Epidural hematoma
Epidural hematoma is an arterial bleed, classically from the middle meningeal artery after a temporal bone fracture, that collects between the skull and dura in a biconvex shape that does not cross suture lines; a lucid interval followed by rapid decline is classic, and a GCS below 9, anisocoria, or hematoma over 30 mL requires urgent surgical evacuation.
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What this article covers
- Overview
Definition: an epidural hematoma is a collection of blood between the inner table of the skull and the dura mater, arising when an arterial structure is breached by head trauma and blood accumulates…
- Epidemiology
Young adults and adolescents sustain epidural hematoma most often, typically from falls, assaults, or motor vehicle collisions with an associated temporal skull fracture.
- Risk factors
Head trauma with temporal bone impact: direct blows to the temporal or temporoparietal skull are the dominant risk factor, given the course of the middle meningeal artery beneath this region.
- Pathophysiology
Arterial laceration: a temporal bone fracture (or, in children, sufficient skull deformation without fracture) lacerates the middle meningeal artery or one of its branches as it courses along a groove on the inner skull table.
- Clinical features
Lucid interval: many patients experience a brief initial loss of consciousness, then a period of apparent neurologic normalcy (the lucid interval), followed by rapid decline in mental status as the…
- Differential diagnosis
Subdural hematoma: a venous bleed from ruptured bridging veins that produces a crescent-shaped collection crossing suture lines, in contrast to the arterial, biconvex, suture-limited epidural…
- Diagnosis
Establishing basis: the diagnosis is established by noncontrast head CT demonstrating a hyperdense, biconvex (lentiform) extra-axial collection that does not cross cranial suture lines, obtained…
- Management
First, stabilize airway, breathing, and circulation, maintaining oxygen saturation and systolic blood pressure above 90 mmHg to prevent secondary brain injury, and elevate the head of the bed once the cervical spine is cleared.
- Complications
Transtentorial (uncal) herniation: the most feared acute complication, producing coma, ipsilateral CN III palsy, and contralateral hemiparesis, and rapidly fatal if not decompressed.
- Prognosis
Excellent if treated before herniation: patients who are surgically evacuated while still neurologically intact or only mildly impaired have a good functional prognosis in most cases.
- Prevention
Helmet use during cycling, motorcycling, and contact sports reduces the risk of the skull fracture that causes most epidural hematomas.
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Related articles
- Acute subdural hematoma
Acute subdural hematoma is venous bleeding between the dura and arachnoid membrane from ruptured bridging veins, producing a crescent-shaped collection that crosses suture lines on CT. Older adults and patients with alcohol use disorder or on anticoagulation are most susceptible; a hematoma over 10 mm, a GCS under 9, or pupillary asymmetry mandate immediate surgical evacuation.
- Chronic subdural hematoma
A collection of liquefied blood between the dura and arachnoid that develops over weeks after often-trivial or forgotten trauma, typically in elderly or anticoagulated patients with cerebral atrophy; CT confirms the diagnosis, and burr-hole drainage is the treatment for a symptomatic hematoma with significant thickness or midline shift.
- Traumatic brain injury
Traumatic brain injury is structural or functional brain damage from biomechanical force, graded moderate (Glasgow Coma Scale 9-12) or severe (Glasgow Coma Scale 3-8) when imaging shows contusion, edema, or hemorrhage; management centers on preventing hypotension and hypoxia, controlling intracranial pressure with hyperosmolar therapy and, when refractory, decompressive craniectomy.
- Concussion
Concussion (mild traumatic brain injury) is a biomechanically induced, temporary alteration of brain function with a normal neurologic examination and, when obtained, a normal head CT. Management is symptom-guided with an early, graduated return to activity; most symptoms resolve within 7 to 10 days.
- Increased intracranial pressure
Sustained intracranial pressure above 20-22 mmHg from mass effect, edema, hydrocephalus, or venous outflow obstruction, diagnosed by clinical signs plus invasive monitoring and treated stepwise with head elevation, hyperosmolar therapy (mannitol or hypertonic saline), CSF diversion, and decompressive surgery when refractory.
- Subarachnoid hemorrhage
Subarachnoid hemorrhage is sudden bleeding into the subarachnoid space, most often from a ruptured saccular (berry) aneurysm, presenting as the worst headache of a patient's life. Diagnosis is noncontrast head CT, then lumbar puncture if CT is negative, then catheter angiography to define the aneurysm; management is early aneurysm securement, blood pressure control, and nimodipine to reduce delayed cerebral ischemia from vasospasm.