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An epidural hematoma (EDH) is a medical condition characterized by the accumulation of blood between the protective skull and the outermost layer of the brain, known as the dura mater. The dura mater serves as a crucial protective barrier for the brain, but when there is a rupture in a blood vessel, typically an artery, it can lead to the leakage of blood into this space, forming a pocket that exerts pressure on the brain. This condition often arises from head injuries and is occasionally categorized as a type of traumatic brain injury (TBI). It is also known by various names such as extradural hematoma, epidural hemorrhage, or intracranial hematoma.
Typically, the classic symptoms associated with EDH involve a brief loss of consciousness followed by a period of alertness that may extend for several hours before a decline in brain function occurs, sometimes resulting in the patient entering a coma. EDH is a critical medical emergency that necessitates immediate medical attention and treatment.
Symptoms
Epidural hematoma (EDH) is a traumatic brain injury characterized by a distinct symptom progression in some cases. Following a head trauma, individuals with EDH typically experience the following stages:
- Initial loss of consciousness: Immediately after the head injury, there is a brief episode of unconsciousness.
- Period of alertness: Subsequently, a period of apparent alertness ensues, lasting several hours in some instances.
- Deterioration: However, this interval of alertness may be followed by a deterioration in consciousness and a decline in brain function. It is important to note that this deterioration does not invariably lead to a coma but may do so in certain cases.
Additional signs and symptoms of EDH may manifest minutes to hours after the head injury, including:
- Severe headache: The individual experiences an intense and often incapacitating headache.
- Nausea and vomiting: They may feel nauseated and may vomit.
- An enlarged pupil in one eye: One eye may exhibit an enlarged pupil (anisocoria) in comparison to the other.
- Confusion: A state of mental confusion and disorientation may become evident.
- Slurred speech: Speech may become incoherent and difficult to understand.
- Dizziness: Feelings of dizziness or vertigo may be reported.
- Hemiparesis: Weakness affecting one side of the body may become apparent, leading to difficulty in movement and coordination.
If left untreated with persistent bleeding, the situation can lead to elevated intracranial pressure, exacerbating symptoms such as seizures, respiratory difficulties, cognitive impairment, eventual coma, and ultimately, fatal outcomes.
Causes
An epidural hematoma (EDH) typically results from a head injury, with a skull fracture occurring in approximately 75% of cases. The primary source of bleeding in most cases is a torn middle meningeal artery. However, in some instances, an EDH can develop due to bleeding from a vein.
In addition to trauma–related causes, EDH can also occur due to non–traumatic factors, including:
- Infection or abscess.
- Coagulopathy, where your blood does not clot properly.
- Hemorrhagic tumors, which are tumors that lead to bleeding.
- Vascular malformations, such as arteriovenous malformations and cavernous malformations.
The primary cause of spinal epidural hematomas is often spontaneous bleeding from veins, which can be triggered by coagulopathies or the use of anticoagulant medications. Other contributing factors and causes include:
- Bone fractures in the vertebrae.
- Medical procedures like lumbar punctures or epidural anesthesia.
- Presence of spinal arteriovenous malformations or other vascular abnormalities.
- Spinal tumors.
- Pregnancy.
Risks factors
Epidural hematomas (EDH) can develop in individuals who sustain head injuries, but they are more frequently observed in younger individuals, particularly those with skull fractures. Common causes of head injuries include sports activities like snowboarding, skateboarding, and biking, as well as automobile or motorcycle accidents. EDHs are four times more prevalent in males than females and are uncommon both in children under two years old and adults over 60 years old.
Diagnosis
The diagnosis of an epidural hematoma (EDH) typically involves several diagnostic steps:
- Imaging Techniques: In cases where an EDH is suspected in the head, it appears as a dense mass that applies pressure on the brain, causing it to displace within the skull. To visualize and confirm this condition, medical professionals commonly employ two imaging methods:
- Computed Tomography (CT): This technology uses X–rays to create detailed cross–sectional images of the affected area.
- Magnetic resonance imaging (MRI) scans: MRI provides highly detailed images using magnetic fields and radio waves.
- Angiogram: In situations where a non–traumatic cause, such as an arteriovenous malformation, is suspected as the underlying factor for the EDH, a diagnostic angiogram may be recommended. This procedure involves injecting a contrast dye into the blood vessels and capturing X–ray images to examine the vascular system.
- Blood test: A blood sample may be collected for laboratory analysis. This serves a dual purpose:
- Identifying any factors that could increase the individual’s risk of bleeding.
- Evaluating potential underlying medical conditions that may interfere with the normal clotting function of the blood.
Treatment
EDH is typically a medical emergency that needs to be treated right away. You may require surgery if you have brain malfunction, a severe headache, or a hematoma with a maximum thickness greater than a pea.
Without surgery to release the pressure on your brain, you risk dying or suffering a permanent brain injury.
Surgery
The preferred surgical approach involves two main procedures:
- Craniotomy with hematoma evacuation: In this procedure, a portion of the skull is temporarily removed to access and remove the blood clot. Any sources of bleeding are also addressed. Afterward, the skull bone is repositioned and secured with small screws.
- Skull holes for blood drainage: Alternatively, one or more openings can be made in the skull to allow the blood to drain. This helps reduce the pressure on the brain caused by the accumulated blood. Sometimes, a drain may be left in place for a few days to facilitate continuous blood drainage.
For individuals with a spinal epidural hematoma:
- Laminectomy: A small section of bone is removed to relieve pressure on the spinal cord and nerve roots caused by the blood clot.
Other treatments
Surgical intervention may not be required for minor brain bleeds that do not cause pressure on the brain and only lead to mild symptoms. The body has the ability to naturally absorb a small amount of blood over several months. When managing a minor brain bleed, regular monitoring with repeat head CT scans will be conducted to ensure the gradual resolution of the hematoma.
Medications
After surgery, your neurologist or neurosurgeon might recommend medications to alleviate inflammation and reduce intracranial pressure. These prescribed drugs could include mannitol, hypertonic saline, and glycerol. Additionally, in certain cases, an antiseizure medication may be prescribed temporarily, as seizures can occasionally arise as a complication of head injuries.
Rehabilitation therapy
Your neurologist will prescribe the appropriate therapy, such as physical therapy, occupational therapy, and/or speech therapy, if you have suffered brain injury.
