Extradural hematoma EDH , also known as an epidural hematoma , is a collection of blood that forms between the inner surface of the skull and outer layer of the dura , which is called the endosteal layer. They are usually associated with a history of head trauma and frequently associated skull fracture. The source of bleeding is usually arterial, most commonly from a torn middle meningeal artery. EDHs are typically biconvex in shape and can cause a mass effect with herniation. They are usually limited by cranial sutures, but not by venous sinuses.
|Published (Last):||28 April 2017|
|PDF File Size:||8.92 Mb|
|ePub File Size:||10.76 Mb|
|Price:||Free* [*Free Regsitration Required]|
NCBI Bookshelf. Ali Khairat ; Muhammad Waseem. Authors Ali Khairat 1 ; Muhammad Waseem 2. An epidural hematoma EDH is an extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull. It is confined by the lateral sutures especially the coronal sutures where the dura inserts. It is a life-threatening condition, which may require immediate intervention and can be associated with significant morbidity and mortality if left untreated.
Both traumatic and non-traumatic mechanisms can cause an epidural hematoma. The majority of cases related to a traumatic mechanism are a result of head injury due to motor vehicle collisions, physical assaults, or accidental falls. Males are more often affected than are females. Furthermore, the incidence is higher among adolescents and young adults.
The mean age of affected patients is 20 to 30 years, and it is rare after 50 to 60 years of age. As an individual's age advances, the dura mater becomes more adherent to the overlying bone. This decreases the chance that a hematoma can develop in the space between the cranium and dura. Most epidural hematomas result from arterial bleeding from a branch of the middle meningeal artery.
The anterior meningeal artery or dural arteriovenous AV fistula at the vertex may be involved. A skull fracture is present in the majority of patients with EDH. These hematomas often present beneath a fracture of the squamous part of the temporal bone.
If this condition occurs within the spine, this entity is described as a spinal epidural hematoma. However, these patients may be unconscious from the beginning or may regain consciousness after a brief coma or may have no loss of consciousness. Beware that the lucid interval is not pathognomonic for an EDH and may occur in patients who sustain other expanding mass lesions.
The classic lucid interval occurs in pure EDHs that are very large and demonstrate a CT scan finding of active bleeding. The presentation of symptoms depends on how quickly the EDH is developing within the cranial vault. A patient with a small EDH may be asymptomatic, but this is rare. A posterior fossa EDH is a rare event.
Patients with posterior fossa EDH may remain conscious until late in the evolution of the hematoma, when they may suddenly lose consciousness, become apneic, and die. These lesions often extend into the supratentorial compartment by stripping the dura over the transverse sinus, resulting in a significant amount of intracranial bleeding. Imaging studies such as a computed tomogram CT scan comprise the mainstay of diagnosis.
CT scan is the most common imaging modality to assess for intracranial bleeding. Its popularity is related to its widespread availability in emergency departments. The classic presentation is a biconvex or lens-shaped mass on brain CT scan, due to the limited ability of blood to expand within the fixed attachment of the dura to the cranial sutures.
EDHs does not cross suture lines. Generally, radiologists use a standard formula for estimating the amount of blood present in an EDH. For example, continued bleeding may be indicated by areas of low density, or a "swirl-sign. If the EDH abuts brain tissue that is hemorrhagic or contused, it may appear shallow, and thus, may be overlooked if the CT scan is not carefully examined.
It should be obtained when there is high clinical suspicion for EDH, accompanying a negative initial head CT scan. EDH is a neurosurgical emergency. It, therefore, requires urgent surgical evacuation to prevent irreversible neurological injury and death secondary to hematoma expansion and herniation.
Neurosurgical consultation should be urgently obtained as it is important to intervene within 1 to 2 hours of presentation. The priority is to stabilize the patient, including the ABCs airway, breathing, circulation , and these should be addressed urgently. In patients with acute and symptomatic EDHs, the treatment is craniotomy and hematoma evacuation.
However, the performance of a craniotomy, if feasible, can provide a more thorough evacuation of the hematoma. There is a scarcity of literature comparing conservative management with surgical intervention in patients with EDH. However, a non-surgical approach may be considered in a patient with acute EDH who has mild symptoms and meets all of the criteria listed below:.
If the decision is made to manage acute EDH non-surgically, close observation with repeated neurological examinations and continuous surveillance with brain imaging is required, as the risk for hematoma expansion and clinical deterioration is present.
