Epidural Hematomas

Pathogenesis and Pathophysiology. An epidural hematoma (EDH) develops when blood collects between the skull and the dura mater as the result of a severe head injury causing a fracture of the squamous portion of the temporal bone and producing a tear in the middle meningeal artery. Blood escaping under arterial pressure dissects the dura inward away from the bone and forms a hematoma. The most common location of EDH is along the lateral wall of the middle cranial fossa. The underlying brain is displaced inward, and brain herniation may follow. '791 Occasionally, epidural hematomas can develop in patients with tumors involving those that have spread into the epidural space.

Epidemiology and Risk Factors. Epidural hematomas are rare when compared with subdural hematomas. They usually develop only in patients with severe head trauma. They may be an important cause of death in patients with severe head injury. Subdural, intracerebral, and subarachnoid hemorrhage often co-exists.

Clinical Features and Associated Disorders. Classically, the patient often has a lucid interval just after head trauma and then often has a progressive reduction in the level of consciousness as the hematoma enlarges. The lucid interval is explained as follows: The initial injury causes brain concussion and loss of consciousness from which the patient awakens and may have some headache but seems otherwise to have recovered. The acute development of epidural bleeding causes pressure on the ipsilateral cerebral hemisphere and headache, reduction in consciousness, and abnormalities of function of the ipsilateral hemisphere. Downward transtentorial herniation may develop rapidly, causing dilatation of the ipsilateral pupil due to third nerve compression and an ipsilateral hemiparesis due to compression of the contralateral cerebral peduncle of the midbrain against the contralateral tentorial edge. '791

Rarely, an EDH may be venous in origin due to laceration of the middle meningeal vein or a dural venous sinus. The time course is more protracted, evolving over several days. Altered mental status and hemiparesis develop before signs of brain herniation. '791

Differential Diagnosis and Evaluation. Diagnosis is made by CT. The hematoma typically appears as a biconvex lens-shaped hyperdense lesion. There is an underlying skull fracture. However, if the patient's condition is rapidly deteriorating, the diagnosis is better made by taking the patient directly to the operating room for a procedure that is both diagnostic and therapeutic.

Management. Epidural hematomas should be surgically

evacuated as soon as possible. There is no place for conservative management of epidural hematomas. Rapid drainage can be life saving.

Prognosis and Future Perspectives. The outcome is usually excellent when epidural hematomas are rapidly diagnosed and treated surgically. Death usually results from unrecognized epidural hematomas. After effective treatment, there are usually no residual neurological deficits.

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