Epidural hematoma is the accumulation of blood in the space between dura and bone in the cranial or spinal region.
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.
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.
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 . 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 .
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 .
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 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 . 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 . Before and after the surgery, CT scan is done to ensure the correct evacuation of the epidural hematoma.
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 .
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 . 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 .
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 .
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.
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 . 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.
Some of the recommendations that can prevent epidural hematoma are as follows:
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%).