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Epidural Hematoma

Epidural hematoma is the accumulation of blood in the space between dura and bone in the cranial or spinal region.


Presentation

Patients who have suffered from head injury/trauma are the prime suspect of the epidural hematoma. Documentation of the interval between the initial loss of consciousness and the time of the impact and changes in the levels of consciousness is all part of the diagnosis.

The hematoma of the posterior fossa can cause rapid or delayed progression, depending on the impact, causing death of the subject within several minutes. Some of the important symptoms of the epidural hematoma include extreme headache, vomiting, nausea and seizures. Visual field cuts, weakness and numbness can follow. Spinal epidural hematoma can cause localized but severe back pain along with weakness, urinary and fecal incontinence.

Soft Tissue Mass
  • Magnetic resonance imaging showed dorsal epidural soft tissue mass that caused posterior compression of the spinal cord at the T12-L3 levels. We performed thoracic lateral retropleural corpectomy and cage insertion at T12.[ncbi.nlm.nih.gov]
Vomiting
  • BACKGROUND: Sub-acute/chronic epidural hematoma (EDH) may present with nagging symptoms of headache, nausea, vomiting, lethargy, etc.[ncbi.nlm.nih.gov]
  • The exam may also show signs of increased ICP, such as: Headaches Somnolence Confusion Nausea and vomiting If there is increased ICP, emergency surgery may be needed to relieve the pressure and prevent further brain injury.[nlm.nih.gov]
  • Clinical features may include HEADACHE; VOMITING; HEMIPARESIS; and impaired mental function.[connects.catalyst.harvard.edu]
  • One occurred in a child associated with an episode of violent vomiting, the second in an adult with a history of remote head trauma who presented with a slowly progressive course suggestive of thyroid eye disease, and the third in a young patient after[journals.lww.com]
  • Some of the important symptoms of the epidural hematoma include extreme headache, vomiting, nausea and seizures. Visual field cuts, weakness and numbness can follow.[symptoma.com]
Nausea
  • A 25-year-old man presented with headache and nausea. Imaging of the brain revealed abnormal signals indicative of acute epidural hematoma in the right frontal convexity. Angiography demonstrated a DAVF in the region of the frontal bone.[ncbi.nlm.nih.gov]
  • BACKGROUND: Sub-acute/chronic epidural hematoma (EDH) may present with nagging symptoms of headache, nausea, vomiting, lethargy, etc.[ncbi.nlm.nih.gov]
  • The exam may also show signs of increased ICP, such as: Headaches Somnolence Confusion Nausea and vomiting If there is increased ICP, emergency surgery may be needed to relieve the pressure and prevent further brain injury.[nlm.nih.gov]
  • Some of the important symptoms of the epidural hematoma include extreme headache, vomiting, nausea and seizures. Visual field cuts, weakness and numbness can follow.[symptoma.com]
Hypertension
  • Her medical history was notable for hypertension. Cervical computed tomography angiography indicated a giant abdominal aortic aneurysm measuring 11.58   17.34   13.00 cm in her abdominal cavity.[ncbi.nlm.nih.gov]
  • She had no history of trauma, spinal surgery, or hypertension. Magnetic resonance imaging revealed a lumbar chronic epidural hematoma which compressed the dural sac behind and extended from L2 to L5.[ncbi.nlm.nih.gov]
  • General examination revealed severe headache, no motor or sensory disturbances, and no clinical signs of intracranial hypertension.[ncbi.nlm.nih.gov]
  • Rupture of AVM Trauma Commonly due to embolisms , thrombi , or microangiopathic changes Arterial hypertension and increasing age are the most important risk factors Clinical features Lucid interval , then loss of consciousness Headache Hemiplegia Increasing[amboss.com]
  • In certain cases of intracranial hypertension it might lead to Cushing triad involving respiratory depression, systemic hypertension and bradycardia. [5] Anisocoria: Unequal pupil size.[howmed.net]
Musculoskeletal Pain
  • Most people understand spinal manipulation therapy to be a safe procedure, and in many cases treatment is provided without a diagnosis if there is musculoskeletal pain.[ncbi.nlm.nih.gov]
Spine Pain
  • Pain Ricardo Ortega-Santiago, PT, PhD ; Maite Maestre-Lerga, PT, MSc ; César Fernández-de-las-Peñas, PT, MSc, PhD, Dr Med ; Joshua A Cleland, PT, PhD ; Gustavo Plaza-Manzano, PT, PhD Published: 1 March 2019 Section: ORIGINAL RESEARCH ARTICLE View article[academic.oup.com]
Pupillary Abnormality
  • Factors that may influence outcome are as follows: Patient age Time lapsed between injury and treatment Immediate coma or lucid interval Presence of pupillary abnormalities GCS/motor score, on arrival CT findings (hematoma volume, the degree of midline[ncbi.nlm.nih.gov]
  • 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) Mortality rates are essentially nil for[emedicine.medscape.com]
Diplopia
  • A 26-year-old Asian woman presented with diplopia occurring at 1 week after conservative treatment for left temporal bone fracture and left temporo-occipital epidural hematoma (EDH).[ncbi.nlm.nih.gov]
