Epidural Hematoma Management in the ED Workup

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



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] .