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.

• Pain

  Safak ERSOZ,Zeynep Sagnak YILMAZ,Ilker EYUBOGLU,Ugur YAZAR Phantom Radicular Pain Treated with Lumbar Microdiscectomy: A Case Report. [turkishneurosurgery.org.tr]

  PATIENT CONCERNS: An 83-year-old woman taking cilostazol received caudal epidural steroid injection because of her chronic back pain. Six hours later, she experienced an acute hip pain which worsened with time. [ncbi.nlm.nih.gov]

• Weakness

  Three months postoperatively, the motor weakness in the patient's right leg improved to MMT = 4 to 5. [ncbi.nlm.nih.gov]

  The brain and nervous system (neurological) examination may show that a specific part of the brain is not working well (for instance, there may be arm weakness on one side). [nlm.nih.gov]

  A 25-year-old woman with sudden-onset weakness of lower limbs, urinary incontinence, and sensory disturbance from the nipple line downward, 8 hours after normal vaginal delivery View Case [ajnr.org]

  Exams and Tests The brain and nervous system (neurological) examination may show that a specific part of the brain is not working well (for instance, there may be arm weakness on one side). [mountsinai.org]

• Asymptomatic

  The neonate remained neurologically asymptomatic. A computed tomography scan 12 days after delivery showed the large-volume epidural hematoma with midline shift. [ncbi.nlm.nih.gov]

  The patient remained asymptomatic over a year of follow-up. A healthy, previously asymptomatic 22-year-old man was admitted to the Emergency Department after a traffic accident. [sogacot.org]

• Surgical Procedure

  Most of lumbar SSEH were acute and secondary with trauma, hematologic disorders, drug, and surgical procedure. Only 20 cases of chronic SSEH in the lumbar spine have been reported and 14 cases among them were considered to be idiopathic. [ncbi.nlm.nih.gov]

  Surgical procedure The patient was placed supine with mild flexion of the head. [jtraumainj.org]

  Cicatrisation from SDH The following are video recordings of surgical procedures from the Department of Neurosurgery of Saint John’s Hospital of Budapest. The videos were made to assist with the training of neurosurgery, residents. [videotorium.hu]

  Surgery In many cases, a doctor will use one of two surgical procedures to remove the blood from the brain. A craniotomy is more likely to be used for a severe hematoma. [medicalnewstoday.com]

  The bone flap is mostly removed with the help of a cranial drill and a craniotome, then replaced using titanium plates and screws or another form of fixation (wire, suture, etc.) after completion of the surgical procedure. [en.wikipedia.org]

• Anemia

  In the present case, the CT findings could be explained by the anemia or by the presence of the skull base fracture. The dura was intact, thus the isodense hematoma could not be related to the CSF mixture. [scielo.br]

  Similarly, Pasaoglu et al. [12] reported that pallor and anemia occurred in 90% of their infantile cases. [jpss.eu]

  Diseases or conditions that may decrease the number of platelets in the bloodstream (thrombocytopenia) or diminish their function: Viral infections (rubella, parvovirus, mumps, chickenpox, HIV, and hepatitis C), aplastic anemia, cancers from other organs [medicinenet.com]

• Respiratory Distress

  distress syndrome, multiple organ dysfunction syndrome, major hemorrhage, and venous thromboembolism. [en.wikipedia.org]

• Vomiting

  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]

  BACKGROUND: Sub-acute/chronic epidural hematoma (EDH) may present with nagging symptoms of headache, nausea, vomiting, lethargy, etc. [ncbi.nlm.nih.gov]

  Clinical features may include HEADACHE; VOMITING; HEMIPARESIS; and impaired mental function. [connects.catalyst.harvard.edu]

  Signs and symptoms can include loss of consciousness, history of trauma, a unilateral paralysis or numbness, unilateral pupil dilation, headache, nausea, vomiting, seizures, slow heart beat, confusion, and even coma. [neurosurgery.med.uky.edu]

• 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]

  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]

  Signs and symptoms can include loss of consciousness, history of trauma, a unilateral paralysis or numbness, unilateral pupil dilation, headache, nausea, vomiting, seizures, slow heart beat, confusion, and even coma. [neurosurgery.med.uky.edu]

  The patient went home, but 2 hours after the injury, he presented to a local emergency department with severe headache, nausea, and vomiting. [nejm.org]

• Hypertension

  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]

  Two-thirds of the patients had history of hypertensive disease or transitory hypertensive status after surgery. No patients had abnormal preoperative coagulation parameters, bleeding diathesis or developed intraoperative coagulopathy. [aott.org.tr]

  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]

  Intraparenchymal hemorrhage occurs in patients with amyloid angiopathy, neoplasms, vasculitis, and uncontrolled systemic hypertension, among other etiologies. The blood is traditionally found in the internal capsule and basal ganglia region. [emra.org]