Esotropia
  • At presentation, right abducens nerve palsy was observed with esotropia and abduction limitation in the right eye. Six weeks later, the abducens nerve palsy fully recovered with complete absorption of the EDH.[ncbi.nlm.nih.gov]
Headache
  • BACKGROUND: Sub-acute/chronic epidural hematoma (EDH) may present with nagging symptoms of headache, nausea, vomiting, lethargy, etc.[ncbi.nlm.nih.gov]
  • The exam may also show signs of increased ICP, such as: Headaches Somnolence Confusion Nausea and vomiting If there is increased ICP, emergency surgery may be needed to relieve the pressure and prevent further brain injury.[nlm.nih.gov]
  • Hemiplegia Increasing headache over days or weeks Changes in mental status Less frequently: lucid interval Sudden, severe headache Loss of consciousness Headache Focal neurologic deficits Loss of consciousness Headache Focal neurologic deficits Loss[amboss.com]
  • A 67-year-old woman complaining of a headache presented with a history of head trauma for the past 1 hour. Emergency head computed tomography initially suggested an epidural hematoma.[ncbi.nlm.nih.gov]
  • Other symptoms may include headache, confusion, vomiting, and an inability to move parts of the body.[en.wikipedia.org]
Confusion
  • A 54-year-old man presented with a 1-week history of headache, confusion, and drowsiness. Computed tomography exposed large, extraaxial, mixed-density lesions with bone destruction and substantial mass effect in the left frontotemporal region.[ncbi.nlm.nih.gov]
  • The exam may also show signs of increased ICP, such as: Headaches Somnolence Confusion Nausea and vomiting If there is increased ICP, emergency surgery may be needed to relieve the pressure and prevent further brain injury.[nlm.nih.gov]
  • However, these can be confused with inflammatory or neoplastic mass lesions ( 1, 2 ), especially when a patient is in acute status or when intravenous contrast material has been administered; this confusion could delay diagnosis and patient management[ajnr.org]
  • This pressure can lead to a depressed level of consciousness, from confusion and lethargy to coma and death. The level of consciousness and coma in an acutely head injured patient is often described by clinicians with the Glasgow Coma Scale.[nervous-system-diseases.com]
Stroke
  • To report an extremely rare case of stroke-mimicking, cervical spontaneous epidural hematoma (SEH) treated with tissue plasminogen activator (tPA) for hemiparesis followed by emergency cervical decompression.[ncbi.nlm.nih.gov]
  • Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, Stroke Council of the American Heart Association Disclosure: Nothing to disclose.[emedicine.com]
  • Sometimes a brain hemorrhage occurs seemingly spontaneously in the form of fetal or infant stroke. Though strokes are more common in adults, they still can occur in children and infants.[cerebralpalsysymptoms.com]
  • In addition, the American Stroke Association suggests maternal preeclampsia and early membrane ruptures may also lead to infant stroke. Although rare, birth injuries due to medical mistakes can lead to epidural hematoma.[birthinjuryguide.org]
Stupor
  • After about ten minutes, he regained consciousness, but he soon became lethargic, and over the next two hours, he was stuporous[4]. His pupils were unequal[5]. Intra cranial hemorrhage was suspected.[howmed.net]
  • During this interval, the patient may be awake and alert, but rapid deterioration leading to stupor, coma, and death can occur over minutes to hours.[pathwaymedicine.org]
  • […] and coma, coma 1 hour with mcc 083 Traumatic stupor and coma, coma 1 hour with cc 084 Traumatic stupor and coma, coma 1 hour without cc/mcc 085 Traumatic stupor and coma, coma 086 Traumatic stupor and coma, coma 087 Traumatic stupor and coma, coma 955[icd10data.com]
  • Stupor: In this state, patients cannot communicate clearly but can be aroused by continued painful stimulation. Arousal may be manifested only as withdrawal from painful stimuli.[emedicine.com]
Altered Mental Status
  • The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed 5.6mm versus failed observation 10.9mm, p CONCLUSION: Patients with no mass effect and EDH volume[ncbi.nlm.nih.gov]
  • Signs of increased ICP include altered mental status, seizures, pupillary changes, and vomiting.[clinicaladvisor.com]
  • Presentation There may be focal signs but clinical signs are most often non-localizing and include headache and altered mental status. Focal signs, if present, may include contralateral hemiparesis.[casemed.case.edu]

Workup

Physical Evaluation

There must be thorough physical check-up of the patient. Understanding of the strength of impact and sequence of trauma can also help to assess the condition. Bradycardia, hypertension and skull fractures must be well documented. Reporting of Glasgow Coma Scale score, determining the facial nerve injury, instability of the spinal cord, level of weakness experienced by the patient must be recorded. Other deficits such as numbness and visual field defects are also noted.

