Epidural hemorrhage
Background
- Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
- Usually associated with temporal bone fracture[1]
- 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
- Subarachnoid hemorrhage
- Intracerebral hemorrhage
- Cerebral contusion
- Diffuse axonal injury
Evaluation
- Non-contrast CT head — test of choice[2]
- 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