Epidural hemorrhage

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"epidural hematoma"[MeSH Terms] AND management

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Epidural Hemorrhage (Epidural Hematoma)

Definition and Anatomy

An epidural hematoma (EDH) is a collection of blood in the potential space between the skull and the dura mater. Because the outer layer of the dura normally serves as the periosteum of the inner skull table, this space does not exist under normal conditions - it forms only when a vessel bleeds with enough pressure to strip the dura away from the bone.

Epidural vs. subdural hematoma diagram - arterial blood between skull and dura (left) vs. venous blood between dura and arachnoid (right)

Etiology and Mechanism

Primary cause: Blunt trauma - most commonly to the temporal or temporoparietal region - causing a skull fracture that crosses the groove of the middle meningeal artery, lacerating it. The resulting high-pressure arterial bleeding strips the dura from the periosteum, creating an expanding hematoma.

Most common location: lateral temporal region (middle meningeal artery territory)
Less commonly: parieto-occipital region or posterior fossa, where a venous sinus tear is more likely
In children: the skull is deformable, so temporary displacement can lacerate a vessel even without a fracture

Less common causes:

Laceration of a dural venous sinus (bleeds more slowly; course may resemble subdural hematoma)
Eosinophilic granuloma, metastatic skull/dural tumors (e.g., hepatocellular carcinoma), or craniofacial infections such as sinusitis

Robbins & Cotran Pathologic Basis of Disease, p. 1162

Plum and Posner's Diagnosis and Treatment of Stupor and Coma, p. 245-246

Classic Clinical Presentation

The "textbook" triad is:

Significant head trauma (often to thin temporal bone - baseball, pool cue, fall)
Brief loss of consciousness or altered sensorium
A lucid interval (minutes to hours) followed by rapid neurologic deterioration

However, this classic triad occurs in only 15-20% of patients ("talk and die" patients). The majority (~70%) are picked up on CT with minimal or no loss of consciousness. About half of pediatric cases involve a fall of less than 0.5 meters.

Symptoms of expansion:

Headache of increasing severity
Vomiting, drowsiness, confusion
Seizures (sometimes focal/unilateral)
Hemiparesis with hyperreflexia and Babinski sign
Ipsilateral pupil dilation (third nerve compression from uncal herniation)
Cushing response: rising systolic BP + bradycardia
As coma deepens: bilateral spasticity, decerebrate rigidity

Signs of basal skull fracture to look for (since the fracture often involves the skull base):

Battle's sign (post-auricular ecchymosis)
Raccoon eyes (periorbital ecchymosis)
Hemotympanum

Tintinalli's Emergency Medicine, p. 1732

Plum and Posner, p. 246-247

Imaging

CT Scan (modality of choice)

Appears as a biconvex (lens-shaped / football-shaped) hyperdense mass between the skull and brain, typically in the temporal region
Convex on both surfaces - this distinguishes it from subdural hematoma, which is concave on the brain-facing surface
Look for an associated skull fracture crossing the middle meningeal groove on bone windows
A vertex hematoma can be missed on axial cuts - coronal reconstructions are needed
MRI is not required for EDH diagnosis but may be needed to assess underlying contusions and edema

CT showing biconvex hyperdense epidural hematoma in the right frontotemporal region

CT demonstrating the characteristic biconvex shape and focal location of an epidural hematoma - Tintinalli's Emergency Medicine

Plum and Posner, p. 247

Tintinalli's Emergency Medicine, p. 1732

Pathophysiology of Deterioration

High-pressure arterial bleeding does not tamponade easily, so blood continues to accumulate. The expanding hematoma:

Compresses the underlying temporal lobe
Stretches and tears pain-sensitive meninges and vessels at the middle fossa base (headache)
Causes uncal herniation - ipsilateral pupil dilation (CN III compression) followed by complete ophthalmoparesis
Compresses the midbrain - bilateral Babinski signs, spasticity
Ultimately: respiratory arrest if not evacuated

Herniation can occur within hours of injury - this is the key reason EDH is a neurosurgical emergency.

Robbins & Cotran, p. 1162

Adams and Victor's Principles of Neurology, p. (Ch. 34)

Treatment

Surgical (definitive)

Emergency surgical evacuation is the treatment for any EDH causing brain displacement or impairment of consciousness. Options:

Craniotomy (preferred) with drainage of the hematoma and ligation of the bleeding vessel
Burr holes in emergency situations when craniotomy is not immediately possible

Prognosis is excellent when surgery is performed promptly, because the underlying brain parenchyma is often uninjured. Even approximately one-third of patients with a fixed, dilated pupil preoperatively can achieve a good recovery with prompt surgery.

Factors determining outcome:

Time from injury to surgical evacuation (most important)
Age
Depth of coma
Degree of midline shift
Hematoma size

If coma, bilateral Babinski signs, decerebrate rigidity, or bilateral spasticity have already supervened before operation, it indicates midbrain compression has occurred; prognosis is less favorable but not hopeless.

Conservative management

Small epidural hemorrhages without neurologic symptoms or signs can be managed conservatively with serial CT scanning and close clinical surveillance. Many small clots enlarge gradually over 1-2 weeks and are then absorbed. However, even "mild" cases require careful follow-up, as occasionally hematoma development is delayed.

Patients with a negative initial CT should be cautioned to remain under observation of a family member for 24 hours, with instructions to return immediately if they cannot be awakened.

Adams and Victor's Principles of Neurology, treatment section (Ch. 34)

Plum and Posner, p. 247

Key Comparisons: EDH vs. Subdural Hematoma

Feature	Epidural Hematoma	Subdural Hematoma
Bleeding source	Middle meningeal artery (arterial)	Bridging veins (venous)
Location	Between skull and dura	Between dura and arachnoid
CT shape	Biconvex (lens-shaped)	Concave (crescent-shaped)
Speed of onset	Rapid (hours)	Variable (acute to chronic)
Lucid interval	Classic (but minority)	Less typical
Brain injury	Often absent	Often concurrent contusion
Skull fracture	Usually present	Less common
Prognosis with Rx	Excellent if early	More variable

Summary

Epidural hemorrhage is an arterial neurosurgical emergency caused most often by middle meningeal artery laceration from temporal skull fracture. The classic lucid-interval presentation is seen in a minority; most cases are now detected on CT with mild or no symptoms. The hallmark CT finding is a biconvex hyperdense mass, typically temporal. Prompt surgical evacuation is life-saving and yields excellent outcomes when performed before uncal herniation is complete. Small, asymptomatic hematomas may be observed with serial imaging.

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