Complete Blood Count

This test helps to rule out and monitor the chances of infection, while the platelet count assesses the risk of hemorrhage. Prothrombin time, chemistry of the serum and toxicological report, serum alcohol level are some of the important tests that need to be done in such patients.

Imaging tests

CT scans can be done to detect the exact location of the Epidural Hematoma which usually confines within the skull suture lines. In children however, epidural hematoma may cross suture lines in 11% of cases compared to adult cases where the crossing of suture lines already implicates a subdural hematoma [6]. Myelography, non-contrast CT scanning, conventional angiography can also be done in the patients, if required. Magnetic Resonance Imaging using the Periodically Rotated Overlapping Parallel Lines with Enhance Reconstruction (PROPELLER) may be used for improved detection of acute spinal epidural hematoma [7].

Treatment

Medical Care

Assessment of the breathing and circulation of the patient is most important. Thorough trauma assessment is considered to be mandatory. In case the spine is immobilized, the patient must be transferred to level I trauma center at the earliest.

Depending on the degree of impairment, the initial management must be planned. Small epidural hematoma must be managed conservatively, though close monitoring is required. Patients suffering from epidural hematoma presenting with blood collection of less than 30ml with a less than 15mm thickness, a minimal 5mm midline shift, no focal neurological deficits and a GCS (Glasgow Coma Scale) of more than 8 may be managed medically [8].

Patients who have suffered from trauma may require further tests of the cervical spine or the chest. Apart from the neurological consultation, the patient must be administered the intravenous fluids. If the patient reports of elevated intracranial pressure, which is likely, osmotic diuretics are recommended along with hyperventilation. In case of coagulopathy, the administration of vitamin K and fresh frozen plasma or other clotting factor concentrates is also advised.

Surgical Care

Surgical treatment is now believed to be the definitive cure of the epidural hematoma. Laminectomy or craniotomy, if performed, is followed by removal of the hematoma. Both the bone and dura are tented, followed by draining of the excess epidural fluid.

Neonates delivered traumatically may present with epidural hematoma which communicates with the cephalhematoma externally, the prompt evacuation of the cephalheamatoma and the confluent epidural hematoma may reduce late neurologic complications in the neonate [9]. During emergency situations where a neurosurgeon is not available, a burr hole on the anterior part of the tragus of the ear on the side of the dilated eye may decompress neurologic symptoms and save a life [10]. Before and after the surgery, CT scan is done to ensure the correct evacuation of the epidural hematoma.

Diet

Head injury causes severe catabolism, thus the patient may require high calorie intake. Thus, caloric supplementation necessitates the enteral feeding soon.

Prognosis

If epidural hematoma is not diagnosed soon, and the intervention (medical or surgical) is not presented immediately, the patient can die. However, if early diagnosis is made and the surgery performed, the chances of survival of the patients increase severalfold.

The level of consciousness before surgery determines the outcome of the surgical intervention, thus correct assessment of the condition of the patient, when presented at the trauma center, is crucial. In cases of epidural hematoma seen in the middle cranial fossa is caused by a disruption of the saphino-parietal sinus, its natural history is usually benign even without surgical intervention [2].

Complications

If the prompt surgical intervention is absent, the subject may be at a higher risk of death. In fact, it has been documented that even after surgery, patient may suffer from permanent brain damage with frequent seizures. One of the common complications is the post-concussion syndrome that manifests as dizziness, vertigo and poor concentration with emotional imbalance.

Trauma to the head involving the temporal bone and the zygomatic arches causing an acute epidural hemorrhage may permanently damage the cranial nerves in the region in adult patients [3]. Abducens nerve palsies may result from epidural hematoma in children during a whiplash injury of the neck which may spontaneously resolves in 14 weeks from injury [4].

In rare occasions, a bedside lumbar puncture can sever the spinal artery and cause an epidural hematoma which may lead to a more serious intraventricular subdural hematoma, thus utmost care should be observed during this very common procedure [5].

Etiology

Trauma, lumbar puncture, coagulopathy, epidural anesthesia, disk herniation, vascular malformation, hypertension, cancer, thrombolysis and Paget disease of the bone are some of the documented causes of the condition.

