Imaging Studies

Head CT scan

Immediate unenhanced CT scan is the procedure of choice for diagnosis. Head CT scan shows location, volume, effect, and other potential intracranial injuries. Epidural hematoma (EDH) forms an extra-axial, smoothly marginated, lenticular, or biconvex homogeneous density.

EDH rarely crosses the suture line because the dura is attached more firmly to the skull at sutures. Focal isodense or hypodense zones within EDH indicate active bleeding. Irregular hypodense swirling indicates active bleeding in the majority of patients. Air in acute EDH suggests fracture of sinuses or mastoid air cells. At surgery or autopsy, 20% of patients have blood in both epidural and subdural spaces.

A retrospective study of pediatric patients with diagnosed traumatic EDH was performed to evaluate CT imaging findings in patients whose condition was managed with observation alone versus surgical evacuation. Forty-seven cases of EDH were analyzed, and 62% were managed by observation alone. Mean initial EDH thickness and volume were 8.0 mm and 8.6 ml in the observed group and 15.5 mm and 35 ml in the surgery group. Repeat CT imaging was performed in 86% of observed patients and in all surgery patients. Repeat CT scan results led to surgery in only 1 patient, who was initially treated with observation.^[15]

Computed tomography angiography (CTA) was able to identify middle meningeal artery (MMA) vascular lesions in patients with EDH. Of 11 patients with small acute EDH, 3 were diagnosed with MMA pseudoaneurysm, and CTA was able to diagnose all 3, with dimensions ranging from 1.5-2.8 mm. Conventional angiography confirmed the findings of CTA.^[16]

Guidelines regarding the role of repeat head CT imaging in the nonoperative management of traumatic EDH do not exist. Consequently, some children and others may be exposed to unnecessary additional ionizing radiation. Reimaging rarely changes management. Limiting reimaging to patients with neurologic findings of concern or with mass effect on initial evaluation could reduce imaging by more than 50%.^[17]

Other Tests

Cervical spine evaluation usually is necessary because of the risk of neck injury associated with EDH.

Perform appropriate laboratory work for associated trauma.

Coagulation abnormalities are a marker of severe head injury. Breakdown of the blood-brain barrier with exposed brain tissue is a potent cause of disseminated intravascular coagulation (DIC).

Procedures

Perform burr hole(s) if the following occur:

Patient is herniating
All other treatments prove insufficient
Neurosurgery is unavailable for urgent consultation
Air or ground medical transport is prolonged

Burr hole procedure includes the following:

Drill hole adjacent to, but not over, skull fracture or in the area located by CT scan
In the absence of CT scan, place a burr hole on the side of the dilated pupil, 2 finger widths anterior to the tragus of the ear and 3 finger widths above

Trephination (or placement of a Burr hole) should ideally be performed if possible by the consulting neurosurgeon at the receiving trauma center^[16].

Treatment & Management

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Paiva WS, Andrade AF, Amorim RL, Bor-Seng-Shu E, Gattas G, Neville IS, et al. Computed tomography angiography for detection of middle meningeal artery lesions associated with acute epidural hematomas. Biomed Res Int. 2014. 2014:413916. [QxMD MEDLINE Link]. [Full Text].
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Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. 2010 Sep. 39(3):377-83. [QxMD MEDLINE Link].
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Media Gallery

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 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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Author

Daniel D Price, MD Director of International Ultrasound, Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital and Trauma Center

Daniel D Price, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Sharon R Wilson, MD Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center

Sharon R Wilson, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, American Association of University Women

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.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Robert M McNamara, MD, FAAEM Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine

Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sections Epidural Hematoma Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
References

Epidural Hematoma Management in the ED Workup

Imaging Studies

Head CT scan

Other Tests

Procedures

References

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