View source for Epidural hemorrhage

==Background==
*Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
*Usually associated with temporal bone fracture<ref name="bullock">Bullock MR, et al. Surgical management of acute epidural hematomas. ''Neurosurgery''. 2006;58(3 Suppl):S7-15. PMID 16710967.</ref>
*Accounts for 1-4% of traumatic [[Head trauma (main)|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 intracranial pressure|increased ICP]]: [[Cushing response]] (hypertension, bradycardia, irregular respirations)
*Ipsilateral fixed, dilated pupil ([[Uncal herniation|uncal herniation]])
*Contralateral hemiparesis
*May present without lucid interval, especially with severe injury

==Differential Diagnosis==
*[[Subdural hemorrhage]]
*[[Subarachnoid hemorrhage]]
*[[Intracerebral hemorrhage]]
*[[Cerebral contusion]]
*[[Diffuse axonal injury]]

==Evaluation==
*Non-contrast CT head — test of choice<ref name="dent">Dent DL, et al. Prognostic factors after acute subdural hematoma. ''J Trauma''. 1995;39(1):36-43. PMID 7636907.</ref>
**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|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 (main)|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)]]
*[[Increased intracranial pressure]]
*[[Subarachnoid hemorrhage]]

==References==
<references/>

[[Category:Neurology]]
[[Category:Trauma]]