Epidural hematoma

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Epidural hematoma
Other namesExtradural hematoma, epidural hemorrhage, epidural haematoma, epidural bleeding
EpiduralHematoma.jpg
Epidural hematoma as seen on a CT scan with overlying skull fracture. Note the biconvex shaped collection of blood. There is also bruising with bleeding on the opposite side of the brain.
Specialty Neurosurgery, Neurology
Symptoms Headache, confusion, paralysis [1]
Usual onsetRapid [2]
Causes Head injury, bleeding disorder, blood vessel malformation [1]
Diagnostic method Medical imaging (CT scan) [1]
Differential diagnosis Subdural hematoma, subarachnoid hemorrhage, traumatic brain injury, [1] transient ischemic attack seizure, intracranial abscess, brain tumor [3]
TreatmentSurgery (craniotomy, burr hole) [1]

Epidural hematoma is when bleeding occurs between the tough outer membrane covering the brain (dura mater) and the skull. [4] Often there is loss of consciousness following a head injury, a brief regaining of consciousness, and then loss of consciousness again. [2] Other symptoms may include headache, confusion, vomiting, and an inability to move parts of the body. [1] Complications may include seizures. [1]

Contents

The cause is typically head injury that results in a break of the temporal bone and bleeding from the middle meningeal artery. [4] Occasionally it can occur as a result of a bleeding disorder or blood vessel malformation. [1] Diagnosis is typically by a CT scan or MRI. [1] When this condition occurs in the spine it is known as a spinal epidural hematoma. [4]

Treatment is generally by urgent surgery in the form of a craniotomy or burr hole. [1] Without treatment, death typically results. [5] The condition occurs in one to four percent of head injuries. [1] Typically it occurs in young adults. [1] Males are more often affected than females. [1]

Signs and symptoms

Many people with epidural hematomas experience a lucid period immediately following the injury, with a delay before symptoms become evident. [6] Because of this initial period of lucidity, it has been called "Talk and Die" syndrome. [7] As blood accumulates, it starts to compress intracranial structures, which may impinge on the third cranial nerve, causing a fixed and dilated pupil on the side of the injury. [6] The eye will be positioned down and out due to unopposed innervation of the fourth and sixth cranial nerves.[ citation needed ]

Other symptoms include severe headache; weakness of the extremities on the opposite side from the lesion due to compression of the crossed pyramid pathways; and vision loss, also on the opposite side, due to compression of the posterior cerebral artery. In rare cases, small hematomas may be asymptomatic. [3]

If not treated promptly, epidural hematomas can cause tonsillar herniation, resulting in respiratory arrest. The trigeminal nerve may be involved late in the process as the pons is compressed, but this is not an important presentation, because the person may already be dead by the time it occurs. [8] In the case of epidural hematoma in the posterior cranial fossa, tonsillar herniation causes Cushing's triad: hypertension, bradycardia, and irregular breathing.[ citation needed ]

Causes

The interior of the skull has sharp ridges by which a moving brain can be injured. Skull interior anatomy.svg
The interior of the skull has sharp ridges by which a moving brain can be injured.

The most common cause of intracranial epidural hematoma is head injury, although spontaneous hemorrhages have been known to occur. Epidural hematomas occur in about 10% of traumatic brain injuries, mostly due to car accidents, assaults, or falls. [3] They are often caused by acceleration-deceleration trauma and transverse forces. [9] [10]

Epidural hematoma commonly results from a blow to the side (temporal bone) of the head. The pterion region, which overlies the middle meningeal artery, is relatively weak and prone to injury. [11] Only 20 to 30% of epidural hematomas occur outside the region of the temporal bone. [12] The brain may be injured by prominences on the inside of the skull as it scrapes past them. Epidural hematoma is usually found on the same side of the brain which was impacted by the blow, but on very rare occasions it can be due to a contrecoup injury. [13]

A "heat hematoma" is an epidural hematoma caused by severe thermal burn, causing contraction and exfoliation of the dura mater and exfoliate from the skull, in turn causing exudation of blood from the venous sinuses. [14] The hematoma can be seen on autopsy as brick red, or as radiolucent on CT scan, because of heat-induced coagulation of the hematoma. [14]

