Epidural hemorrhage: Difference between revisions
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==Background== | ==Background== | ||
*Bleeding between the skull and dura mater, typically from rupture of the '''middle meningeal artery''' | |||
* | *Usually associated with temporal bone fracture<ref name="bullock">Bullock MR, et al. Surgical management of acute epidural hematomas. ''Neurosurgery''. 2006;58(3 Suppl):S7-15. PMID 16710967.</ref> | ||
* | *Accounts for 1-4% of traumatic [[Head trauma (main)|head injuries]] | ||
*Bimodal age distribution: most common in adolescents and young adults | |||
*Rare in elderly (dura more adherent to skull) and infants <2 years | |||
*Carries ~5-10% mortality with prompt treatment; higher if uncal herniation occurs | |||
==Clinical Features== | ==Clinical Features== | ||
* | *Classic presentation ('''lucid interval''' in ~30% of cases): | ||
* | **Initial loss of consciousness (LOC) after head trauma | ||
**Transient period of lucidity | |||
**Rapid deterioration with decreasing [[GCS]], ipsilateral pupil dilation | |||
*Headache, nausea, vomiting | |||
*Signs of [[Increased intracranial pressure|increased ICP]]: [[Cushing response]] (hypertension, bradycardia, irregular respirations) | |||
*Ipsilateral fixed, dilated pupil ([[Uncal herniation|uncal herniation]]) | |||
*Contralateral hemiparesis | |||
*May present without lucid interval, especially with severe injury | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*[[Subdural hemorrhage]] | |||
*[[Subarachnoid hemorrhage]] | |||
*[[Intracerebral hemorrhage]] | |||
*[[Cerebral contusion]] | |||
*[[Diffuse axonal injury]] | |||
==Evaluation== | ==Evaluation== | ||
*'''Non-contrast CT head''' — test of choice<ref name="dent">Dent DL, et al. Prognostic factors after acute subdural hematoma. ''J Trauma''. 1995;39(1):36-43. PMID 7636907.</ref> | |||
* | **Biconvex (lens-shaped) hyperdense collection | ||
* | **Does NOT cross suture lines (confined by dural attachments) | ||
* | **May see associated skull fracture, midline shift, mass effect | ||
*Labs: CBC, coagulation studies, type and screen | |||
** | *Evaluate for [[Cervical spine injury|cervical spine injury]] and other traumatic injuries | ||
* | |||
* | |||
==Management== | ==Management== | ||
*'''ABCs''' — secure airway early if declining GCS | |||
*'''Emergent neurosurgical consultation''' | |||
*Indications for surgical evacuation (craniotomy): | |||
**EDH >30 mL regardless of GCS | |||
**Clot thickness >15 mm or midline shift >5 mm | |||
**GCS declining or GCS <9 with pupil abnormalities | |||
*ICP management while awaiting surgery: | |||
**Elevate head of bed 30 degrees | |||
**'''[[Mannitol]]''' 1-1.5 g/kg IV bolus or '''[[Hypertonic saline]]''' 23.4% 30 mL IV | |||
**Controlled [[Intubation (main)|intubation]] if GCS <=8; target PaCO2 35 mmHg | |||
**Avoid hypotension (maintain MAP >80) | |||
*Small EDH (<30 mL, <15 mm thick, <5 mm shift, GCS >8): may be managed non-operatively with serial CT and close neuro monitoring | |||
==Disposition== | ==Disposition== | ||
* | *All EDH require '''admission''' with neurosurgical involvement | ||
*ICU admission for any operative EDH or declining neurologic exam | |||
*Repeat CT in 6-8 hours for non-operative cases | |||
==See Also== | ==See Also== | ||
*[[ | *[[Subdural hemorrhage]] | ||
*[[ | *[[Head trauma (main)]] | ||
*[[ | *[[Increased intracranial pressure]] | ||
*[[ | *[[Subarachnoid hemorrhage]] | ||
==References== | ==References== | ||
Revision as of 18:30, 21 March 2026
Background
- Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
- Usually associated with temporal bone fracture[1]
- Accounts for 1-4% of traumatic head injuries
- Bimodal age distribution: most common in adolescents and young adults
- Rare in elderly (dura more adherent to skull) and infants <2 years
- Carries ~5-10% mortality with prompt treatment; higher if uncal herniation occurs
Clinical Features
- Classic presentation (lucid interval in ~30% of cases):
- Initial loss of consciousness (LOC) after head trauma
- Transient period of lucidity
- Rapid deterioration with decreasing GCS, ipsilateral pupil dilation
- Headache, nausea, vomiting
- Signs of increased ICP: Cushing response (hypertension, bradycardia, irregular respirations)
- Ipsilateral fixed, dilated pupil (uncal herniation)
- Contralateral hemiparesis
- May present without lucid interval, especially with severe injury
Differential Diagnosis
- Subdural hemorrhage
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Cerebral contusion
- Diffuse axonal injury
Evaluation
- Non-contrast CT head — test of choice[2]
- Biconvex (lens-shaped) hyperdense collection
- Does NOT cross suture lines (confined by dural attachments)
- May see associated skull fracture, midline shift, mass effect
- Labs: CBC, coagulation studies, type and screen
- Evaluate for cervical spine injury and other traumatic injuries
Management
- ABCs — secure airway early if declining GCS
- Emergent neurosurgical consultation
- Indications for surgical evacuation (craniotomy):
- EDH >30 mL regardless of GCS
- Clot thickness >15 mm or midline shift >5 mm
- GCS declining or GCS <9 with pupil abnormalities
- ICP management while awaiting surgery:
- Elevate head of bed 30 degrees
- Mannitol 1-1.5 g/kg IV bolus or Hypertonic saline 23.4% 30 mL IV
- Controlled intubation if GCS <=8; target PaCO2 35 mmHg
- Avoid hypotension (maintain MAP >80)
- Small EDH (<30 mL, <15 mm thick, <5 mm shift, GCS >8): may be managed non-operatively with serial CT and close neuro monitoring
Disposition
- All EDH require admission with neurosurgical involvement
- ICU admission for any operative EDH or declining neurologic exam
- Repeat CT in 6-8 hours for non-operative cases