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Definition

Epidural hematoma (EDH) is characterized by a blood collection in the potential space between skull and dura (epidural space).

 

Etiology and Phatophysiology 

Both traumatic and non-traumatic etiologies are discussed. Traumatic head injuries are the most important etiology.

Traumatic head injury

A high-speed head injury produced by a lateral acceleration along the diameter of the skull can produce injury to vessels or brain parenchyma resulting in both a SDH, epidural hematoma or contusion.
Note that one of the differences between SDH (subdural hematoma) and EDH is that in EDH the vessel that is more frequently damaged is the middle meningeal artery: this result in an hemorrhage in the cerebral convexity in the middle cranial fossa. 
Occasionally the hemorrhage can occur in both the anterior cranial fossa, if the anterior meningeal artery is damaged, and at the vertex due to a dural arteriovenous fistula. 

Non-traumatic acute EDH

  • Hemorragic tumors, vascular malformations of the dura, congenital malformations, infections
  • Coagulopathy
  • Complication of neurosurgical procedures
  • Epidural abscess that produce necrosis of the meningeal vessels
  • Pregnancy

Common sites

70-80% of the EDH are located in the temporoparietal region in the setting of a skull fracture that transverse the course of the middle meningeal artery. Instead, frontal and occipital EDH account for 10% of EDHs.

A damage of a dural sinus or of a confluence of sinuses can produce an hemorrhage in the posterior cranial fossa.

Other pathologies that cause non-traumatic EDH: sickle-cell disease, LES, cardiac open surgery, Paget disease, hemodialysis

 

Clinical Presentation

As with SDH, EDH can present a lot of different symptoms and signs.

  • Lucid interval: in 47% of cases, after the injury there is a period followed by a progressive neurological decline to coma. This presentation is characteristic of a continuous arterial bleeding.
  • High ICP in unchecked SDH:
    • Ipsilateral dilated pupil due to uncal herniation (compression of the III CN)
    • Cushing reflex (hypertension, bradycardia, respiratory depression/irregularity)
  • Cortical blindness due to bioccipital dysfunction in the setting of posterior cranial fossa bleeding. 
  • Spinal EDH: paraparesis, back pain, sensory loss with discernible level, bladder or bowel dysfunction

Symptoms correlated to neurological decline

Note that the deterioration of the lucid interval is accompanied by some neurological deficits:

  • Headache
  • Drowsiness
  • Aphasia
  • Seizure
  • Confusion
  • Hemiparesis
  • Vomiting

 

Diagnosis

In the setting of a traumatic brain injury a variety of lesions (fractures, contusions, hemorrages, etc.) could happen. It’s important to recognize and treat those that are life-threatening.

Head CT

The finding of a mixed density blood clot (isodense and hypodense) suggest a continue bleeding and it’s an indication for surgery.

Air in acute EDH suggest fractures of sinuses or mastoid air cells.

Differential diagnosis

Note that SDH can cross the sutural margins but is limited by dural attachments. Instead, epidural hematomas are limited by sutural margins but can cross dural attachments so it has a lens-shape appearance.

A non-diagnostic head CT can be present in 8% of cases, particularly if there is some conditions:

  • Severe anemia that lower the density of the blood clot
  • Severe hypotension that cause a minor blood flow
  • Too early scanning
  • Venous bleeding with slow collection of blood

 

References

Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol 2002; 12:1237.

John Shillito, Jr., M.D. Management of Head Injuries. N Engl J Med 1961; 265:898-900

Chmielewski P, et.al. Clinical importance of the middle meningeal artery. Folia Med Cracov. 2013;53(1):41-6.

Provenzale J. Emerg Radiol. CT and MR imaging of acute cranial trauma. 2007 Apr;14(1):1-12. Epub 2007 Feb 22.

Bor-Seng-Shu E, Aguiar PH, de Almeida Leme RJ, Mandel M, Andrade AF, Marino R Jr. Epidural hematomas of the posterior cranial fossa. Neurosurg Focus. 2004 Feb 15;16(2):ECP1.

Mendelow AD, Teasdale GM. Pathophysiology of head injuries. Br J Surg. 1983 Nov;70(11):641-50.

Domenicucci M, Signorini P, Strzelecki J, Delfini R. Delayed post-traumatic epidural hematoma. A review. Neurosurg Rev. 1995;18(2):109-22.

Mark S. Greenberg. Handbook of neurosurgery. Thieme

 

Authors

 

Antonio D'Ammando, MD

Neurosurgery Resident
University of Milan (Italy)
"Spedali Civili" Hospital Brescia (Italy)
Scientific Team UpSurgeOn

 

Giorgio Saraceno, MS

Medical Student
University of Brescia (Italy) 
Scientific Team UpSurgeOn