Epidural hematoma

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Epidural hematoma may be classified to into three groups: Traumatic epidural hematoma which is the main cause of epidural hematoma, spontaneous spinal epidural hematomas and postoperative epidural spinal hematoma.

Epidural hematoma is the result of the bleeding within the epidural space, which lies between dura mater and skull bone. The main cause of epidural hematoma is typically head injury that results in a break of the temporal bone and bleeding from the middle meningeal artery in the epidural space. Because the bleeding is caused by arterial rupture, it has a high tendency to progress and it causes a hematoma in epidural space. Progression of bleeding may expand the hematoma and cause increasing of the intracranial pressure and it may lead to brain herniation. Occasionally epidural hematoma may occur as a result of a Bleeding disorders or blood vessel malformation or after CNS surgery or lumbar acupunctures or Spinal injections or metastatic cancer and sometimes is may occur spontaneously.

The leading cuase of epidural hematoma is head trauma. Other common causes of epidural hematoma include: Spinal trauma, bleeding disorders, blood vessel malformation, CNS surgery, dengue virus infection, lumbar acupunctures, spinal injections, metastatic cancer, sickle cell anemia and kummell’s disease.

Epidural hematoma must be differentiated from other diseases that cause severe headache such as subarachnoid hemorrhage, Subarachnoid hemorrhage, meningitis, intracranial mass, cerebral hemorrhage, cerebral infarction, intracranial venous thrombosis, migraine, pituitary apoplexy, and lymphocytic hypophysitis.

Epidural hematoma occurs in approximately 2000 per 100,000 of patients with head injury. Epidural hematoma is the cause of 5% to 15% of fatal head injuries. Approximately 85% to 95% of patients with epidural hematoma have an overlying skull fracture. The in-hospital mortality rate of epidural hematoma in young patients with epidural hematoma is approximately 4800 per 100,000 individuals with a case-mortality rate of 4.8%. Patients of all age groups may develop epidural hematoma as the main cause of epidural hematoma is traumatic head injury. There is no racial predilection to epidural hematoma.Epidural hematoma affects men and women equally.

The most potent risk factor in the development of epidural hematoma is Head trauma. Other risk factors include: Spinal trauma, bleeding disorders, anticoagulant drugs usage, blood vessel malformation, CNS surgery, lumbar acupunctures ,spinal injections, metastatic cancer, sickle cell anemiaand kummell’s disease.

There is insufficient evidence to recommend routine screening for epidural hematoma.

If left untreated, patients with epidural hematoma may progress to develop permanent paraplegia, loss of sensation, brain herniation, coma and death. Common complications of epidural hematoma include: brain herniation, death, post-traumatic seizures, visual problems, persistent paraplegia, Coma, loss of sensation, priapism, disturbed circulation of the cerebrospinal fluid and Urinary retention. Prognosis is generally good in patients treated surgically without delay. In patients with acute epidural hematoma the surgery in an interval under two hours leads to 17% mortality rate and 67% of good recoveries but in patients who recover after an interval of more than two hours the mortality rate is 65% and good recovery rate is 13%. Overall mortality rate of patients with epidural hematoma is approximately 25%. The percentages of overall good recoveries and minimal neurologic deficit in patients with epidural hematoma is approximately 58%. The prognosis is worse in older patients and in patients with concomitant injuries of other body regions.

The CT scan is the gold standard test for the diagnosis of epidural hematoma. The following findings on performing CT scan are confirmatory for epidural hematoma: Bi-convex (or lentiform) shaped hematoma in epidural space which can cross the dural reflections unlike a subdural hematoma but it does not cross skull‘s suture lines where the dura tightly adheres to the adjacent skull, depressed skull fracture in some cases of epidural hematoma, midline shift of brain tissue, subfalcine herniation and uncal herniation. Among patients with head trauma CT scan is indicated for detecting epidural hematoma and other kind of intracranial hemorrhages in patients with: age > 60 years, glasgow Coma Scale under 15, Headache, Vomiting, Loss of consciousness, Amnesia, alcohol or drug intoxication. Screening for cervical spinal hematoma by CT scan is recommended among patients with acute onset of hemiparesis, specially when they are associated with neck pain. MRI is the preferred imaging study for diagnosis of spinal epidural hematoma. In patients with spinal epidural hematoma findings on MRI suggestive of spinal epidural hematoma include: A variable signal intensity( Isointensity to cord in T1-weighted images and Hyperintensity with areas of hypointensity in T2-weighted images), capping of epidural fat, direct continuity with the adjacent osseous structures and compression of epidural fat, subarachnoid sac, and spinal cord. MRI is sensitive for diagnosis of intracranial epidural hematoma but it is rarely used for diagnosis of it because of its limited availability and because more time is needed to prepare the patients for MRI.

