Diagnosis

Epidural hematoma

Etiology

Cause [th7]

1. Traumatic (most common) --> tearing of the middle meningeal artery (85%) [ttw][ipo]

2. Nontraumatic spontaneous etiologies include: [ttw]

   • Craniofacial infection, coagulopathy, congenital anomalies, vascular malformations, and hemorrhagic tumors

   • Complication of neurosurgical procedures

   • Epidural abscess, leading to pressure necrosis of meningeal vessels

   • Pregnancy, sickle cell disease, systemic lupus erythematosus, open heart surgery, Paget disease of the skull, and hemodialysis

Pathophysiology [th7]

1. Arterial bleeding from the middle meningeal artery --> high-pressure arterial system

2. Lentiform intracranial hematoma --> Elevated intracranial pressure

   • Reduced cerebral perfusion pressure

   • Brain herniation --> death

Complications [th7]

• Cognitive impairment

• Seizure

• Uncal herniation

• Pneumonia

• Delirium

• Cardiac arrest

• Deep vein thrombosis

• Pulmonary embolism

• Acute respiratory distress syndrome

• Sepsis

• Stroke

Epidemiology

Incidence per 100.000 [ttw][rvn][om1][5en]

Approach

• Ophtalmoscopy

• CT caput

• MR caput

• Lumbar puncture

Treatment

1. Reduce elevated intracranial pressure: [om1][ttw][th7]

   • Head elevation

   • Hyperventilation

   • Osmotic diuresis (mannitol or hypertonic saline i.v.)

   • Craniotomy and hematoma evacuation

2. Correction of coagulopathy:

   • Massive transfusion protocol: packed rRBC, fresh frozen plasma, and platelets

   • Tailored reversal of the anticoagulant (vitamin K, Protamine) or antiplatelet agents

3. Surgery: Craniotomy + hematoma evacuation + ligation of the bleeding vessel

   • Focal signs or symptoms

   • Glasgow Coma Scale score <9

   • Large hematoma volume (>30 cm3 or >30 mL)

   • Hematoma growth causing elevated intracranial pressure or symptoms

4. Non-operative conservative management with serial CT scanning is attempted if the patient satisfies all of the following criteria and has mild symptoms:

   • Glasgow Coma Scale score > 8

   • No focal neurological symptoms

   • Epidural hematoma volume of less than 30 mL

   • A clot diameter of less than 15 mm

   • Midline shift of less than 5 mm

Differential diagnoses

Arteriovenous malformation, Brain abscess, Brain tumor, Cerebral aneurysm, Hydrocephalus, Intracerebral hemorrhage, Multiple sclerosis, Stroke, Subarachnoid hemorrhage, Subdural hematoma, Toxoplasmosis