Epidural hematoma

Definition

Epidural hematoma is an accumulation of blood filling the space between the bones of the skull and the dura mater formed due to trauma. In typical cases, it is characterized by impaired consciousness with the presence of a light period, signs of intracranial hypertension and compression of the brain, and focal manifestations corresponding to the location of the hematoma. Diagnosis is based on the clinic with craniography, cerebral angiography, CT, and MRI. Treatment is predominantly surgical – cranial trepanation, removal of the hematoma, search, and elimination of the source of bleeding. 

General information

Epidural hematoma is formed when blood accumulates above the dura mater, which is accompanied by detachment of the latter from the inner surface of the skull bones. Since at the age of 2 years and after 60 years of age, the dura is tightly fused with the bones of the skull; in these age periods, hematomas of epidural localization are extremely rare. On average, epidural hematoma is about 1-1.5% of all craniocerebral injuries, but severe craniocerebral injuries occur in 9% of victims. In such cases, epidural hematoma may be combined with cerebral contusion and subdural hematoma.

Epidural hematoma is most common among young people aged 16-25. In this age group, 75% of cases are male. Among young children and the elderly, epidural hemorrhage in boys and men is two times more common than in girls and women. Patients with posttraumatic hematomas are jointly managed by specialists in traumatology and neurology.

Causes

Epidural hematoma has a traumatic genesis. Two mechanisms of trauma are most typical. In the first case, a small object (hammer, stick, stone, bottle, etc.) strikes a slow-moving head, while in the second case, the head strikes a stationary object (falling from a bicycle, hitting the corner of a shelf or step, etc.). In this case, the area of direct application of the traumatic factor is most often the skull’s temporal or lower parietal regions.

The source of bleeding may be the middle meningeal artery and its branches, meningeal veins, venous sinuses, and diploid veins – venous channels located in the thickness of the bones of the skull. Vascular damage is often caused by a depressed skull fracture.

Symptoms of epidural hematoma

The most common is the classic clinical picture of epidural hemorrhage, characterized by a pronounced lucid interval. A brief loss of consciousness and subsequent recovery or preservation of some stunned state is typical. The victim complains of dizziness, weakness, and moderate headache. Retrograde and congrade amnesia, anisoreflexia, some asymmetry of nasolabial folds, mild meningeal signs, and spontaneous nystagmus are observed. The condition is initially regarded as mild to moderate craniocerebral trauma. The duration of the lucid interval varies from 30-40 min to several hours.

After the light period, the condition of the victim deteriorates sharply. Headache increases, nausea and vomiting appear, and a rapidly progressing disorder of consciousness replaces psychomotor agitation: from stunned to sopor and coma. Sometimes, there is a rapid fading of consciousness with a transition immediately into a coma. There is bradycardia and arterial hypertension in the neurological status – increasing brachiocephalic paresis (facial nerve paresis and muscle weakness in the upper extremity) on the opposite side of the hematoma. On the side of the hematoma is pupil dilation and then the absence of reaction to light. In some cases of epidural hematoma, focal symptoms (paresis, anisocoria) come to the forefront, outpacing the development of symptoms of brain compression.

It is not uncommon for an epidural hematoma to present with an abbreviated lucid period. As a rule, in such cases, initially, there is a deep disturbance of consciousness (coma), and the trauma is considered as severe. After a few hours, the coma is replaced by sports, and some verbal contact with the patient becomes possible. It is clear from the victim’s behavior that they have an intense headache. Mild to moderate hemiparesis is usually noted. Such a pronounced lucid period can last from a few minutes to a day.

Following this, the condition worsens: agitation increases, which then turns into a coma, and paresis worsens up to complete plegia contralateral to the hematoma limbs. 

Subacute epidural hematoma is characterized by a long light period (up to 10-12 days). During this period, the victim’s consciousness is primarily clear; there is a tendency to bradycardia and some mild focal symptoms. Subsequently, there is a gradual, sometimes wavy, aggravation of disorders of consciousness to profound deafness, which is preceded by severe headache and agitation. On the ocular fundus, ophthalmoscopy may reveal stagnant optic discs indicative of cerebral compression.

Focal manifestations accompanied by epidural hematoma depend on its location. With hemorrhage in the parasagittal region, pyramidal disorders dominate with the greatest severity of paresis in the foot. Epidural hematoma of the frontal lobe is accompanied by mental disorders with frontal coloration with little expression of other focal symptomatology. 

Diagnosis

Epidural hematoma is diagnosed by a neurologist or neurosurgeon with the participation of a trauma surgeon based on history and typical clinical manifestations: impaired consciousness, unilateral mydriasis and contralateral hemiparesis, bradycardia, etc. Diagnostic minimum:

• Radiography. Skull radiography establishes the presence of a fracture that crosses the furrows of meningeal vessels. In 90% of cases, the epidural hematoma is localized accordingly to the fracture site. Epidural hematoma can be confirmed by cerebral angiography, which reveals a vascular-free area in the shape of a convex lens.
• Echoencephalography usually diagnoses progressive displacement of the midline echo. It has retained its value in the diagnosis of intracranial hematomas in the absence of modern techniques such as MRI or CT.
• Tomography. CT of the brain can provide more accurate data on the volume and location of the hematoma and other intracranial injuries. MRI is used to differentiate epi- and subdural hematomas and assess the state of basal structures and the brainstem.

Treatment of epidural hematoma

Conservative treatment under constant dynamic control of hematoma volume is possible in cases when epidural hematoma does not exceed 30-50 ml in size, does not cause gross and progressive symptoms, and is not accompanied by signs of brain compression.

In most cases, surgical treatment is performed. A milling hole is made in the skull over the site of the suspected hematoma localization. In case of rapid increase in cerebral compression through the hole aspirate part of the hematoma, perform a full-fledged skull trepanation with complete removal of the epidural hematoma, search, and ligation of the damaged vessel. In case of bleeding from veins, they are coagulated and tamponed with a hemostatic sponge. When sinuses are damaged, they are coagulated and tamponaded with hemostatic sponge. In bleeding from diploid veins, surgical wax is used.

Surgery is performed against the background of anti-edema, hemostatic, and symptomatic therapy. In the recovery period, resorption and neurometabolic drugs are used, and massage and therapeutic exercise are performed to restore strength in the muscles of paretic limbs as soon as possible.

All these treatment options are available in more than 310 hospitals worldwide (https://doctor.global/results/diseases/epidural-hematoma-edh). For example, Epidural hematoma treatment can be done in 15 clinics across Turkey for an approximate price of $4.0 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/epidural-hematoma-treatment). 

Prognosis

About a quarter of epidural hemorrhages are fatal. The prognosis depends on the hematoma volume, the patient’s age, and the surgical treatment timing. When surgery is performed at the stage of moderate decompensation, mortality is minimal, and mostly good recovery of lost neurological functions is noted. The favorable outcome also has a conservative treatment of subacute hematomas of small size performed by strict indications. An alarming prognosis has hematomas operated at the stage of decompensation. In such cases, the mortality rate reaches 40%, and the survivors often have significant neurological deficits.