The recommendation is to obtain a follow-up head CT scan within 6 to 8 hours following brain injury. In general, patients with pure EDHs have an excellent prognosis of a functional outcome after the surgical evacuation, when it is rapidly detected and evacuated. A delay in diagnosis and treatment increases morbidity and mortality. EDHs caused by arterial bleeding develop rapidly and can be detected quickly. But those due to a dural sinus tear develop more slowly.
Thus, clinical manifestations may be delayed, with a resultant delay in recognition and evacuation. EDH is a relatively common presentation to the emergency department, and if not diagnosed is associated with high mortality.
The condition is best managed by an interprofessional team that includes the emergency room physician, the trauma team, radiologist, neurologist, neurosurgeon, intensivist and the ICU nurses.
Healthcare workers should educate the public on the importance of head safety equipment when playing sports or while working. To access free multiple choice questions on this topic, click here. CT head Epidural Hematoma. Contributed by Scott Dulebohn, MD. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U. StatPearls [Internet].
Search term. Affiliations 1 Weill Cornell Medicine - Qatar. Introduction An epidural hematoma EDH is an extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull.
Pathophysiology Arterial Injury Most epidural hematomas result from arterial bleeding from a branch of the middle meningeal artery. Type III: Chronic occurring between days 7 to 20; mixed or lucent appearance with contrast enhancement. Evaluation Imaging studies such as a computed tomogram CT scan comprise the mainstay of diagnosis. Several factors may lead to a non-diagnostic CT scan. A positive finding on CT requires that enough blood accumulates for visualization.
If the EDH is secondary to venous bleeding, blood accumulation may be slow. This could potentially result in difficulty with CT interpretation. Surgical intervention is recommended in patients with: Acute EDH. Differential Diagnosis Intracranial abscess.
Prognosis In general, patients with pure EDHs have an excellent prognosis of a functional outcome after the surgical evacuation, when it is rapidly detected and evacuated. Associated intracranial lesions such as contusions, intracerebral hemorrhage, subarachnoid hemorrhage, and diffuse brain swelling.
Complications Mass effect: compression of the brain if bleeding is significant. Patients with EDH may be unconscious, may regain consciousness after a brief loss of consciousness or may have no loss of consciousness; Patients with small EDH may be asymptomatic.
Enhancing Healthcare Team Outcomes EDH is a relatively common presentation to the emergency department, and if not diagnosed is associated with high mortality. Questions To access free multiple choice questions on this topic, click here. Figure CT head Epidural Hematoma. References 1. Am Surg. Spinal Emergencies in Primary Care Practice.
World Neurosurg. Etiopathogenesis of Traumatic Spinal Epidural Hematoma. P R Health Sci J. Epidemiology of traumatic brain injury in the elderly over a 25 year period. Rev Esp Anestesiol Reanim. Reg Anesth Pain Med. Epidural Hematoma: Vigilance beyond Guidelines. Indian J Crit Care Med. Can J Neurol Sci. Update in intracerebral hemorrhage. Korean J Neurotrauma. Epidural Hematoma.
In: StatPearls [Internet]. In this Page. Related information. Similar articles in PubMed. Review [A case of acute intracranial epidural hematoma caused by chronic nasal sinusitis].
NCBI Bookshelf. Ali Khairat ; Muhammad Waseem. Authors Ali Khairat 1 ; Muhammad Waseem 2. An epidural hematoma EDH is an extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull.
A subdural hematoma SDH is a type of bleeding in which a collection of blood —usually associated with a traumatic brain injury —gathers between the inner layer of the dura mater and the arachnoid mater of the meninges surrounding the brain. It usually results from tears in bridging veins that cross the subdural space. Subdural hematomas may cause an increase in the pressure inside the skull , which in turn can cause compression of and damage to delicate brain tissue. Acute subdural hematomas are often life-threatening.
Differentiating extradural EDH from subdural SDH hemorrhage in the head is usually straightforward, but occasionally it can be challenging. SDHs are more common and there are a few distinguishing features which are usually reliable. The typical presentation is of a young patient involved in a head strike either during sport or a result of a motor vehicle accident who may or may not lose consciousness transiently. Following the injury they regain a normal level of consciousness lucid interval , but usually have an ongoing and often severe headache. Over the next few hours they gradually lose consciousness.