Patients with epidural hematoma may have a positive history of: Head trauma, spinal trauma, Bleeding disorders, blood vessel malformation and NS surgery. In traumatic cases of epidural hematoma, patients may develop signs and symptoms right after trauma, or weeks after that. Some patients with epidural hematoma may experience a lucid interval which is a period of time in which patient regains consciousness after a short period of unconsciousness. after lucid interval the sign and symptoms of epidural hematoma may get worse. The most common symptoms of epidural hematoma include: Severe headache, nausea and vomiting, dizziness, drowsiness or altered level of alertness, enlarged pupils, weakness and slurred speech. Less common symptoms of epidural hematoma include: seizures, unconsciousness and visual disturbance. As the hematoma expands, epidural bleeds can become large and raise intracranial pressure, causing the brain herniation in which the brain stem may be compressed and causing unconsciousness, bradycardia and irregular respiration or apnea.

Findings in physical examination of patients with epidural hematoma may vary depend on the site and size of the hematoma. In patients with cranial epidural hematoma various focal neurologic signs may be seen depend on the site of hematoma. Physical examination of patients with cranial epidural hematoma is usually remarkable for loss of consciousness, unilateral diminished deep tendon reflexes, unilateral fixed mydriasis and abnormal pupillary reflex, down and out positioned eyes, loss of vision in contralateral side of hematoma and abnormal vertical gaze, unilaterally muscle weakness and unilateral sensory loss.

Glasgow coma scale in most patients with epidural hematoma is reduced. In patients with brain herniation due to the epidural hematoma respiratory arrest and Cushing’s triad(hypertension, bradycardia, and irregular respiration) may be seen. Findings in neck examination of patients with spinal epidural hematoma is usually include stiffness and tenderness.

Laboratory studies should also be considered in all patients with epidural hematoma, including: A complete blood count to check for thrombocytopenia, Coagulation studies (PTT, PT/INR) to check for coagulopathy and Basic metabolic panel to check for electrolyte abnormalities.

There are no ECG findings associated with epidural hematoma.

Linear fractures in the cranial bones may be presesnt in skull X ray in patients with traumatic cranial epidural hematoma.

There are no echocardiography/ultrasound findings associated with epidural hematoma.

The CT scan is the gold standard test for the diagnosis of epidural hematoma. The following findings on performing CT scan are confirmatory for epidural hematoma: Bi-convex (or lentiform) shaped hematoma in epidural space which can cross the dural reflections unlike a subdural hematoma but it does not cross skull‘s suture lines where the dura tightly adheres to the adjacent skull, depressed skull fracture in some cases of epidural hematoma, midline shift of brain tissue, subfalcine herniation and uncal herniation. Among patients with head trauma CT scan is indicated for detecting epidural hematoma and other kind of intracranial hemorrhages in patients with: age > 60 years, glasgow Coma Scale under 15, Headache, Vomiting, Loss of consciousness, Amnesia, alcohol or drug intoxication. Screening for cervical spinal hematoma by CT scan is recommended among patients with acute onset of hemiparesis, specially when they are associated with neck pain.

MRI is the preferred imaging study for diagnosis of spinal epidural hematoma. In patients with spinal epidural hematoma findings on MRI suggestive of spinal epidural hematoma include: A variable signal intensity( Isointensity to cord in T1-weighted images and Hyperintensity with areas of hypointensity in T2-weighted images), capping of epidural fat, direct continuity with the adjacent osseous structures and compression of epidural fat, subarachnoid sac, and spinal cord. MRI is sensitive for diagnosis of intracranial epidural hematoma but it is rarely used for diagnosis of it because of its limited availability and because more time is needed to prepare the patients for MRI.

There are no widely used other imaging findings associated with epidural hematoma.

There are no widely used other diagnostic studies associated with epidural hematoma.

The mainstay of treatment for epidural hematoma is urgent surgery.

Surgery is the mainstay of treatment for epidural hematoma. An epidural hematoma greater than 30 cm3 should be surgically evacuated regardless of the patient’s Glasgow Coma Scale (GCS) score. An epidural hematoma less than 30 cm3 and with less than a 15-mm thickness and with less than a 5-mm midline shift in patients with a GCS score greater than 8 without focal deficit can be managed nonoperatively with serial computed tomographic scanning and close neurological observation in a neurosurgical center. Acute epidural hematoma with a small amount of bleeding(less than 50 mL)may be treated by minimal invasive surgery methods which avoids craniotomy.

