Epidural hemorrhage

Background

• Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
• Usually associated with temporal bone fracture
• Accounts for 1-4% of traumatic head injuries
• Bimodal age distribution: most common in adolescents and young adults
• Rare in elderly (dura more adherent to skull) and infants <2 years
• Carries ~5-10% mortality with prompt treatment; higher if uncal herniation occurs

Clinical Features

• Classic presentation (lucid interval in ~30% of cases):
  • Initial loss of consciousness (LOC) after head trauma
  • Transient period of lucidity
  • Rapid deterioration with decreasing GCS, ipsilateral pupil dilation
• Headache, nausea, vomiting
• Signs of increased ICP: Cushing response (hypertension, bradycardia, irregular respirations)
• Ipsilateral fixed, dilated pupil (uncal herniation)
• Contralateral hemiparesis
• May present without lucid interval, especially with severe injury

Differential Diagnosis

• Subdural hemorrhage
• Traumatic subarachnoid hemorrhage
• Intracerebral hemorrhage
• Cerebral contusion
• Diffuse axonal injury

Evaluation

• Non-contrast CT head — test of choice
  • Biconvex (lens-shaped) hyperdense collection
  • Does NOT cross suture lines (confined by dural attachments)
  • May see associated skull fracture, midline shift, mass effect
• Labs: CBC, coagulation studies, type and screen
• Evaluate for cervical spine injury and other traumatic injuries

Management

• ABCs — secure airway early if declining GCS
• Emergent neurosurgical consultation
• Indications for surgical evacuation (craniotomy):
  • EDH >30 mL regardless of GCS
  • Clot thickness >15 mm or midline shift >5 mm
  • GCS declining or GCS <9 with pupil abnormalities
• ICP management while awaiting surgery:
  • Elevate head of bed 30 degrees
  • Mannitol 1-1.5 g/kg IV bolus or Hypertonic saline 23.4% 30 mL IV
  • Controlled intubation if GCS <=8; target PaCO2 35 mmHg
  • Avoid hypotension (maintain MAP >80)
• Small EDH (<30 mL, <15 mm thick, <5 mm shift, GCS >8): may be managed non-operatively with serial CT and close neuro monitoring

Disposition

• All EDH require admission with neurosurgical involvement
• ICU admission for any operative EDH or declining neurologic exam
• Repeat CT in 6-8 hours for non-operative cases

See Also

• Subdural hemorrhage
• Head trauma (main)
• Traumatic subarachnoid hemorrhage
• Modified brain injury guideline (mBIG) — isolated EDH ≤4 mm in mild TBI is technically an mBIG 1 finding; given EDH expansion risk, neurosurgical consultation is still recommended for any EDH