Pathophysiology

The break of the temporal bone causes bleeding from the middle meningeal artery, [4] hence epidural bleeding is often rapid as arteries are high-pressure flow. In 10% of cases, however, it comes from veins and can progress more slowly. [11] A venous hematoma may be acute (occurring within a day of the injury and appearing as a swirling mass of blood without a clot), subacute (occurring in 2–4 days and appearing solid), or chronic (occurring in 7–20 days and appearing mixed or lucent). [3]

In adults, the temporal region accounts for 75% of cases. In children, however, they occur with similar frequency in the occipital, frontal, and posterior fossa regions. [3] Epidural bleeds from arteries can grow until they reach their peak size 6–8 hours post-injury, spilling 25–75 cubic centimeters of blood into the intracranial space. [9] As the hematoma expands, it strips the dura from the inside of the skull, causing an intense headache. It also increases intracranial pressure, causing the brain to shift, lose blood supply, be crushed against the skull, or herniate. Larger hematomas cause more damage. Epidural bleeds can quickly compress the brainstem, causing unconsciousness, abnormal posturing, and abnormal pupil responses to light. [15]

Diagnosis

Diagnosis is typically by CT scan or MRI. [1] MRIs have greater sensitivity and should be used if there is a high suspicion of epidural hematoma and a negative CT scan. [3] Differential diagnoses include a transient ischemic attack, intracranial mass, or brain abscess. [3]

Epidural hematomas usually appear convex in shape because their expansion stops at the skull's sutures, where the dura mater is tightly attached to the skull. Thus, they expand inward toward the brain rather than along the inside of the skull, as occurs in subdural hematomas. Most people also have a skull fracture. [3]

Epidural hematomas may occur in combination with subdural hematomas, or either may occur alone. [11] CT scans reveal subdural or epidural hematomas in 20% of unconscious people. [16] In the hallmark of epidural hematoma, people may regain consciousness and appear completely normal during what is called a lucid interval, only to descend suddenly and rapidly into unconsciousness later. This lucid interval, which depends on the extent of the injury, is a key to diagnosing an epidural hematoma. [3]

Treatment

Epidural hematoma is a surgical emergency. Delayed surgery can result in permanent brain damage or death. Without surgery, death usually follows, due to enlargement of the hematoma, causing a brain herniation. [3] As with other types of intracranial hematomas, the blood almost always must be removed surgically to reduce the pressure on the brain. [10] The hematoma is evacuated through a burr hole or craniotomy. If transfer to a facility with neurosurgery is unavailable, prolonged trephination (drilling a hole into the skull) may be performed in the emergency department. [17] Large hematomas and blood clots may require an open craniotomy. [18]

Medications may be given after surgery. They may include antiseizure medications and hyperosmotic agents to reduce brain swelling and intracranial pressure. [18]

It is extremely rare to not require surgery. If the volume of the epidural hematoma is less than 30 mL, the clot diameter less than 15 mm, a Glasgow Coma Score above 8, and no visible neurological symptoms, then it may be possible to treat it conservatively. A CT scan should be performed, and watchful waiting should be done, as the hematoma may suddenly expand. [3]

Prognosis

The prognosis is better if there was a lucid interval than if the person was comatose from the time of injury. Arterial epidural hematomas usually progress rapidly. However, venous epidural hematomas, caused by a dural sinus tear, are slower. [3]

Outcomes are worse if there is more than 50 mL of blood in the hematoma before surgery. Age, pupil abnormalities, and Glasgow Coma Scale score on arrival to the emergency department also influence the prognosis. In contrast to most forms of traumatic brain injury, people with epidural hematoma and a Glasgow Coma Score of 15 (the highest score, indicating the best prognosis) usually have a good outcome if they receive surgery quickly. [3]

Epidemiology

About 2 percent of head injuries and 15 percent of fatal head injuries involve an epidural hematoma. The condition is more common in teenagers and young adults than in older people, because the dura mater sticks more to the skull as a person ages, reducing the probability of a hematoma forming. Males are affected more than females. [3]

Related Research Articles

<span class="mw-page-title-main">Head injury</span> Serious trauma to the cranium

A head injury is any injury that results in trauma to the skull or brain. The terms traumatic brain injury and head injury are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of injuries, there are many causes—including accidents, falls, physical assault, or traffic accidents—that can cause head injuries.

<span class="mw-page-title-main">Meninges</span> Three membranes that envelop the brain and spinal cord

In anatomy, the meninges are the three membranes that envelop the brain and spinal cord. In mammals, the meninges are the dura mater, the arachnoid mater, and the pia mater. Cerebrospinal fluid is located in the subarachnoid space between the arachnoid mater and the pia mater. The primary function of the meninges is to protect the central nervous system.

