Epidural Hematoma in Emergency Medicine Workup

Updated: Oct 27, 2016
  • Author: Daniel D Price, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Workup

Laboratory Studies

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).

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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 extraaxial, smoothly marginated, lenticular, or biconvex homogenous 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 diagnosed with traumatic EDH was performed to evaluate CT imaging findings in patients managed with observation alone versus surgical evacuation. Forty-seven cases of EDH were analyzed, and 62% were managed by observation alone. The 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 the observed patients and in all surgery patients. The repeat CT scan results led to surgery in only 1 patient who was initially treated with observation. [6]

Computed tomography angiography (CTA) was able to identify middle meningeal artery (MMA) vascular lesions in patients with an EDH. Of 11 patients with small acute epidural hematomas, 3 were diagnosed with MMA pseudoaneurysms, and CTA was able to diagnose all 3, with dimensions ranging from 1.5-2.8 mm. Conventional angiography confirmed the findings of CTA. [7]

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Other Tests

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

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Procedures

Perform burr hole(s) if the following occur:

  • Patient is herniating
  • All other treatments prove insufficient
  • Neurosurgery is unavailable for urgent consultation
  • Trephination (or placement of a Burr hole) should ideally be performed if possible by the consulting neurosurgeon at the receiving trauma center [8]
  • 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 tragus of ear and 3 finger widths above.
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