  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]

• Chest Pain

  pain that typically occurs when a person is at rest). [press.pfizer.com]

• Purpura

  Prolonged Prolonged Decreased Uremia Unaffected Unaffected Prolonged Unaffected Congenital afibrinogenemia Prolonged Prolonged Prolonged Unaffected Factor V deficiency Prolonged Prolonged Unaffected Unaffected Factor X deficiency as seen in amyloid purpura [en.wikipedia.org]

• Fracture

  Goktekin TENEKECI,Yavuz BASTERZI,Sakir UNAL,Alper SARI,Yavuz DEMIR,Celal BAGDATOGLU,Bahar TASDELEN Percutaneous Vertebroplasty for the Treatment of Osteoporotic Thoracolumbar Fractures with Posterior Body Involved in Elderly Patients. [turkishneurosurgery.org.tr]

  Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p CONCLUSION: DPFEDH, combined [ncbi.nlm.nih.gov]

  The overlying calvarium has a defect which is better visualized on the CT at bone window settings; a mildly depressed skull fracture is seen. 90% of epidural hematomas are caused by head trauma with a skull fracture that crosses a portion of the middle [www2.med.wayne.edu]

• Back Pain

  PATIENT CONCERNS: An 83-year-old woman taking cilostazol received caudal epidural steroid injection because of her chronic back pain. Six hours later, she experienced an acute hip pain which worsened with time. [ncbi.nlm.nih.gov]

  Symptoms and Signs Symptoms of a spinal subdural or epidural hematoma begin with local or radicular back pain and percussion tenderness; they are often severe. [merckmanuals.com]

• Pupillary Abnormality

  The risk factors identified, age, GCS, pupillary abnormalities, lucid interval, volume and location of the EDH, midline shift and other focal lesions. [biomedpharmajournal.org]

  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]

• 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]

  Clinical signs include persistent headache, nausea, vomiting, photophobia, diplopia, focal neurological signs, and impairment of the consciousness.[10] In this case, intracranial SDH was caused by a lumbar posttraumatic dural fistula as a complication [asianjns.org]

  Diplopia from subacute bilateral hematoma after spinal anesthesia. West J Emerg Med. 2012;13:108–10. 21. Gerard C, Busl KM. Treatment of acute subdural hematoma. Curr Treat Options Neurol. 2014;16:275. 22. Girgis F, Shing M, Duplessis S. [intjem.biomedcentral.com]

• Headache

  The majority of these headaches are benign primary headaches, such as migraine and tension type [25]. [intjem.biomedcentral.com]

  CSH A pregnant patient with a headache has a broad differential, which includes the following: pre-eclampsia, posterior reversible encephalopathy syndrome (PRES), hypertensive emergency, drug-induced headaches, migraines, postdural puncture headache, [emra.org]

  The differential diagnosis includes unspecified headache, sinusitis headache, drug-induced headache, cortical vein thrombosis, fistula of the dura mater, and bacterial, viral, and aseptic meningitis. [asianjns.org]

  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]

  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]

• Seizure

  Symptoms (such as seizures ) may persist for several months, even after treatment. In time they may become less frequent or disappear. Seizures may begin up to 2 years after the injury. In adults, most recovery occurs in the first 6 months. [nlm.nih.gov]

  Seizures: Although there is no indication to start patients on seizure prophylaxis, it is important to monitor the patient for development of seizures. Levetiracetam and phenytoin would be the traditional treatment options. [emra.org]

  Symptoms (such as seizures) may persist for several months, even after treatment. In time they may become less frequent or disappear. Seizures may begin up to 2 years after the injury. In adults, most recovery occurs in the first 6 months. [mountsinai.org]

  Post-traumatic seizures due to cortical damage may develop 1 to 3 months after the injury: The risk diminishes with time. Alcoholism increases the risk of post-traumatic seizures. [patient.info]

• 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]

  Signs and symptoms can include loss of consciousness, history of trauma, a unilateral paralysis or numbness, unilateral pupil dilation, headache, nausea, vomiting, seizures, slow heart beat, confusion, and even coma. [neurosurgery.med.uky.edu]

• 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]

• Dizziness

  The most important symptoms of an EDH are: Confusion Dizziness Drowsiness or altered level of alertness Enlarged pupil in one eye Headache (severe) Head injury or trauma followed by loss of consciousness, a period of alertness, then rapid deterioration [nlm.nih.gov]

  Symptoms Injury that is accompanied with the rupture of middle meningeal artery may manifest with symptoms that are expectable by a “non-complicated” head trauma such as short period of unconsciousness, dizziness, headache, vomiting, etc. [health-tutor.com]

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].

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.

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].

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.

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 [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.

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.

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%).

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

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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)
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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)
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