, and death within hours following the inciting traumatic incident, unless surgical evacuation is accomplished. [11]

Approximately 70-80% of epidural hematomas (EDHs) are located in the temporoparietal region, where skull fractures cross the path of the middle meningeal artery or its dural branches. Frontal and occipital epidural hematomas each constitute about 10%, with the latter occasionally extending above and below the tentorium. Association of hematoma and skull fracture is less common in young children because of calvarial plasticity.

Epidural hematomas are usually arterial in origin but result from venous bleeding in one third of patients. Occasionally, torn venous sinuses cause an epidural hematoma, particularly in the parietal-occipital region or the posterior fossa. These injuries tend to be smaller and associated with a more benign course. Usually, venous epidural hematoma forms only with a depressed skull fracture, which strips the dura from the bone and thus creates a space for blood to accumulate. For certain patients, especially those with delayed presentation, venous EDH is treated nonsurgically.

Expanding high-volume EDH can produce a midline shift and subfalcine herniation of the brain. Compressed cerebral tissue can impinge on the third cranial nerve, resulting in ipsilateral pupillary dilation and contralateral hemiparesis or extensor motor response.

Epidural hematomas are usually stable, attaining maximum size within minutes of injury; however, Borovich et al demonstrated progression of epidural hematoma in 9% of patients during the first 24 hours. [12] Rebleeding or continuous oozing presumably causes this progression. An epidural hematoma can occasionally run a more chronic course that is only detected days after injury.

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Epidemiology

Epidural hematoma occurs in 1-2% of all head trauma cases and in about 10% of patients who present with traumatic coma. Reported mortality rates range from 5-43%. Higher rates are associated with the following:

  • Advanced age

  • Intradural lesions

  • Temporal location

  • Increased hematoma volume

  • Rapid clinical progression

  • Pupillary abnormalities

  • Increased intracranial pressure (ICP)

  • Lower Glasgow coma scale score (GCS; see the Glasgow Coma Scale calculator)

Patients younger than 5 years and older than 55 years have increased mortality. Patients younger than 20 years account for 60% of EDHs. EDH is uncommon in elderly patients because the dura is strongly adhered to the inner table of the skull. In case series of EDH, fewer than 10% of patients are older than 50 years. Study results suggest that combined treatments (endovascular embolization + drainage surgery + use of urokinase) can provide an alternative minimally invasive option for acute traumatic EDH, especially for elderly patients or for those with contraindications for general anesthesia. [13]

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