<span class="mw-page-title-main">Intracranial pressure</span> Pressure exerted by fluids inside the skull and on the brain

Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and at rest, is normally 7–15 mmHg for a supine adult. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.

<span class="mw-page-title-main">Dura mater</span> Outermost layer of the protective tissues around the central nervous system (meninges)

In neuroanatomy, dura mater is a thick membrane made of dense irregular connective tissue that surrounds the brain and spinal cord. It is the outermost of the three layers of membrane called the meninges that protect the central nervous system. The other two meningeal layers are the arachnoid mater and the pia mater. It envelops the arachnoid mater, which is responsible for keeping in the cerebrospinal fluid. It is derived primarily from the neural crest cell population, with postnatal contributions of the paraxial mesoderm.

<span class="mw-page-title-main">Hematoma</span> Medical condition

A hematoma, also spelled haematoma, or blood suffusion is a localized bleeding outside of blood vessels, due to either disease or trauma including injury or surgery and may involve blood continuing to seep from broken capillaries. A hematoma is benign and is initially in liquid form spread among the tissues including in sacs between tissues where it may coagulate and solidify before blood is reabsorbed into blood vessels. An ecchymosis is a hematoma of the skin larger than 10 mm.

<span class="mw-page-title-main">Subdural hematoma</span> Hematoma usually associated with traumatic brain injury

A subdural hematoma (SDH) is a type of bleeding in which a collection of blood—usually but not always 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.

<span class="mw-page-title-main">Intracranial hemorrhage</span> Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds. More often than not it ends in a lethal outcome.

<span class="mw-page-title-main">Middle meningeal artery</span>

The middle meningeal artery is typically the third branch of the first portion of the maxillary artery. After branching off the maxillary artery in the infratemporal fossa, it runs through the foramen spinosum to supply the dura mater and the calvaria. The middle meningeal artery is the largest of the three (paired) arteries that supply the meninges, the others being the anterior meningeal artery and the posterior meningeal artery.

<span class="mw-page-title-main">Penetrating head injury</span> Medical condition

A penetrating head injury, or open head injury, is a head injury in which the dura mater, the outer layer of the meninges, is breached. Penetrating injury can be caused by high-velocity projectiles or objects of lower velocity such as knives, or bone fragments from a skull fracture that are driven into the brain. Head injuries caused by penetrating trauma are serious medical emergencies and may cause permanent disability or death.

<span class="mw-page-title-main">Intracerebral hemorrhage</span> Type of intracranial bleeding that occurs within the brain tissue itself

Intracerebral hemorrhage (ICH), also known as cerebral bleed, intraparenchymal bleed, and hemorrhagic stroke, or haemorrhagic stroke, is a sudden bleeding into the tissues of the brain, into its ventricles, or into both. It is one kind of bleeding within the skull and one kind of stroke. Symptoms can include headache, one-sided weakness, vomiting, seizures, decreased level of consciousness, and neck stiffness. Often, symptoms get worse over time. Fever is also common.

<span class="mw-page-title-main">Cerebral contusion</span> Medical condition

Cerebral contusion, Latin contusio cerebri, a form of traumatic brain injury, is a bruise of the brain tissue. Like bruises in other tissues, cerebral contusion can be associated with multiple microhemorrhages, small blood vessel leaks into brain tissue. Contusion occurs in 20–30% of severe head injuries. A cerebral laceration is a similar injury except that, according to their respective definitions, the pia-arachnoid membranes are torn over the site of injury in laceration and are not torn in contusion. The injury can cause a decline in mental function in the long term and in the emergency setting may result in brain herniation, a life-threatening condition in which parts of the brain are squeezed past parts of the skull. Thus treatment aims to prevent dangerous rises in intracranial pressure, the pressure within the skull.

<span class="mw-page-title-main">Brain herniation</span> Potentially deadly side effect of very high pressure within the skull

Brain herniation is a potentially deadly side effect of very high pressure within the skull that occurs when a part of the brain is squeezed across structures within the skull. The brain can shift across such structures as the falx cerebri, the tentorium cerebelli, and even through the foramen magnum. Herniation can be caused by a number of factors that cause a mass effect and increase intracranial pressure (ICP): these include traumatic brain injury, intracranial hemorrhage, or brain tumor.