There are no established measures for the primary prevention of epidural hematoma.

There are no established measures for the secondary prevention of epidural hematoma.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Epidural hematoma is the result of the bleeding within the epidural space, which lies between dura mater and skull bone. The main cause of epidural hematoma is typically head injury that results in a break of the temporal bone and bleeding from the middle meningeal artery in the epidural space. Because the bleeding is caused by arterial rupture, it has a high tendency to progress and it causes a hematoma in epidural space. Progression of bleeding may expand the hematoma and cause increasing of the intracranial pressure and it may lead to brain herniation. Occasionally epidural hematoma may occur as a result of a Bleeding disorders or blood vessel malformation or after CNS surgery or lumbar acupunctures or Spinal injections or metastatic cancer and sometimes is may occur spontaneously.

• Epidural hematoma is the result of the bleeding within the epidural space, which lies between dura mater and skull bone.^[1]
• The main cause of epidural hematoma is typically head injury that results in a break of the temporal bone and bleeding from the middle meningeal artery in the epidural space.^[2][3][4][5]
• Because the bleeding is caused by arterial rupture, it has a high tendency to progress and it causes a hematoma in epidural space.
• Progression of bleeding may expand the hematoma and cause increasing of the intracranial pressure and it may lead to brain herniation.^[6]
• Occasionally epidural hematoma may occur as a result of a Bleeding disorders or blood vessel malformation or after CNS surgery or lumbar acupunctures or Spinal injections or metastatic cancer and sometimes is may occur spontaneously.^{[7][8][9][10][11]}

• Head trauma^[5][4]
• Bleeding disorders^[7]
• Blood vessel malformation^[8]
• CNS surgery^[9]
• Sickle Cell Anemia^[12][13]
• Kummell’s disease^[14]
• Dengue virus infection^[15]
• Lumbar acupunctures^[10]
• Spinal injections^[16][17]
• Metastatic cancer^[11]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

The leading cuase of epidural hematoma is head trauma. Other common causes of epidural hematoma include: Spinal trauma, Bleeding disorders, blood vessel malformation, CNS surgery, dengue virus infection, Lumbar acupunctures, spinal injections, Metastatic cancer, sickle cell anemia and kummell’s disease.

• The leading cuase of epidural hematoma is Head trauma.^[1][2]

• Other common causes of epidural hematoma include:
  • Spinal trauma^[3]
  • Bleeding disorders^[4]
  • Blood vessel malformation^[5]
  • CNS surgery^[6]

Less common causes of epidural hematoma include:

• Dengue virus infection^[7]
• Lumbar acupunctures^[8]
• Spinal injections^[9][10]
• Metastatic cancer^[11]

• Sickle cell anemia^[12][13]
• Kummell’s disease^[14]

Cardiovascular	Blood vessel malformation
Chemical/Poisoning	No underlying causes
Dental	No underlying causes
Dermatologic	No underlying causes
Drug Side Effect	No underlying causes
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	No underlying causes
Gastroenterologic	No underlying causes
Genetic	No underlying causes
Hematologic	No underlying causes
Iatrogenic	Head trauma Spinal trauma Lumbar acupuncture Spinal injections
Infectious Disease	Dengue virus infection
Musculoskeletal/Orthopedic	Kummell’s disease
Neurologic	CNS surgery Spinal trauma Head trauma Lumbar acupuncture Spinal injections
Nutritional/Metabolic	No underlying causes
Obstetric/Gynecologic	No underlying causes
Oncologic	Bleeding disorders Metastatic cancer Sickle cell anemia
Ophthalmologic	No underlying causes
Overdose/Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal/Electrolyte	No underlying causes
Rheumatology/Immunology/Allergy	No underlying causes
Sexual	No underlying causes
Trauma	Head trauma Spinal trauma
Urologic	No underlying causes
Miscellaneous	No underlying causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Epidural hematoma must be differentiated from other diseases that cause severe headache such as subarachnoid hemorrhage, Subarachnoid hemorrhage, meningitis, intracranial mass, cerebral hemorrhage, cerebral infarction, intracranial venous thrombosis, migraine, pituitary apoplexy, and lymphocytic hypophysitis.

