Epidural hemorrhage

Background

• Occur as a result of blood collecting between the skull and the dura mater
• Most commonly secondary to a tear of the middle meningeal artery

Clinical Features

• Generally associated with blunt trauma to the temporal or temporoparietal region
• There is a high incidence of associated skull fractures (>75%) and additional cerebral injuries (intraparenchymal hemorrhage, cerebral contusion, contrecoup injuries, subdural hematoma, subarachnoid hemorrhage)

Differential Diagnosis

Intracranial Hemorrhage Types

• Intra-axial
  • Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
  • Traumatic intracerebral hemorrhage
• Extra-axial
  • Epidural hemorrhage
  • Subdural hemorrhage
  • Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)

Diagnosis

• Any patient with a neurologic deficit, depressed GCS, palpable skull fracture, or worrisome mechanism will warrant a non-contrast head CT after initial stabilization and resuscitation.
• Canadian CT Head Rule for patients with minor head injury
  • Can be used to decide which minor injuries will require head CT
• Findings on CT are, classically, a lens (or lemon-shaped) shaped hyperdense lesion with sharp margins in the temporoparietal region
  • Blood along the inside of the skull will not cross the sutures. This helps differentiate acute epidural hematoma from acute subdural hematoma.

Workup

Epidural hematoma with biconvex shape hemorrhage.

Workup

• Consider head CT (rule out intracranial hemorrhage)
  • Use validated decision rule to determine need
  • Avoid CT in patients with minor head injury who are at low risk based on validated decision rules.
• Consider cervical and/or facial CT
• Appropriate trauma resuscitation of all patients with head trauma
• A thorough neurological examination of any patient with head trauma BEFORE administration of RSI

Management

• Emergent neurosurgical evacuation
• Bilateral trephination (burr holes) if neurosurgery is unavailable
• Medical care - general goal of decreasing ICP
  • RSI with possible lidocaine and fentanyl premedication
  • Elevate HOB 30 degrees (or reverse Trendelenburg position)
  • If continued signs of increasing ICP:
    • Mannitol 0.25 - 1 g/kg IV if MAP > 90 mmHg after NSGY c/s
    • Hyperventilation to 30-35 mmHg, no lower than 25 mmHg

Disposition

• Transfer to tertiary medical center
• Admission to NS or Trauma Surgery

See Also

• Intracranial Hemorrhage (Main)
• Head Trauma
• Epidural hematoma (spinal)

External Links

• Extradural haemorrhage on Radiography
• Canadian Head CT MDCalc

References

• Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357(9266):1391-6.
• Judith E. Tintinalli, Gabor Kelen, J. Stephan Stapczynski. SAMJ. New York : McGraw-Hill, Medical Pub. Division, c2004.; 2008.
• Irie F, Le Brocque R, Kenardy J et-al. Epidemiology of traumatic epidural hematoma in young age. J Trauma. 2011;71 (4): 847-53.