Epidemiology

In the United States, head trauma that manifests as epidural hematoma is around 2%, though spinal epidural hematoma occurs 0.0001% of the population only. Alcohol and intoxicating agents are considered as the most important cause of such incidents.

The world data about the condition is not known, however it is believed the figures do not vary much. In as high as 50% of the cases, the outcome of the condition is death. Race has little impact on the epidemiology of the condition, though men more frequently suffer from the outcome of epidural hematoma than women with male:female ratio being 4:1. Epidural hematoma is more common in the people belonging to the 50’s and 60’s years of their life.

An increase in age is considered as a positive risk factor.

Sex distribution
Age distribution

Pathophysiology

Fracture of the skull is more common among adults than children due to the plasticity of the calvaria, which remains immature. Epidural hematoma occurs when there is a short blunt force to the calvaria.

The trauma can lead to the separation of the dura from the bone leading to the disruption of the meningeal artery due to the immense pressure applied in this region [1]. Due to this impact, the arteries and veins supplying the blood to this region is destroyed causing expansion of the hematoma.

The most common arteries, which is compromised, are the ones supplying to the temporo-parietal or the middle meningeal region. Spinal epidural hematoma may cause minor trauma and is associated with thrombolysis, thrombocytopenia, lumbar puncture and coagulopathies.

Prevention

Since epidural hematoma can occur to anyone and anytime, some precautions can help prevent the condition. The goal is to minimize the head injury.

Some of the recommendations that can prevent epidural hematoma are as follows:

  • Wearing a properly fitting helmet to protect the skull and avoid head injury. 
  • Use of the seat belts while driving or when on motor vehicles to reduce the impact of a collision on the spinal cord.

Summary

Epidural hematoma can be defined as the accumulation of the blood spaces between the dura and the bone in the cranial or spinal region. Around 2% of all the head injuries are intracranial epidural hematoma.

Though spinal epidural hematoma can cause significant trauma, intracranial epidural hematoma is considered as the most severe complication of the head injury which needs immediate medical intervention. It is categorized into acute (58%), subacute (31%) or chronic (11%).

Patient Information

Epidural hematoma is a consequence of severe trauma most often. Watch for the symptoms of loss of consciousness, nausea, vomiting, headache, blurred vision and other neurological symptoms. Consult a Neurophysician immediately after you encounter such symptoms

References

Article

  1. de Andrade AF; Figueiredo EG; Caldas JG; Paiva WS; De Amorim RL; Puglia P; Frudit M; Teixeira MJ. Intracranial vascular lesions associated with small epidural hematomas.Neurosurgery. 2008; 62(2):416-20; discussion 420-1 (ISSN: 1524-4040)
  2. Gean AD; Fischbein NJ; Purcell DD; Aiken AH; Manley GT; Stiver SI. Benign anterior temporal epidural hematoma: indolent lesion with a characteristic CT imaging appearance after blunt head trauma. Radiology. 2010; 257(1):212-8 (ISSN: 1527-1315)
  3. Yanagawa Y; Sakamoto T; Okada Y. Clinical features of temporal tip epidural hematomas.J Neurosurg. 2007; 107(1):18-20 (ISSN: 0022-3085)
  4. Topcu-Yilmaz P; Repka MX. Abducens nerve palsy associated with a clival epidural hematoma.J AAPOS. 2011; 15(1):69-70 (ISSN: 1528-3933)
  5. Lee SJ; Lin YY; Hsu CW; Chu SJ; Tsai SH. Intraventricular hematoma, subarachnoid hematoma and spinal epidural hematoma caused by lumbar puncture: an unusual complication. Am J Med Sci. 2009; 337(2):143-5 (ISSN: 0002-9629)
  6. Huisman TA; Tschirch FT. Epidural hematoma in children: do cranial sutures act as a barrier?J Neuroradiol. 2009; 36(2):93-7 (ISSN: 0150-9861).
  7. Fujiwara H, Oki K, Momoshima S. PROPELLER diffusion-weighted magnetic resonance imaging of acute spinal epidural hematoma. Acta Radiol. Aug 2005;46(5):539-42.
  8. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW. Surgical management of acute epidural hematomas. Neurosurgery. Mar 2006;58(3 Suppl):S7-15; discussion Si-iv.
  9. Smets KJ; Vanhauwaert D. Treatment of cranial epidural hematoma in a neonate by needle aspiration of a communicating cephalhematoma. Eur J Pediatr. 2010; 169(5):617-9 (ISSN: 1432-1076)
  10. Liu JT, Tyan YS, Lee YK. Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report. Acta Neurochir (Wien). Mar 2006;148(3):313-7.

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Last updated: 2019-06-28 11:43