Epidural hematoma should be differentiated from other diseases causing severe sudden headache for example: ^{[1][2][3][4][5][6][7][8][9][10][11]}

Onset	Disease	Symptoms		Gold Standard Test	CT/MRI Findings	Other Investigation Findings
		Headache Characteristics	Associated Features
Sudden	Epidural hematoma	Dull Throbbing One sided or all around	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Biconvex lens shaped hematoma which expand inward toward the brain rather than along the inside of the skull	The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
	Subdural hematoma	Gradually increasing headache and confusion	Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Crescent-shaped hematoma with a concave surface away from the skull	The Glasgow Coma Scale is a tool for measuring degree of unconsciousness and is a useful tool for determining severity of injury. The Pediatric Glasgow Coma Scale is used in young children.
	Subarachnoid hemorrhage	Thunderclap headache Worst headache in life Pulsates towards the back of the head	Confusion Drowsiness Personality change Seizures Nausea and vomiting Loss of consciousness	CT scan without contrast	Hyperattenuating material is seen filling the subarachnoid space Most commonly around the circle of Willis Small amounts of blood may sometimes be appreciated pooling in the interpeduncular fossa	MRI is sensitive to subarachnoid blood and is able to visualise it well in the first 12 hours typically as a hyperintensity in the subarachnoid space on FLAIR Lumbar puncture is performed to evaluate the cerebrospinal fluid for the presence of red blood cells and xanthochromia
	Pituitary apoplexy	Severe headache	Nausea and vomiting Paralysis of eye muscles (diplopia) Changes in vision	MRI	CT scan without contrast is the initial test of choice. Pituitary hemorrhage on CT presents as a hyper-dense lesion. MRI is done in cases of inconclusive CT. An MRI is more sensitive in identifying intrasellar mass and soft tissue changes.	Blood tests may be done to check: PT/INR and aPTT Pituitary hormonal assay
	Subarachnoid hemorrhage	Severe headache Thunderclap Described as the worst headache of life	Double vision Nausea and vomiting Symptoms of meningeal irritation Sudden decreased level of consciousness	Digital subtraction angiography	The modality of choice for diagnosis of subarachnoid hemorrhage is non-contrast head computed tomography (CT), with or without lumbar puncture.[1] CT shows hyperattenuating material filling the subarachnoid space.	Lumbar puncture (LP) is necessary when there is a strong suspicion of subarachnoid hemorrhage. LP will show: Elevated opening pressure Elevated red blood cell (RBC) Xanthochromia
	Meningitis	Headache is associated with: Fever Neck stiffness	Photophobia    Phonophobia  Irritability Altered mental status	Lumbar puncture for CSF	CT scan of the head may be performed before LP to determine the risk of herniation.	Diagnosis is based on clinical presentation in combination with CSF analysis. CSF analysis is the investigation of choice. For more information on CSF analysis in meningitis please click here.
						PT/INR and aPTT should be checked to rule out coagulopathy.
	Migraine	Severe to moderate headache One-sided Pulsating Lasts between several hours to three days.	Nausea and vomiting Preceding aura Photophobia Phonophobia	—	CT and MRI may be needed to rule out other suspected possible causes of headache.	Migraine is a clinical diagnosis that does not require any laboratory tests. Laboratory tests may be ordered to rule out any suspected coexistent metabolic problems.
	Lymphocytic hypophysitis	Generalized headache Retro-orbital or Bitemporal pain	Most often seen in late pregnancy or the postpartum period Mass lesion effect such as visual field defects Hypopituitarism	Pituitary biopsy	CT & MRI typically reveal features of a pituitary mass.	The most accurate test is a pituitary biopsy which will show lymphocytic infiltration.
Gradual	Intracranial mass	Morning headache	Nausea Vomiting Change in mental status Seizures Focal neurological deficits	MRI	CT or MRI is the initial test to detect intracranial lesions (ring enhancing lesions). These imaging tests determine the location of intracranial mass lesion(s) and help in guiding therapy.	Biopsy of the lesion may be done to identify the nature of the lesion such as: Tumor Abscess X-ray of the skull is a non specific test, but useful if any of the lesions are calcified
	Intracranial venous thrombosis	Diffuse headache Headache can be the only symptom of cerebral venous thrombosis	Focal neurological deficits Seizures Depressed level of consciousness	Digital subtraction angiography	The classic finding of sinus thrombosis on unenhanced CT images is a hyperattenuating thrombus in the occluded sinus. CT and MRI may identify Cerebral edema and venous infarction may be apparent.	CT venography detects the thrombus, computed tomography with radiocontrast in the venous phase (CT venography or CTV) has a detection rate that in some regards exceeds that of MRI. Cerebral angiography may demonstrate smaller clots, and obstructed veins may give the “corkscrew appearance.”