In emergency medicine, a lucid interval is a temporary improvement in a patient's condition after a traumatic brain injury, after which the condition deteriorates. A lucid interval is especially indicative of an epidural hematoma. An estimated 20 to 50% of patients with epidural hematoma experience such a lucid interval.

<span class="mw-page-title-main">Blunt trauma</span> Physical trauma caused to a body part, either by impact, injury or physical attack

Blunt trauma, also known as blunt force trauma or non-penetrating trauma, is physical traumas, and particularly in the elderly who fall. It is contrasted with penetrating trauma which occurs when an object pierces the skin and enters a tissue of the body, creating an open wound and bruise.

<span class="mw-page-title-main">Subdural hygroma</span> Collection of cerebrospinal fluid (CSF), without blood, located under the dural membrane

A subdural hygroma (SDG) is a collection of cerebrospinal fluid (CSF), without blood, located under the dural membrane of the brain. Most subdural hygromas are believed to be derived from chronic subdural hematomas. They are commonly seen in elderly people after minor trauma but can also be seen in children following infection or trauma. One of the common causes of subdural hygroma is a sudden decrease in pressure as a result of placing a ventricular shunt. This can lead to leakage of CSF into the subdural space especially in cases with moderate to severe brain atrophy. In these cases the symptoms such as mild fever, headache, drowsiness and confusion can be seen, which are relieved by draining this subdural fluid.

<span class="mw-page-title-main">Focal and diffuse brain injury</span> Medical condition

Focal and diffuse brain injury are ways to classify brain injury: focal injury occurs in a specific location, while diffuse injury occurs over a more widespread area. It is common for both focal and diffuse damage to occur as a result of the same event; many traumatic brain injuries have aspects of both focal and diffuse injury. Focal injuries are commonly associated with an injury in which the head strikes or is struck by an object; diffuse injuries are more often found in acceleration/deceleration injuries, in which the head does not necessarily contact anything, but brain tissue is damaged because tissue types with varying densities accelerate at different rates. In addition to physical trauma, other types of brain injury, such as stroke, can also produce focal and diffuse injuries. There may be primary and secondary brain injury processes.

Kernohan's notch is a cerebral peduncle indentation associated with some forms of transtentorial herniation. It is a secondary condition caused by a primary injury on the opposite hemisphere of the brain. Kernohan's notch is an ipsilateral condition, in that a left-sided primary lesion evokes motor impairment in the left side of the body and a right-sided primary injury evokes motor impairment in the right side of the body. The seriousness of Kernohan's notch varies depending on the primary problem causing it, which may range from benign brain tumors to advanced subdural hematoma.

<span class="mw-page-title-main">Midline shift</span> Sideways displacement of the brain

Midline shift is a shift of the brain past its center line. The sign may be evident on neuroimaging such as CT scanning. The sign is considered ominous because it is commonly associated with a distortion of the brain stem that can cause serious dysfunction evidenced by abnormal posturing and failure of the pupils to constrict in response to light. Midline shift is often associated with high intracranial pressure (ICP), which can be deadly. In fact, midline shift is a measure of ICP; presence of the former is an indication of the latter. Presence of midline shift is an indication for neurosurgeons to take measures to monitor and control ICP. Immediate surgery may be indicated when there is a midline shift of over 5 mm. The sign can be caused by conditions including traumatic brain injury, stroke, hematoma, or birth deformity that leads to a raised intracranial pressure.

<span class="mw-page-title-main">Cerebrospinal fluid leak</span> Medical condition

A cerebrospinal fluid leak is a medical condition where the cerebrospinal fluid (CSF) surrounding the brain or spinal cord leaks out of one or more holes or tears in the dura mater. A cerebrospinal fluid leak can be either cranial or spinal, and these are two different disorders. A spinal CSF leak can be caused by one or more meningeal diverticula or CSF-venous fistulas not associated with an epidural leak.

A sports-related traumatic brain injury is a serious accident which may lead to significant morbidity or mortality. Traumatic brain injury (TBI) in sports are usually a result of physical contact with another person or stationary object, These sports may include boxing, gridiron football, field/ice hockey, lacrosse, martial arts, rugby, soccer, wrestling, auto racing, cycling, equestrian, rollerblading, skateboarding, skiing or snowboarding.

References

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