• Brain contusion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

Epidural hematoma occurs in approximately 2000 per 100,000 of patients with head injury. Epidural hematoma is the cause of 5% to 15% of fatal head injuries. Approximately 85% to 95% of patients with epidural hematoma have an overlying skull fracture. The in-hospital mortality rate of epidural hematoma in young patients with epidural hematoma is approximately 4800 per 100,000 individuals with a case-mortality rate of 4.8%. Patients of all age groups may develop epidural hematoma as the main cause of epidural hematoma is traumatic head injury. There is no racial predilection to epidural hematoma.Epidural hematoma affects men and women equally.

• Epidural hematoma occurs in approximately 2000 per 100,000 of patients with head injury.^[1]
• Epidural hematoma is the cause of 5% to 15% of fatal head injuries.^[1]
• Approximately 85% to 95% of patients with epidural hematoma have an overlying skull fracture.^[1]

• The in-hospital mortality rate of epidural hematoma in young patients with epidural hematoma is approximately 4800 per 100,000 individuals with a case-mortality rate of 4.8%.^[2]

• Patients of all age groups may develop epidural hematoma as the main cause of epidural hematoma is traumatic head injury.^[3]

• There is no racial predilection to epidural hematoma.^[3][4]

• Epidural hematoma affects men and women equally.^[3][4]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

The most potent risk factor in the development of epidural hematoma is Head trauma. Other risk factors include: Spinal trauma, Bleeding disorders, anticoagulant drugs usage, blood vessel malformation, CNS surgery, Lumbar acupunctures ,spinal injections, Metastatic cancer, sickle cell anemiaand kummell’s disease.

The most potent risk factor in the development of epidural hematoma is Head trauma^[1][2]. Other risk factors include: Spinal trauma^[3], bleeding disorders^[4], anticoagulant drugs usage^[5], blood vessel malformation^[6], CNS surgery^[7], Lumbar acupunctures^[8] ,spinal injections^[9][10], Metastatic cancer^[11], sickle cell anemia^[12][13] and kummell’s disease^[14].

• Common risk factors in the development of epidural hematoma may be occupational, environmental, genetic, and viral.
• Common risk factors in the development of epidural hematoma include:
  • Head trauma^[1][2]
  • Spinal trauma^[3]
  • Bleeding disorders^[4]
  • Anticoagulant drugs usage^[5]
  • Blood vessel malformation^[6]
  • CNS surgery^[7]
  • Lumbar acupunctures^[8]

• Less common risk factors in the development of epidural hematoma include:
  • Spinal injections^[9][10]
  • Metastatic cancer^[11]
  • Sickle cell anemia^[12][13]
  • Kummell’s disease^[14]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohamadmostafa Jahansouz M.D.[2]

If left untreated, patients with epidural hematoma may progress to develop permanent paraplegia, loss of sensation, brain herniation, coma and death. Common complications of epidural hematoma include: brain herniation, death, post-traumatic seizures, visual problems, persistent paraplegia, Coma, loss of sensation, priapism, disturbed circulation of the cerebrospinal fluid and Urinary retention. Prognosis is generally good in patients treated surgically without delay. In patients with acute epidural hematoma the surgery in an interval under two hours leads to 17% mortality rate and 67% of good recoveries but in patients who recover after an interval of more than two hours the mortality rate is 65% and good recovery rate is 13%. Overall mortality rate of patients with epidural hematoma is approximately 25%. The percentages of overall good recoveries and minimal neurologic deficit in patients with epidural hematoma is approximately 58%. The prognosis is worse in older patients and in patients with concomitant injuries of other body regions.

• If left untreated, patients with epidural hematoma may progress to develop permanent paraplegia, loss of sensation, brain herniation, coma and death.^{[1][2][3][4][5]}

• Common complications of epidural hematoma include:
  • Brain herniation^[4]
  • Death^[6]
  • Post-traumatic seizures^[7]
  • Infarction of the brain tissue which may cause:
    • Visual problems^[8]
    • Persistent paraplegia^[2][3]
    • Coma^[5]
    • Loss of sensation^[1]
    • Priapism^[1]
  • Disturbed circulation of the cerebrospinal fluid^[9]
  • Urinary retention^[10]

• Prognosis is generally good in patients treated surgically without delay.^[11]
• In patients with acute epidural hematoma the surgery in an interval under two hours leads to 17% mortality rate and 67% of good recoveries but in patients who recover after an interval of more than two hours the mortality rate is 65% and good recovery rate is 13%.^[12]
• Overall mortality rate of patients with epidural hematoma is approximately 25%.^[12]
• The percentages of overall good recoveries and minimal neurologic deficit in patients with epidural hematoma is approximately 58%.^[12]

• The prognosis is worse in older patients and in patients with concomitant injuries of other body regions.^[12]

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